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Review of Case Materials
Reviews records, documents, testimony, data, and other relevant materials and consults with counsel regarding technical issues related to the matter.
Provide Expert Analysis
Applies specialized knowledge and experience to evaluate the technical or professional issues involved.
Form Expert Opinions
Develops independent, supportable opinions based on the available evidence and relevant standards.
Prepare Expert Reports
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An audit trail can help reconstruct activity within an electronic health record, including when particular actions occurred and, depending on the system and available data, which user account performed them. Current ONC certification criteria address audit logging of actions involving electronic health information, including additions, deletions, changes, queries, printing, and copying, along with associated date and time information. An EHR expert can interpret those records in the context of the system involved and compare them with the clinical chart, user histories, and other available data. The audit trail should not be assumed to contain information the particular system was not configured or designed to record.
Available audit data may show that an entry was added, edited, deleted, or otherwise changed and can help establish the chronology of those actions. ONC's certification materials specifically recognize additions, deletions, and changes as actions that may be recorded in an EHR audit log. Determining exactly what changed can require comparison of audit reports, historical versions, timestamps, exported data, and the chart as displayed to users. The expert should distinguish what the system data demonstrates from assumptions that cannot be supported by the available record.
Depending on the dispute and system, potentially useful material may include audit trails, access logs, amendment histories, user information, system-generated reports, data exports, configuration information, and records showing when particular entries or actions occurred. A conventional PDF or printed chart may not contain all of the activity information maintained elsewhere within the EHR environment. This distinction can be important when the dispute concerns who accessed the record, when documentation was entered, whether an entry was later changed, or how the displayed chart relates to underlying system activity.
Prepares clear, well-supported expert reports outlining methodology, analysis, findings, and opinions.
Provide Deposition Testimony
Explains findings and opinions under oath and responds to questioning during deposition testimony.
Testify in Court
Presents specialized findings and opinions clearly to judges, juries, arbitrators, or other decision-makers.
EHR access and audit information can establish or help reconstruct activity within an electronic information system. It does not, by itself, determine whether the underlying diagnosis, treatment, or clinical decision met the applicable medical standard of care. HHS's HIPAA Security Rule separately requires regulated entities to use access controls and audit controls for systems containing electronic protected health information, including mechanisms to record and examine system activity. An EHR expert can address the technical record and system behavior, while the clinical significance of medical decisions may require an appropriately qualified medical expert.
Separate expertise may be appropriate when the central question concerns unauthorized disclosure, privacy obligations, data breaches, security vulnerabilities, or cybersecurity controls rather than the integrity or chronology of the health record itself. HHS distinguishes privacy requirements governing uses and disclosures of protected health information from Security Rule safeguards for electronic protected health information. The HIPAA Security Rule includes technical safeguards addressing access control, authentication, integrity protections, and audit controls. EHR evidence may form part of such a dispute, but broader privacy and security analysis can fall within separate data privacy or data security expertise.
