EHR Notes Reveal Implicit Bias and Racial Health Inequities

The Problem of Racial Health Inequities

Health disparities in America are not new, they have been a constant issue. The country’s history of racism and discrimination has led to inequities in health that continue to persist today.

The problem of health inequities is not just an American problem, but it is also an international one. A recent study published in the Lancet found that the United States has the worst record on reducing inequalities among high-income countries, with significant disparities in life expectancy and death rates by race and ethnicity.

Health Inequalities Among Blacks & Africans Americans

This year’s theme for Black History Month, “Black Health and Wellness”, looks at how American healthcare has often underserved the African American community.  Racial health disparities in the US are staggering, and the quality of care that black patients receive is far below that of white patients.

The health inequalities among African Americans are not just a result of poverty. The racism that African Americans experience in society, the lack of access to quality healthcare and the high rates of violence are also key factors.  Racism can be found in the workplace, schools, neighborhoods and even healthcare facilities. Racism has been shown to have an impact on mental health as well as physical health outcomes.

Implicit Bias

First let’s look at how implicit bias can contribute to these disparities by influencing clinical documentation, which is a major concern in the medical industry because it can lead to poor treatment.

Implicit bias is a type of bias that occurs without a person’s awareness. People with implicit biases may not even be aware that they have them. Implicit biases can lead to racial disparities in clinical interactions and decision making, as well as other social inequalities. We need to do more research on the ways implicit bias influences clinical documentation and what we need to do in order to reduce its influence on care providers.

EHR Notes Reveal Implicit Bias in Clinical Documentation

Comparing EHR notes between Black patients and White patients, Black patients were almost three times more likely to have at least one negative descriptor in their EHR notes. This raises concerns about stigmatizing language in clinical documentation and its potential to worsen racial health disparities.

According to a study published in Health Affairs, researchers analyzed 18,459 patients’ medical records and found sentences in their history and physical notes that contained negative descriptors about the patient or their behavior.

Negative descriptors included ‘resistant’ or ‘noncompliant’. The study authors stated that these and similar allusions are not explicitly stigmatizing types, but their verbiage may carry a negative connotation in the context of describing a patient.

In addition, these negative connotations may likely be copied into subsequent notes, recommunicating, and amplifying potential biases. This highlights the need and responsibility of providers who document the initial patient encounter to do so in an aware (non-biased) and sensitive manner.

The researchers stated that the potential for subsequent providers who read those notes could be affected by, and perpetuate the negative descriptors, reinforcing stigma to other healthcare teams.

It is interesting to note that after COVID-19 began, EHR notes were less likely to have a negative descriptor due to the heightened responses to racialized state violence. Yet, COVID-19 infection and mortality rates continue to highlight racial health disparities.

Addressing The Issues

To address the issues, we must get to the underlying mechanisms that encourage the use of negative descriptors to describe patients.  Interventions such as provider bias training can help educate clinicians on the use of nonstigmatizing language in clinical documentation.

Whether through awareness education or social pressures, providers are now being sensitized to racial bias and have begun documenting with increased empathy for the experiences of their patients. However, future research is needed to understand the long-term consequences and if we are truly improving patient outcomes.

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