Expert Audit Trail Analysis and electronic medical records

An Audit Trail is the automated tracking feature within an Electronic Health Record (EHR) that monitors the activity within that EHR.  The Audit Trail is the metadata that shows who has accessed an EHR, when it was accessed, and what operations were performed. The Audit Trail should always answer the 4 W's:  WHO, WHAT, WHEN, WHERE. 

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), medical providers that utilize EHR technology must have systems in place to review and audit access to records, as well as prevent unauthorized access.  Additionally, all Audit Trails produced must meet ASTM E2147-18 Standard Specification for Audit and Disclosure Logs for Use in Health Information Systems and should contain all the auditable actions within the medical record. 

 There are multiple reasons an Audit Trail Review is warranted.  A few reasons include: 

• whenever there are large gaps in or missing medical records
• when there are time stamps that are different than the date of service
• pended/unsigned notes
• discrepancies in the records
• addendums a significant time later

• Plaintiff - Most likely to use an Audit Trail analysis
• BOTH - Provides verification of the data integrity and validation of the completeness of a medical record
• BOTH - Identifies internal messages sent between individuals that are not part of the medical records
• BOTH - Can identify additional individuals not present in the actual medical record that could be called for deposition or testimony
• BOTH - Identifies clinical decision support tools and order sets not identified in the EHR
• BOTH - Tighter timelines and better accuracy with a complete chronology that fills in the gaps in the medical records
• BOTH - Helps the attorney ensure the consistency of any testimony
• BOTH - Prepares the attorney for what may be brought up in deposition and trial     
• BOTH - Can help protect the client during deposition  
• BOTH - Corroborates and/or refutes testimony

Audit Trails should never be used or reviewed in a vacuum. They are indecipherable to most people and are inconsistent across different practices and different EHR systems.  A Legal Nurse Consultant with specialty training in Audit Trail Analysis can review the Audit Trail against the EHR and identify key items surrounding an event that might otherwise be overlooked.  Once you understand how to read and analyze the EHR Audit Trail, and you see the benefit it brings, would you ever be satisfied looking at the medical records alone?