Electronic Health Records (EHR) have revolutionized healthcare, making patient data more accessible, reducing paperwork, and improving efficiency. However, despite these benefits, EHR errors can result in misdiagnoses, delayed treatments, and other critical medical mistakes. In Pennsylvania, EHR-related errors have led to medical malpractice lawsuits, where courts analyze digital records to determine liability.
This guide examines how EHR impacts malpractice claims, legal risks for healthcare providers, and patient rights under Pennsylvania law. If you suspect an EHR-related medical error has affected your care, understanding the legal landscape can help you take the next steps.
Understanding Electronic Health Records (EHR)
What Are Electronic Health Records?
EHRs are digital patient records that contain medical histories, prescriptions, lab results, physician notes, and imaging studies. These digital systems replace paper records, allowing medical professionals to access and update patient information in real-time.
Unlike traditional medical charts, EHRs integrate with hospital networks, pharmacies, and insurance databases. This connectivity is meant to streamline care, but it also introduces new legal and technical challenges when errors or alterations occur.
Why Are EHRs Used in Medical Malpractice Cases?
EHRs serve as crucial evidence in medical malpractice lawsuits because they provide a timestamped record of patient care. Courts and attorneys use EHR data to determine whether:
- A doctor reviewed the patient’s medical history before prescribing treatment.
- A medical error resulted from human negligence or an EHR system failure.
- A hospital staff member altered records after a malpractice incident.
Because EHRs store metadata, audit trails, and modification logs, they can help establish liability in malpractice cases.
Common EHR Errors That Lead to Malpractice Claims
1. Documentation Errors and Omissions
One of the most frequent EHR-related malpractice issues is incomplete or inaccurate documentation. Physicians rely on accurate patient histories to make informed decisions. If critical information is missing—such as allergies, prior treatments, or symptoms—it can lead to incorrect diagnoses or improper treatments.
For example, if a doctor fails to document a patient’s allergy to penicillin, the patient may be prescribed an antibiotic that causes a severe allergic reaction. In a Pennsylvania malpractice lawsuit, an attorney could argue that the missing information directly led to patient harm.
2. System Glitches and Software Malfunctions
Like all digital systems, EHRs can experience technical failures, connectivity issues, or software bugs. When these glitches prevent doctors from accessing medical records, it can delay critical treatments or lead to medical errors.
Hospitals and healthcare facilities have a legal duty to ensure their EHR systems function properly. If a patient suffers harm due to EHR downtime or lost medical data, the healthcare provider may be held liable.
3. Unauthorized Edits and Data Tampering
EHRs maintain an audit trail that records who accessed a file, what changes were made, and when they occurred. This feature is crucial in malpractice cases where hospitals or physicians are accused of altering records to cover up mistakes.
If a doctor modifies a diagnosis or prescription history after an adverse event, this can be considered evidence of negligence or fraud. Courts in Pennsylvania analyze EHR metadata to determine whether unauthorized edits were made.
How EHR Evidence is Used in Medical Malpractice Lawsuits
What Is an EHR Audit Trail?
An EHR audit trail is a digital log that tracks every action within a patient’s medical record. This log includes:
- Timestamps showing when a file was accessed or modified.
- User details identifying which healthcare provider made changes.
- Changes in diagnoses, prescriptions, and treatment plans.
Audit trails help legal experts determine whether a doctor followed proper procedures or if a record was altered after a malpractice incident.
Metadata Analysis in Court Cases
Metadata in EHR systems includes timestamps, access logs, and modification records. Lawyers and forensic investigators use metadata to confirm or dispute claims in a malpractice lawsuit.
For instance, if a physician claims to have reviewed a patient’s test results before making a diagnosis, but metadata shows the file was opened after the diagnosis, this could be evidence of negligence.
Who Can Be Held Liable for EHR-Related Errors?
Liability in an EHR malpractice lawsuit depends on whether the error was caused by human negligence, a system malfunction, or both. In Pennsylvania, the following parties may be held responsible:
- Doctors and nurses if they fail to correctly document patient information.
- Hospitals and healthcare facilities if they use faulty EHR systems or lack proper training protocols.
- EHR software vendors if a system error or malfunction directly caused harm to a patient.
