Vargas v. Lee

What happened

Jose Vargas underwent foot surgery and subsequently brought a medical malpractice claim. Vargas sought production of the full audit trail from the defendant's electronic health record system, the system-level log that records when each entry was created, accessed or modified, and by which user account. The trial court declined to compel production. The Appellate Division, Second Department reversed, issuing what it identified as a case of first impression for New York appellate courts: EHR system audit trails are discoverable in medical malpractice actions and must be produced. The decision established as binding authority the principle that the displayed EMR record alone is insufficient: parties are entitled to the underlying audit trail, which may reveal when entries were actually created versus when they are shown to have been created. The ruling has since been cited in multiple subsequent cases and academic publications on EHR metadata in litigation.