Electronic medical records as legal evidence in Indonesian healthcare disputes: A review of authentication, confidentiality, and evidentiary challenges

Abstract

Introduction: The nationwide implementation of electronic medical records in Indonesia has transformed clinical documentation into a digital legal artifact. Although electronic medical records improve continuity of care and administrative efficiency, their use as legal evidence in healthcare disputes raises complex questions regarding authenticity, confidentiality, integrity, and evidentiary reliability. This review aims to analyze the legal position of electronic medical records as evidence in Indonesian healthcare disputes, with particular attention to authentication, confidentiality, audit trails, chain of custody, and practical evidentiary barriers.

Methods: A normative-juridical narrative review was conducted by synthesizing Indonesian health law, electronic information law, personal data protection law, procedural law, and scholarly literature on electronic health records, digital evidence, cybersecurity, and health data governance.

Results: Electronic medical records have a legal basis as electronic documents and may support civil, criminal, administrative, ethical, disciplinary, and insurance-related proceedings. Their probative value depends on reliable electronic systems, user-specific authentication, certified electronic signatures, immutable audit trails, accurate timestamps, metadata preservation, confidentiality safeguards, and controlled extraction procedures. Current Indonesian regulation provides a strong normative basis, but operational gaps remain in system certification, shared-account prevention, forensic readiness, interoperability, and medico-legal disclosure protocols.

Conclusion: Electronic medical records can function as important legal evidence in Indonesian healthcare disputes. Their evidentiary strength requires integrated governance that combines legal compliance, clinical documentation discipline, technical security, and ethical protection of patient confidentiality.