Pennsylvania Medical Malpractice Laws and EHR Regulations
HIPAA Compliance and Patient Rights
The Health Insurance Portability and Accountability Act (HIPAA) regulates how patient data is stored and accessed. Under HIPAA and Pennsylvania law, patients have the right to:
- Request a complete copy of their EHR, including audit trails.
- Challenge inaccuracies in their medical records.
- Seek legal action if their records were altered, falsified, or lost.
Pennsylvania Laws on Electronic Medical Records
Pennsylvania requires medical providers to retain patient records for at least seven years. If an EHR record is missing or has been altered illegally, courts may consider this an indication of negligence or an attempt to conceal malpractice.
Legal Precedents in EHR-Based Malpractice Cases
Several Pennsylvania court cases have set legal precedents for using EHRs as evidence in malpractice lawsuits. Courts have ruled in favor of plaintiffs when they could prove that EHR errors or tampering directly contributed to patient harm.
One case involved a hospital altering medical records after a surgical error, which led to a significant malpractice settlement. In another case, metadata analysis revealed that a physician prescribed medication without reviewing the patient’s history, strengthening the plaintiff’s claim.
How to Defend Against EHR-Based Malpractice Claims
Challenging the Accuracy of EHR Evidence
Defense attorneys may argue that EHR metadata is unreliable due to system bugs, software errors, or shared logins among multiple hospital staff members. They may also claim that record modifications were made in good faith, not to conceal an error.
Proving System Failures vs. Human Negligence
Hospitals often defend malpractice claims by arguing that the EHR system itself was responsible for the error. They may shift blame to software vendors if system glitches, rather than human mistakes, caused the malpractice event.
Protecting Healthcare Providers from Liability
Doctors and hospitals can protect themselves from EHR-related malpractice claims by:
- Conducting routine EHR audits to ensure accuracy.
- Implementing backup systems in case of software failures.
- Training staff to properly document and update patient records.
Frequently Asked Questions (FAQ) About EHR and Medical Malpractice in Pennsylvania
Can EHR mistakes lead to medical malpractice claims in Pennsylvania?
Yes, if an EHR error results in harm to a patient, it can serve as the basis for a medical malpractice lawsuit. Errors such as missing records, incorrect diagnoses, unauthorized edits, or system failures that lead to improper treatment can be considered medical negligence. Courts often analyze audit trails and metadata to determine if the mistake was due to human error or a technical failure.
How do electronic health records affect malpractice lawsuits?
EHRs play a significant role in malpractice cases because they provide a detailed record of patient care. The timestamps and audit trails in EHR systems allow courts to see when medical decisions were made, who accessed a patient’s records, and whether any changes were made after a medical incident. These digital records can either support or undermine a plaintiff’s claim, depending on how they were maintained and accessed.
What legal rights do patients have if their EHR contains errors?
Patients in Pennsylvania have the right to request a copy of their full medical records, including EHR audit trails. If they find inaccuracies, they can ask the healthcare provider to correct them. Under HIPAA, patients also have the right to know who has accessed their records and can file complaints if they suspect unauthorized changes or tampering.
Can doctors or hospitals alter EHRs after a malpractice incident?
Doctors and hospitals can make necessary corrections to patient records, but all changes must be logged in the system. If records are altered to hide a mistake, this could be considered medical fraud or evidence tampering. Courts in Pennsylvania take such allegations seriously and will review metadata to determine if unauthorized edits were made.
What is an EHR audit trail, and how is it used in malpractice cases?
An EHR audit trail is a digital log that tracks every action taken within an electronic medical record. It records when a file was accessed, who accessed it, and what modifications were made. In malpractice lawsuits, audit trails are analyzed to determine if a provider reviewed a patient’s medical history, followed proper procedures, or altered records after an incident.
Contact Purchase, George & Murphey, P.C. Today
If you believe an EHR-related error led to your injury, you may have a medical malpractice case. Pennsylvania law allows victims to sue for damages if negligence caused harm.
A Pennsylvania medical malpractice attorney can help you obtain EHR evidence, review audit trails, and determine whether a lawsuit is warranted. Since malpractice claims must be filed within two years, it is critical to seek legal help as soon as possible.
If you suspect an EHR error has compromised your treatment, contact Purchase, George & Murphey, P.C. today to explore your legal options.
