General Requirements for Admissibility
Generally, the rules of evidence are no different for electronic records than for paper records. Medical records are first subject to the hearsay rule, which says that any statement made out of court by a person not currently testifying is not admissible. However there are a number of exceptions to this rule, one of which is the Business Records Rule. Medical records are considered business records.
For any business record to be admissible in a legal proceeding, it must be properly authenticated. In the case of medical records, a "sponsoring witness" must normally testify that the medical record meets certain conditions. Usually the sponsoring witness will be someone who knows enough about your medical record procedures to testify about how they are created and maintained.
Computer print-outs are often used when the evidence is stored electronically. This is typical procedures for producing records from EHR or other electronic data systems.
Evidence in Electronic Form
While the basic rules of evidence are the same for paper and electronic records, there are several important differences. Compared to paper records, most courts consider electronic records to be more voluminous, more difficult to destroy, easily modified, easily duplicated, potentially more expressive, and more readily available. As a consequence, strict new rules were enacted in December 2006 requiring the preservation and disclosure of electronically stored evidence.
Authentication of Electronic Records
Authenticating records means showing they are a reliable representation of the event recorded. With EHR systems, this means paying special attention to factors such as the reliability of the computer equipment, the manner in which the data was original collected, the measures taken to insure the accuracy of the data when entered, the methods to ensure stored data is not tampered with, changed, or destroyed, and the overall measures to verify the accuracy of the application programming. With the increased publicity surrounding all types of security breaches, data tampering, and unauthorized access to computer systems, at some point courts wills stop routinely admitting computer print-outs without questions about their overall security and reliability.
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