Electronic Medical Records - Expert Witness Services
Assisting attorneys navigate the modern electronic medical records. Unleash the power for your client.
My goal is to provide professional expert services to attorneys working with healthcare medical legal cases regarding audit trails and related electronic medical record systems issues.
My ability to serve attorneys derives from over thirty years of experience with manual and automated access logs and audit trails starting in the 1990’s. At least 36 times I have been involved in requests for logs while employed by hospital or medical groups. These included child rape, child pregnancies, possible criminal behavior by doctors, and other compliance matters.
In at least 24 of those I was directly involved in the development and production of the access log, activity log or audit trail.
I have had project responsibility to implement EMR systems with reporting functionality including audit trail/access logs at health systems and medical groups. For example, at the University of Washington I was directly involved with the data analytics and reporting department experts to oversee the development and configuration of the reporting including audit trail / access log. In a recent position I had to secure the records and logs of providers who may have committed unethical or criminal behaviors.
As part of legal cases I have examined access logs or audit trails for multiple cases. What I have observed is a range of quality in the production of the data and am able to opine on issues related to poor quality medical records.
Contact Us
douglas.j.blair@gmail.com
614.315.3068
Areas of Practice
Audit Trails
Analysis and forensics of E H R audit trails; 45 CFR 163, 164, and 170; ATSM - E-2147 and other related HIPAA security and privacy regulations.
An audit trail is a comprehensive record of all actions, activities, and transactions within an electronic medical records system. It provides a detailed chronological account of changes made to patient records, including modifications, additions, and deletions. The audit trail captures not only user access and actions but also any modifications made to the records, allowing for a comprehensive review of the system's activity. It offers a more comprehensive view of the system's usage, changes, and potential data breaches or unauthorized access.
The requirement to have an audit log in an EMR derives from the Health Insurance Portability and Accountability Act of 1996 and codified in 45 CFR § 170.210 (and others).
EMR Business Agreements
·EMR business agreements, implementations, process, testing and go live.
Implementing an Electronic Medical Record (EMR) system should include a thorough requirements gathering process to ensure the system would meet the needs of the client. There are standard industry protocols regarding systems implementations that should be followed.
EMR Generated Medical Records
Review documents produced by the hospital or doctor. Detailed analysis of audit trail. Expert opinions and testimony on issues with the legal medical record and compliance with HIPAA.
Expert technical guidance and advice on audit trails and medical records and compliance. Staff training, presentations to client hospitals compliance and legal departments.
The patient has a right of access and to obtain a copy of his/her protected health information and the covered entity must provide the individual with access to the protected health information in the form and format requested by the individual…
per 45 C.F.R § 164.524(c)(2) and specifically 45 C.F.R § 164.524(c)(2)(i).
Get in Touch
Please call to discuss your case and for a no charge preliminary review.