Racial bias seen in electronic health records, study finds

Black patients were more likely to have negative descriptions. The authors suggest bias in records could exacerbate inequities in healthcare.

Racial bias can be found in the description of patients in electronic health records, raising the potential for disparities in health outcomes, a new study indicates.

The study, published in Health Affairs on Jan. 19, found Black patients were more than twice as likely to have at least one negative description in the records.

Researchers from the University of Chicago examined 40,113 records from 18,459 patients between January 2019 and October 2020.

“​​Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities,” the study said.

Additionally, patients with Medicaid and Medicare were more likely to have negative descriptors in their records compared to those with private insurance. Unmarried patients also had greater odds of negative descriptors compared to patients who were married.

Key findings

More attention has been paid to inequity in health care among minority groups, particularly in the wake of the COVID-19 pandemic. National surveys have indicated Black patients said they have experienced discrimination in healthcare.

But the study notes that there hasn’t been much research on bias in clinical settings. The study noted stigmatizing terms such as “frequent flyer” or “sickler” are commonly used by healthcare professionals.

Researchers examined records from a large academic medical center in Chicago. The study included all patients with a history and at least one physical note in their electronic records. Roughly 60% of the patients were Black, while about 30% were white, 6% were Hispanic or Latino and the rest were categorized as “other.”

Black patients had 2.54 times the odds of having a negative descriptor, the researchers found. The most commonly used terms were “refused,” “agitated,” or descriptions indicating the patients were not compliant.

“Our findings are especially alarming because we limited our evaluation of negative descriptors to the history and physical notes of patient EHRs,” the study stated. The authors explain that the medical history and notes are frequently referenced by other care providers, so negative descriptors can be copied into notes from other providers. So it’s important for the initial patient evaluation to be done thoughtfully, the authors wrote.

“Subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” the authors stated.

The study period includes the first several months of the COVID-19 pandemic. The researchers noted that records of patients who were treated after the pandemic began were less likely to have negative descriptors.

The authors suggested the rise of the pandemic and the increasing focus on social justice in the wake of the killing of George Floyd may have led to more empathy and sensitivity from providers for members of minority groups.

What can be done

Medical institutions must work with their clinicians on understanding implicit bias and racial bias, the researchers said. For example, a clinician who describes a Black man as “aggressive” may be revealing his own inherent bias, but that descriptor can stay in the patient’s record and could influence the perceptions of other healthcare providers, even if they don’t have tendencies toward racial bias.

Healthcare providers need to train their staff on bias and the importance of using language with sensitivity in professional communications, including patient records.

Since healthcare organizations will share more electronic records in the future, it's crucial that patient descriptions don’t reflect racial bias, or other biases that could have an impact on their perception and even their treatment.

There’s another pressing reason to be more thoughtful about the language used by providers: patients can get access to their health records, including the notes. Providers should strive to ensure medical records are fully professional and without bias to avoid eroding the trust of patients and even potential lawsuits.

The study points to the need for greater emphasis on professional language standards in medical communications. Researchers suggested bodies such as the Accreditation Council for Graduate Medical Education should develop more specific recommendations on standards to be used in records.

The study also noted that expressions of bias are often symptoms of burnout, and many health professionals have struggled with burnout during the pandemic. Healthcare providers must address factors that contribute to burnout, the researchers said.

If healthcare providers tell their employees to change their behavior without addressing the stress they are experiencing, it could inadvertently compound burnout and expressions of bias, the authors stated.