Hospitals and healthcare provider facilities are facing a new conundrum regarding the retention and location of data generated during the course of treating a patient.  In Griffith v. Aultman Hosp., Slip Opinion No. 2016-Ohio-1138, issued this week by the Ohio Supreme Court (click here to view the opinion), the Court ruled the state law definition of “medical record” is not limited to the data maintained in the provider’s medical records department, and the physical location of where the data is stored does not determine if the data qualifies as a medical record.  The 5-2 majority opinion reversed a Fifth District Court of Appeals decision that limited the information to what was maintained by Aultman Hospital’s medical records department.

At the center of this case is whether data captured and stored on a cardiac monitor, including the print out of cardiac-rhythm monitoring strips, is part of the patient’s medical record if that data was not provided by the nursing staff to be included in the patient’s medical record, which in turn, was “maintained” by the medical records department.  Following her father’s death, Gean’a Griffith requested medical records from Autlman Hospital.  The hospital produced the records maintained in its medical records department.  Ms. Griffith made a follow-up request for the complete medical record.  The hospital again produced the records maintained in the medical records department.  Then, Ms. Griffith filed a lawsuit in Stark County Common Pleas Court alleging the hospital was not producing the complete record, specifically referencing the failure to produce the cardiac-rhythm monitoring strips and nursing records.  The hospital then produced hard copies of the cardiac monitoring data as part of the litigation request but characterized them as “not part of the medical record.” 

Relevant Case Background

At Autlman Hospital, monitoring strips are typically received by the department and are made part of the patient’s medical record.  Additionally, the cardiac monitor data is electronically stored for 24 hours after a patient is discharged and then deleted unless a physician orders it to be saved. Mr. Griffith’s printouts were not part of his record, however, because the nursing staff did not provide them to the medical records department.  But, further discovery revealed that the strips were printed out by the hospital’s risk management department shortly after Mr. Griffith’s death.  According to the hospital in its motion for summary judgment, because the strips were printed out by the risk department and never provided to the medical records department, the strips were not part of the patient’s medical record. 

Summary judgment for the hospital was granted, finding it produced all of the medical records as defined by R.C. 3701.74(A)(8). On appeal, the Fifth District affirmed the ruling by a 2-1 vote, finding only the information the provider decides to “maintain” in the medical records department is a medical record, and records kept by other departments, such as risk management, are not. The appellate court held that, under R.C. 3701.74(A)(8), documents maintained by any other department, including risk management, “do not meet the definition of a medical record because they were not ‘maintained’ by the medical records department.”  The Ohio Supreme Court disagreed and reversed.

Supreme Court Ruling and Analysis

In the majority opinion written by Justice Sharon L. Kennedy, the Court considered the definition of “medical record” as it is used in R.C. 3701.74 (A)(8).  The majority concluded that, because the Ohio General Assembly did not limit the definition of  “medical record” in R.C. 3701.74 (A)(8) to data in the medical records department, the physical location of the data is not relevant as to the determination whether the data qualifies as a medical record.   The focus is whether a healthcare provider made a decision to keep data that was generated in the process of the patient’s healthcare treatment and pertains to the patient’s medical history, diagnosis, prognosis, or medical condition.  Therefore the Court held that for purposes of R.C. 3701.74(A)(8), “maintain” means that the healthcare provider has made a decision to keep or preserve the data.  The Court reversed the judgment of the Fifth District Court of Appeals and remanded the matter to trial court to determine whether the hospital met its burden on a motion for summary judgment to show it had produced the entire “medical record” in accordance with the Supreme Court’s decision.

In a dissenting opinion, Justice Terrence O’Donnell noted that, because the cardiac monitoring records were generated and maintained by the hospital’s risk management department, they were not records used in the patient’s healthcare treatment and are not medical records as defined by law.  “The legislature could have mandated that health care providers maintain and produce all patient data generated for any purpose, but it did not do so. Rather, it particularly specified that medical records are those generated and maintained by a medical provider in the process of the patient’s health care treatment,” he wrote.  Because the monitoring strips were generated following Mr. Griffith’s discharge, Justice O’Donnell believes the records did not meet the plain language definition of “medical record” under the statute. 

Justice Judith Ann Lanzinger also dissented stating that she would have dismissed without a decision on the medical records issue because the wrongful death claim had been settled between the parties.  She wrote that the judgment of healthcare providers must be relied on, and they are best able to determine what information is relevant to a patient’s treatment.  She wrote that the language of R.C. 3701.74(A)(8) “implies that it is within a hospital’s discretion, through its employees, to select, preserve, and store records relevant to the health care provider of a particular patient in the manner it sees fit.” 

Impact to Healthcare Providers

Healthcare providers should pay special attention to this ruling, as it could alter the manner in which medical recordkeeping processes and procedures are implemented.  Most importantly, this decision should cause healthcare providers to pay special attention to the information gathered by risk management departments.  Moreover, this decision may create new avenues of litigation in medical malpractice cases for plaintiffs who may speculate regarding the scope of available medical records, and who want to improperly seek the contents of a risk management file.