Study: Evidence of Racial Bias Found in EHR Notes

Key Insights

• A new study found that clinicians are more likely to use negative descriptors for Black patients
• The study analyzed more than 40,000 “history and physical notes” in an electronic health record (EHR)
• The number of negative descriptors for Black patients doubled that of white patients

Racial Bias Evident in EHR Records

In January 2022, Health Affairs published a study finding that Black patients had “disproportionately higher odds of negative patient descriptors appearing in the history and physical notes of their EHRs compared with white patients.” The study used natural language processing to analyze more than 40,000 EHR records from more than 18,400 patients at an unnamed academic medical center to “investigate whether providers’ use of negative patient descriptors varied by patient race or ethnicity.”

The study notes that it’s not uncommon for clinicians to describe a patient as “difficult,” although the word could mean any behavior that a particular provider deems “difficult.” However, such words and synonyms may “impart a negative connotation in the context of describing a patient.” This study defines “negative descriptors” as words that portray “patients as difficult” or stereotype them “on the basis of race or social class.”

Of the patients whose records were reviewed, 31 percent were white, 60.6 percent were Black, 6.2 percent were Hispanic or Latino, and 3.5 percent identified as “Other.” The study showed that, even after adjusting for sociodemographic and demographic characteristics, Black patients were 2.54 times more likely to be referred to with one or more negative descriptors in EHR records than white patients. The negative descriptors most commonly found were “refused,” “non-adherent,” “non-compliant,” and “agitated.” In addition to race, patients who used Medicaid, did not have health insurance, or weren’t married also had “higher adjusted odds of a negative descriptor” than their counterparts.

The Effect on Patient Care

It may be impossible to correlate the use of negative language with a clinician’s beliefs, but the study’s researchers believe that words with negative connotations used to describe Black patients in these EHR records are evidence of implicit bias. These descriptors may have far-reaching health implications because they can impact the beliefs and attitudes of other members of the patient’s care team. Patients who perceive stigmatization and discrimination from their providers are less likely to return for annual visits, follow through with care plans, get vaccines, or get cancer screenings.

The study calls for increased intervention in the aspects of care delivery models that contribute to physician burnout, which has been linked to “greater explicit and implicit biases among resident physicians.” Interestingly, researchers for the Health Affairs study found fewer instances of negative descriptors in outpatient settings. Further research is needed as to why this is the case, but the study highlights the reason may be the care delivery model. Providers in inpatient care settings are prone to “stressful clinical environments characterized by time pressure, increased cognitive burden, and decreased resources,” and are more likely to use negative descriptors and stereotypes as “cognitive shortcuts.”

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