Curtailing Implicit Racial Biases in Electronic Health Records
December 14, 2022
Overview
It’s well established that individual and structural racism has led to disparities in the quality of and access to health care in the U.S. Recent studies show how medical records are another avenue through which bias and discrimination negatively impact care and further perpetuate racial inequities in delivery. Some states and organizations have taken steps to prevent racial inequities from percolating within medical records by issuing recommendations, publishing guidelines, or by mandating implicit bias training for those in the health care field.
Health care providers’ detailed information about their patients’ health conditions, past encounters and treatment, family history, and clinical notes help them make informed decisions about patient care. Most providers utilize electronic health records (EHRs) to enhance the quality and safety of care by ensuring accurate and up-to-date records that can be exchanged easily between facilities to coordinate care while safeguarding the patient’s information.
Since 2003, the HIPAA Privacy Rule has provided national standards for privacy of individually identifiable health information, including the patient’s right to access to their health information. Additionally, the 21st Century Cures Act of 2016 and its final rule implementation expressly require U.S. healthcare providers to give patients immediate and free access to their EHRs, generally through online patient portals. Open access to patient health records provides new insights to implicit discrimination in health services.
It is well established that individual and structural racism led to disparities in the quality of and access to care in the U.S. Recent studies show how medical records are another avenue through which bias and discrimination negatively impact care and further perpetuate racial inequities in delivery. For example, providers’ explicit language describing patients as “difficult” or “noncompliant” or subconscious use of “quotes” could indicate the provider doubted the accuracy or legitimacy of a patient’s self-reported symptoms.
As U.S. researchers found in three distinct studies in 2021 and 2022, these linguistic features and other negative indicators proliferate Black patients’ clinical notes at notably higher rates than White patients. A meta-analysis published in the Journal of National Medicine in 2009 found that patients with sickle cell disease (which disproportionately affects persons of African descent) frequently being treated with suspicion when discussing their pain. Black women are at particularly high risk of being disbelieved compared to other patients, which may contribute to racial disparities in U.S. maternal and infant mortality.
To the extent that EHRs allow providers to easily import previous notes and information into patients’ future documentation, potential biases from prior encounters are perpetuated. They may be “passed on” to other providers who later treat the patient. Providers may be more likely to misdiagnose or withhold effective care from patients based on biases in the data. Additionally, the provider-patient relationship may be impacted by patients’ access to full clinical records if patients feel offended or judged after reviewing the content of their providers’ notes. As researchers found in a 2004 study published in the Journal of Family Practice, roughly 10 percent more patients who reported being treated disrespectfully by doctors (with larger proportions of Black, Latin, and Asian patients reported being treated with disrespect or unfairly, or would have received better care if their race had been different) did not follow medical advice or delayed seeking further treatment than patients who did not report feeling disrespected.
Some states and organizations have taken steps to prevent racial inequities from percolating within medical records. Faculty at the University of Washington School of Medicine and Harvard School of Medicine proffered detailed recommendations in 2016 on how to document clinical notes that would be the most beneficial to a strong provider-patient relationship, including using supportive language and directly and respectfully addressing concerns.
Last year, the American Medical Association’s Center for Health Equity provided guidance on using health equity language to further awareness of the harmful health consequences of some common phrases, such as avoiding use of certain adjectives (vulnerable, marginalized, high-risk) and “dehumanizing” language. States including California, Maryland, Michigan, Minnesota, and Washington, mandate implicit bias training for certain health professionals to help them recognize their own unconscious thoughts arising from harmful racial biases.
Reaching accord on what providers’ clinical notes may or may not include is not easy. Eliminating harmful language is key, but it should not discourage providers’ use of subjective language that may validate information in the patients’ EHR supporting the provision of appropriate care. At balance are the legitimate need for accurate clinical notes and avoidance of language and linguistic features that may further racial inequities in health care delivery. Promoting the public’s health through appropriate health care services based on non-biased clinical observations and findings is the end goal.
This post was written by Cleo Goeckner, Legal Researcher, and Erica N. White, J.D., Senior Attorney, Network for Public Health Law – Western Region Office, at ASU’s Sandra Day O’Connor College of Law.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document do not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not represent the views of (and should not be attributed to) RWJF.