Racial Disparities in EHR Engagement Highlight Implicit Bias Concerns

Patients from racial and ethnic minority groups were more likely to receive a lower amount of EHR engagement during inpatient stays compared to White patients, according to a study published in JAMA Network Open that draws concern for implicit bias.

The cross-sectional study analyzed EHR access log data from two major medical institutions, Vanderbilt University Medical Center (VUMC) and Northwestern Medicine (NW Medicine), over three years. The study included all adult patients who were discharged alive after hospitalization for at least 24 hours.

The quantity of EHR engagement reflects how much information providers document and access regarding the treatment of their patients.

Healthcare providers’ efforts to document and access patient EHR data could shape data quality in terms of accuracy and completeness. The quality of EHR data can influence care on several levels, such as the accuracy and timeliness of disease diagnosis, medication prescription, and treatment execution.

Additionally, healthcare organizations have increasingly used EHR data (including EHR access log data) for secondary analysis, such as clinical research and public health surveillance. If unaddressed, racial and ethnic differences in EHR engagement could impact all downstream investigations and lead to biased results, the study authors noted.

“Patient subpopulations with less EHR engagement could contribute fewer data points and less evidence reflecting health professionals’ behaviors,” the researchers wrote.

There are several possible causes for the observed differences in EHR engagement.  

First, patients in minority racial and ethnic populations have less access to healthcare services than White patients. This disparity may lead to differences in the integrity and precision of information in patient EHRs.

Second, Hispanic patients and other minority racial and ethnic groups may more commonly experience language and communication barriers, which could partially explain lower levels of EHR engagement.

“Normal care requests that were withheld from patients due to communication difficulties could have triggered less engagement from health professionals,” the study authors pointed out.

Third, healthcare organizations increasingly use EHRs in clinical research to facilitate cohort identification, streamline data collection, and serve as part of the intervention. In addition to regular EHR use, providers must routinely monitor study cohorts to ensure medication or procedure adherence. However, clinical research trials generally underrepresent minority groups, which can contribute to differences in EHR engagement.

Fourth, racial discrimination in healthcare could impact the disparity in levels of EHR engagement.

“Racial discrimination against minoritized populations may occur unintentionally or subconsciously and can manifest in various forms, such as implicit bias and stereotyping, which can lead to unfair allocation of healthcare resources,” the researchers said.

Several studies have revealed evidence of implicit racial bias among healthcare professionals. For instance, an implicit association test conducted in the Denver, Colorado, metropolitan area found that PCPs harbored unconscious biases against Latino and Black patients.

“While there is no evidence of overt discrimination, our study suggests that minoritized subpopulations may be at a disadvantage in terms of how health professionals distribute their care attention,” the authors wrote.