Trial News

A New York appellate court has compelled a hospital sued for medical negligence to produce an audit trail of a patient’s records. The patient alleges that the hospital’s negligent care following his surgery ultimately led to the amputation of his leg and that the audit trail is relevant to the sequence of events surrounding the alleged negligence. (Vargas v. Lee, 2019 WL 1271883 (N.Y. App. Div. Mar. 20, 2019).)

Jose Vargas underwent surgery at Wyckoff Heights Medical Center in May 2012 to correct his congenital clubfoot. Vargas experienced post-surgical complications while there, including swelling and gangrene, which resulted in the amputation of his leg at the knee.

Vargas sued Wyckoff Heights in New York state court for medical negligence. In June 2014, he served a discovery notice requesting the hospital’s electronic medical record audit trail for the period of his post-surgical care, May 1 to May 17, 2012. He argued that the audit trail could reveal information about his care at the hospital and the sequence of events that resulted in the amputation.

The defendant objected to the request, arguing it was “overbroad and unduly burdensome” and “not relevant to any issue to be litigated in this case.” (Vargas v. Lee, 2015 WL 3857323 (N.Y. Sup. Ct. June 18, 2015).) Vargas filed a motion to compel the audit trail. The trial court looked to Aguilar v. Immigration & Customs Enforcement Division of U.S. Department of Homeland Security and determined that “[s]ystem metadata is not routinely produced unless the requesting party shows good cause.” (255 F.R.D. 350 (S.D.N.Y. 2008).) The court found Vargas’s argument insufficient and denied his motion.

The plaintiff renewed the motion, submitting a deposition transcript and affirmation that he alleged demonstrated that the defendant had not provided his full medical records. However, the lower court denied the motion again, and the plaintiff appealed.

The New York appellate court noted both parties agreed that an electronic medical record audit trail would typically show “who accessed [a patient’s] records, when and where the records were accessed, and changes made to the records.” The court then looked to its recent holding in Forman v. Henkin that a “party seeking discovery must satisfy the threshold requirement that the request is reasonably calculated to yield information that is . . . relevant.” (30 N.Y.3d 656 (2018).) Relying on this test, the court found that Vargas had met his burden of showing that the audit trail is reasonably likely to yield relevant information.

The appellate court ruled that the defendant had “failed to demonstrate that the requested disclosure was improper or otherwise unwarranted.” Though the audit trail may contain some information that would be irrelevant to Vargas’s claim, the court found it also may contain information relevant to Vargas’s care. The court also rejected the defendant’s argument that the audit trail request was unduly onerous and that the information in the audit trail had already been provided to Vargas via his medical records.  

Garden City, N.Y., attorney Michael Lauterborn, who represents Vargas, said that “the audit trail is an important part of a patient’s medical records.” Lauterborn explained that “in medical negligence cases, it’s extremely important to know which physician accessed the patient's chart and when. This lets us know who had what information and who could have acted on that information. The decision will help us get closer to the truth of what happened to a patient and who is responsible for any harm the patient suffered.”