Who is the fault of a baby girl who died from suffocation after being born for ten hours? Appraisal engineers explore the truth

After waiting for more than 10 hours of childbirth in the hospital, the doctor performed a cesarean section on Huang Ran, but the baby girl who gave birth died due to severe suffocation. Afterwards, Huang Ran believed that the hospital was delaying treatment and also suspected that doctors had artificially tampered with electronic medical records, so he sued the hospital to court.

Recently, Lu Qimeng, an electronic data engineer at the Judicial Appraisal Science Research Institute, told reporters from the Legal Daily about the appraisal case she handled more than 4 years ago.

Back then, the Judicial Yuan received a commission from the court to verify the authenticity of the electronic medical records involved in the Huang Ran case. Electronic data engineer Lu Qimeng and her colleagues became the appraisers of this case.

Afterwards, the appraiser went to a small town in Guangxi Zhuang Autonomous Region to retrieve medical record data and uncovered the truth about the tampering of electronic medical records.

The case can be traced back to May 3, 2018, when Huang Ran, who was 40 weeks pregnant, was admitted to a hospital in a certain city in Guangxi for childbirth. At 6:10 the next day, Huang Ran entered the delivery room, but due to an incorrect fetal position causing difficult delivery, she was sent to the operating room for a cesarean section at around 8:30 pm that evening.

At around 10 pm that evening, the baby girl born to Huang Ran was unable to breathe on her own and was rescued by the hospital. But on the morning of May 5th, the baby girl died due to severe suffocation.

Huang Ran said that despite knowing the fetal position was not correct, the hospital delayed the cesarean section for 4 hours, which directly led to the severe suffocation of the baby girl and her death. The hospital should bear the responsibility for this.

In addition, 10 days later, when Huang Ran's husband went to the hospital to request a photocopy of medical records, he was politely refused and only received a small portion of the medical records, including discharge records. Until June 28, 2018, the medical records of Huang Ran's treatment were fixed and sealed.

Huang Ran sued the hospital in court, and his lawyer suspected that the medical records provided by the hospital were no longer original and were likely to be tampered with by humans.

In response, the hospital stated that there were no cases of misdiagnosis or mistreatment, and claimed that after discovering that Huang Ran's second stage of labor had stagnated on the same day, the hospital recommended a cesarean section to end the delivery and informed the family. The newborn has severe asphyxia and is quite critical. The hospital has explained the relevant conditions to the mother's family and suggested transferring to a higher-level hospital for further treatment. However, the family has given up the opportunity to transfer to another hospital for treatment.

Both doctors and patients have their own opinions, and whether electronic medical records have been tampered with has become the biggest controversial focus of this case. However, it is difficult to fully mine electronic medical record data, and the mined data is cumbersome and tedious, making it extremely difficult to organize. Currently, there are very few institutions in China that have the ability to carry out this appraisal. Therefore, the judge traveled thousands of miles to the Judicial Yuan located in Shanghai to seek help, hoping to provide professional appraisal opinions.

After understanding the background of the case, after multiple communications and confirmations with the judge, dozens of medical records including daily medical history records, surgical records, and female infant death records were finally identified as the main objects of identification.

In April 2019, the appraiser went to a small town on the southwest border and, with the witness of the judge and both parties, retrieved the front-end and back-end data of patient and female baby treatment from the hospital's medical record system. Then return to Shanghai and immediately carry out subsequent data processing and analysis work.

"The inspection items mainly include the traceability function of the front-end system, the data version reflected in the front-end system, the creation time, modification time, completion time in the back-end system data table, and the saving time of the superior's approval." Lu Qimeng said that through inspection, they found that in the hospital's electronic medical record system, the system only leaves traces when non record creators modify the medical record, while the system does not leave traces when the medical record creator modifies it.

This also means that the electronic medical record system only records the time when the medical record creator made the last electronic signature and the time when the last modification was saved, but cannot determine the content that was previously modified by the medical record creator.

After inspection, it was found that out of the 35 medical record records of Huang Ran and her newborn, there were two records created later than the title time and exceeding 24 hours, 28 records completed later than the creation time and exceeding 24 hours, and two approval records were saved later than the completion time and exceeding 24 hours.

Based on this, although the appraiser was unable to determine the content of the modification, they objectively made an appraisal opinion based on relevant evidence and norms.

The final court accepted the appraisal opinion and found in the first instance that the hospital had modified the electronic medical record without authorization, and was responsible for all compensation, compensating the family members with more than 370000 yuan. The verdict of this case has attracted widespread attention from all sectors of society and has become the first case in Guangxi Zhuang Autonomous Region to bear full responsibility for medical compensation for tampering with electronic medical records.

In recent years, there have been constant disputes between doctors and patients, and whether to tamper with electronic medical records has become a focal point of controversy. The demand for data authentication in electronic medical records is growing day by day.

"The data system of general hospitals has a self risk protection function, and it is difficult to find evidence at the left traces. In this case, we need to study whether the medical record records are logical. For example, if the patient died in the evening and the data records show that the doctor had a physical examination in the latter half of the night, or if some data, although logical, does not comply with medical regulations. For example, some medical regulations require that the record must be completed within 6 hours and the medical record must be submitted within 48 hours after completion, but the actual completion and submission time is greatly delayed." Lu Qimeng said.

With the popularization of information technology construction in the medical field, software development can be described as diverse, with vastly different data formats, transmission ports, and system compatibility. There are also multiple subsystems developed by different manufacturers that are interconnected or developed in a secondary manner. The complexity of the system, the diversity of data, and the difficulty of identification can be imagined.

At the same time, in practical operation, doctors may have text errors in medical records, or there may be errors when others view medical records, which need to be modified and saved again. If the hospital's electronic medical record system cannot fully record and prove these modifications, there is a possibility and suspicion of tampering, and the risk of medical institutions bearing infringement liability will greatly increase.

Based on this, Lu Qimeng suggests that hospitals should further improve their medical record systems. They should not only save modification records, but also record the content of the modifications. At the same time, they should strictly follow operating standards to prevent arbitrary modification and submission of data. Only in this way can doctors fill out electronic medical records more reliably and reduce medical disputes.