EMR Forensic and Audit Trail Analysis for Healthcare Litigation

An EMR audit trail is a system-generated log that records every interaction with an electronic medical record who accessed the chart, what they viewed or changed, from which workstation, and at what time. Unlike the printed chart, the audit trail is generated automatically by the EMR and is not edited by clinical staff, which is what makes it valuable as evidence.

An audit trail can establish when an entry was actually created versus the time it appears to describe, whether a record was amended or deleted after the fact, who accessed a chart and when, whether results were viewed before a clinical decision was made, and whether documentation was completed after a notice of claim or records request.

It depends on the system and on what was produced. EMR systems retain metadata showing original entry times, revision history, and the identity of each user who created or modified an entry. Comperio analyzes that metadata alongside the audit trail to determine whether documentation was added, amended, or removed after the events it describes and, just as often, to demonstrate that it was not. Where the available data cannot answer the question, we say so.

Both, along with hospital and in-house counsel. Comperio’s analysis is grounded in what the EMR objectively records, so the methodology and the findings do not change with the posture of the case. That neutrality is what allows the work to withstand challenges.

We publish what that neutrality rests on and how it is tested.

No. Our analysis is grounded in what the EMR system objectively recorded, and the same method produces the same result regardless of which party commissioned it. Findings that are unhelpful to the engaging party are reported as readily as findings that help. That is what allows Comperio to work for plaintiff, defense, and in-house teams alike.

Comperio works across the major electronic medical record platforms, including Epic, Cerner/Oracle Health, Meditech, PointClickCare, NextGen, Allscripts/Veradigm, and other EMR systems as well as ancillary clinical systems such as PACS imaging systems, fetal monitoring systems, drug dispensing systems and more..

As early as possible, ideally before the discovery requests are drafted. EMR audit trail and metadata productions are frequently incomplete because the request did not specify the correct system artifacts. Involving an EMR expert at the discovery-planning stage can be a powerful difference and completely change the trajectory of your case.

You describe the case and the EMR system involved, and a Comperio expert tells you what the audit trail and metadata are likely to show, what to request in discovery, and whether forensic analysis would meaningfully advance the case. The consultation is confidential and carries no obligation.