Medical images have become an increasingly common part of medical examinations and diagnoses. It should then come as no surprise that medical images are playing a more important role in legal trials involving personal injuries, medical malpractice and sometimes criminal law. 

Medical images include those images commonly generated by X-rays, MRIs, CT scans, ultrasounds and other medical scanners. They are used at trial by both defense and plaintiff’s counsel as visual proof - pivotal in substantiating claims or defenses. Medical images include more than just a picture; they are specifically formatted digital files in a standard called DICOM (Digital Imaging and Communications for Medicine).  DICOM files include both pictures and metadata, each including a host of detailed information about the origination of the digital file.

Introducing medical images as evidence in a legal trial involves navigating complex legal and procedural requirements. This blog explores the essential steps and considerations for entering medical images into evidence in a legal trial.

Relevance and Materiality

Before medical images can be entered into evidence, they must meet the legal standards of relevance and materiality. The images must be directly related to the case and have the potential to prove or disprove a fact that is in dispute. For instance, in a personal injury case, an MRI scan showing a herniated disc may be relevant to demonstrating the extent of the plaintiff’s injuries.

When considering relevance or materiality, it is important that the image be directly connected to the facts of the case. Images may be used to prove causation, severity of a disease or injury or the discovery or progression of a condition over time. Use of the image at trial should help to clarify or substantial the claims of the plaintiff or the defenses being presented.

Authentication of Medical Images

Authentication is a critical step in the evidentiary process. The party seeking to introduce medical images as evidence at trial, must prove that the images are what they purport to be. This typically involves testimony from a medical professional, such as a radiologist or treating physician, who can confirm the origin and accuracy of the images. The metadata or DICOM tag associated with the image, may also be of value to self-authenticate the image by identifying the date, location, modality (scanner type), ordering physician and other relevant facts related to the origination of the image.

Often, to authenticate an image being entered into evidence, a medical expert can testify that the images were taken as part of the patient’s medical treatment and that they accurately depict the condition being claimed. While this may be determinative of the origin of the image, it is also important to establish a clear chain of custody, ensuring that the images have not been tampered with or altered.

Images that have had portions of its metadata altered may cause the evidence to be disqualified. This means that the metadata (DICOM) associated with an image, should never be edited prior to its introduction at trial. Similarly, images that have been compressed (a common technique that is used to make it easier to transmit or store images) may also be rejected. It is important that for anyone handling evidentiary images, that any compression used is always lossless (as opposed to lossy).  This ensures that no information is lost if compression is required.

Overcoming Hearsay Objections

Medical images often fall under the category of hearsay, a common objection to the introduction of such evidence. They are created outside of the courtroom and offered as evidence to prove the truth of the matter asserted. However, there are several exceptions to the hearsay rule that are generally relied upon to enable medical images to be admitted into evidence

Using the Business Records Exception, medical images may be offered as part of the patient's medical records. Evidence falling into this category of a business record, usually overcomes objections raised under the hearsay rule.

Similarly, Statements Made for Medical Diagnosis or Treatment, might also qualify under this hearsay exception. Assuming the images were created as part of the patient’s regular diagnosis or treatment plan, might qualify this evidence as a Statement Made for Medical Diagnosis or Treatment, and be rightfully admitted as evidence at trial.

Ensuring the Reliability of Digital Images

With advances in digital imaging, questions of reliability and potential manipulation have become more common. Knowledgeable courts may require additional steps to ensure the integrity of digital medical images, prior to allowing them to be introduced as evidence at trial.

We’ve already identified the metadata associated with a digital image as having a rich trove of information relating to how the image was created, helping to verify its authenticity. Courts may focus on these DICOM tags to ensure they authentically depict the origination of the image.

Further, if there is any evidence that the images may have undergone any processing or enhancement (including compression), expert testimony may be required to explain these modifications and confirm that they do not alter the image’s reliability.

Presenting Medical Images to the Jury

Once the medical images have been admitted into evidence, they must be presented to the jury in the most clear and understandable manner.  Often, medical images appear obscure or unintelligible to a lay jury. In order to enhance the impact of this important evidence at trial, attorneys often offer up a qualified medical expert to explain the images to the jury. 

Effective experts speak in plain English, rather than medical lingo, and highlight the relevant details and context of what these images represent. Experts often rely on enlargements of the images, supplementary diagrams or increasingly popular digital displays.  Rather than simply presenting a two-dimensional image, a digital display may enable a 3-dimensional reconstruction of an image (used for CTs or MRIs) or CINE (moving video) used for Ultrasounds or time-related imaging.

Challenges and Objections

Opposing counsel may challenge the admissibility of medical images on several grounds, such as questioning their relevance, authenticity or objecting to the qualifications of the presenting expert witness. Being prepared to address these objections is crucial for ensuring that the images are successfully admitted into evidence. Even with properly authenticated images, the court may still find that their potential to prejudice the jury outweighs their probative value. 

The Role of Advanced Imaging Techniques

In some cases, advanced imaging techniques such as 3D reconstructions or Multi-Planar Reconstruction (MPR) may be introduced. These technologies can offer a more detailed and immersive view of the evidence but may also raise additional legal challenges, particularly concerning their novelty and the need for expert testimony to explain their accuracy and relevance. Introducing the pedigree of the viewer (FDA approved for primary diagnosis is the gold standard) that is used to display these images in court, is one way to counter these types of challenges.

Conclusion

Entering medical images into evidence is a complex process that requires careful attention to technology, legal standards and procedural requirements. By ensuring relevance, authenticity, and reliability, and by effectively presenting the images to the jury using a certified viewer with a well-qualified expert, legal professionals can leverage these powerful visual tools to strengthen their cases.

For more about handling medical records during litigation, watch the webinar:
The Fast and Secure Way to Share Medical Records to Win Your Case
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