Why medical record review is the biggest hidden bottleneck in medico-legal work

As a consultant neurologist working in clinical practice and as an expert witness, a significant part of my work involves reviewing medical records in detail.

Once I have been instructed to provide an expert opinion in any personal injury or clinical negligence matter by a firm of solicitors, there is a need to understand the chronology of events clearly. Understanding what happened, when it happened, and how those events relate to one another is essential before any opinion can be formed; whether on breach of duty, causation or prognosis.

In straightforward cases, this process can be relatively quick and painless, but the reality is that the record review for claimants who have suffered serious or catastrophic injuries, or those with complex medical backgrounds that pre-date the index event, is usually anything but straightforward.

The reality of modern medical records

In many medico-legal cases today, the sheer volume of documentation that needs to be reviewed can be a considerable hurdle. It is not unusual for me to be asked to review 2,000–4,000 pages of records, and in rare cases I’ve been asked to review bundles exceeding 12,000 pages. Fortunately, it has been a few years since I have had to receive the boxes of lever arch files containing medical records that used to overtake my offices when I first started out in medico-legal practice. But, nonetheless, even electronic records, although more accessible, present their own challenges. Often, the information is fragmented, sometimes repetitive, occasionally incomplete, and regularly formatted in ways that demand careful interpretation. The task of reviewing medical records, therefore, extends beyond simply reading the material; it requires extracting meaningful information from a complex and disorganised collection of documents.

The work behind the opinion

What is less visible to those outside the process is how much work is required before any formal report is written.

For most experts and legal professionals, this involves:

• Reading through large volumes of unstructured material
• Identifying relevant clinical events
• Establishing a reliable timeline
• Cross-referencing entries across different sources
• Distinguishing between material and non-material information

Only once this groundwork has been completed can the meaningful analysis begin. This process is time-consuming, and it requires sustained concentration. Much of the effort at this stage of the process lies in extracting and organising information, rather than in applying specialist clinical or legal judgement.

The hidden bottleneck

In my experience, this stage of the workflow is one of the most significant bottlenecks in medico-legal practice. Typically, it delays:

• Experts forming opinions
• Solicitors assessing the merits of a case
• Strategic decisions being made

In complex cases, it can take many hours, sometimes even several days, before the factual chronology is sufficiently clear to proceed to forming a clinical opinion; this is simply a reflection of the scale and nature of the task.

Is this still sustainable in the long term?

What I have seen over the past 25+ years working within the NHS is that medical record volumes have only continued to rise, as advances in medical practice result in more frequent and detailed investigations of symptoms, and healthcare providers are required to produce more documentation from clinical encounters.

Meanwhile, patients have also become more mobile and often move their care between different NHS providers. As a result, records are frequently dispersed across multiple systems, and as yet, the NHS has still not succeeded in solving the problems of medical record migration.

At the same time, medico-legal work faces tighter time and cost constraints, faster turnaround expectations, and more complex cases. In this context, workflows that rely on manual information extraction and organisation will, in my view, become increasingly unsustainable.

Where technology has (and hasn’t) helped

There have been improvements in how medical records are stored and accessed. Electronic records have made documentation more available, and digital bundles have replaced paper in many settings. However, accessibility is not the same as usability. The fundamental tasks of reading, extracting, organising, and interpreting medical records remain largely unchanged. In that sense, the majority of medico-legal work still relies on processes that have not evolved significantly, despite the dramatic increase in data volume.

A shift that feels increasingly necessary

In other areas of law, similar challenges have led to the adoption of new approaches. Electronic disclosure transformed how large document sets are managed in commercial litigation. What was once a manual, labour-intensive process is now supported by structured tools that assist with searching, filtering, and reviewing large volumes of information.

Medical record review may be approaching a similar point. The aim will not be to replace professional judgement. That remains central. But there is a growing recognition that the way we interact with large volumes of information may need to change.

A practical perspective

From a clinical and medico-legal standpoint, the most valuable work will always lie not in locating information, but in applying deep specialist knowledge and experience in interpreting it.

Understanding the significance of a clinical decision, assessing whether there has been a delay in diagnosis, evaluating the likely trajectory of a condition — these are the tasks that require expertise and experience.

If more of the preliminary work of organising and structuring information could be made more efficient, it would allow medical expert witnesses to focus more of their time on those higher-value activities.

Looking ahead

Medical record review will always be a central part of medico-legal practice. That is unlikely to change. What may change is how that review is conducted.

As the volume of data continues to grow, and as expectations around efficiency and turnaround increase, there is a clear need to consider how workflows can evolve to better support both the medical and legal professionals working in this space.

Within the current model, highly skilled individuals are spending large amounts of time extracting and organising information manually. While this approach has served the profession well, it is placing workflows under increasing pressure. Recognising that pressure is the first step.

Final thought

In many ways, the challenge is not a lack of expertise. It is the volume of information that expertise must be applied to. The question, therefore, is not whether medical record review is important — it clearly is, and always will be.

The question is whether the way we approach it today is the most effective way to do so in the future.