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Racial Disparity in ED EHR Behavioral Flags Draws Implicit Bias Concerns

ED clinicians were more likely to use EHR behavioral flags for Black patients than White patients, which could have implications for implicit bias.

Black patients received EHR behavioral flags at a rate of 4.0 per 1000, while White patients received flags at a rate of 2.4 per 1000, according to a study published by JAMA Network Open that draws concerns for implicit bias.

The study analyzed ED visits across a large urban academic health system to investigate physician use of EHR behavioral flag notifications, which aim to alert clinicians of potentially unsafe or aggressive patients.

Patients with a behavioral flag in the EHR had longer wait times and were less likely to undergo laboratory testing and imaging.

There is a growing body of research on the intersections of structural racism and EHR use. For example, a 2022 study found that Black patients were 2.54 times more likely to have at least one negative descriptor in their EHR notes compared to White patients 

“Behavioral flags may represent another aspect of the EHR that could contribute to racial and ethnic disparities in outcomes and requires exploration,” the study authors wrote. “As these alerts become part of the EHR, it is important to continuously review the duration of the flag placement and appoint oversight to have flags reevaluated for content, validity, and duration.”

The study authors noted that despite reports of high rates of violence against ED staff, clinicians did not use EHR behavioral flags commonly, with just 0.3 percent of patients having flags.

“This may suggest a lack of reporting workplace violence or low perceived benefit in placing the flag,” the researchers said.

The study has some limitations. Since it was a retrospective cohort study conducted in an academic, urban health system, its findings may not generalize to other care settings.

Additionally, the authors noted that the study did not include data on who was placing the flag or more detailed insights on why the flag was placed, although this is a focus of future work.

“Understanding why and when flags are placed remains understudied in clinical environments, and future studies may explore who is placing flags, their reasoning or motivations, the effectiveness of flags in curtailing ED workplace violence, and the systems in place to oversee flag placement,” they added.

“Outcomes recorded in EHR data may also not fully capture the patient experience influenced by placement of a behavioral flag, such as increased microaggressions from staff primed to think of a patient as disruptive,” the researchers said.

Lastly, the researchers excluded visits related to sickle cell disease in the study, as this diagnosis may cause multiple ED visits and predominately impacts Black patients.

While excluding sickle-cell–related visits was necessary to enhance comparability, the analysis may understate the size of the racial disparity in flag placement, the authors said.

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