Medical professionals spend more time engaging with medical records of white patients.

Hospital health care professionals engage with the electronic health records of white patients more often than those of other ethnicities, according to the results of a recent study.

The retrospective, cross-sectional study provocatively suggests that differences in the level of health care professionals’ EHR engagement levels could indicate implicit bias.

“Minoritized groups may receive less attention in terms of how health professionals engage with their EHR.”

“There is no evidence of overt discrimination, but our study suggests that minoritized groups may receive less attention in terms of how health professionals engage with their EHR,” said co-author Bradley Malin, Ph.D., Accenture Professor of Biomedical Informatics, Biostatistics and Computer Science at Vanderbilt University Medical Center.

Racial Disparities in the Hospital

The study, led by senior author You Chen, Ph.D., an associate professor of biomedical informatics at Vanderbilt and reported in JAMA Network Open, analyzed EHR access log data from two major medical institutions, Vanderbilt University Medical Center and Northwestern Medicine. Combined, 243,416 adult patients were included.

The study involved patients who had been discharged after at least 24 hours of hospitalization. White patients made up the majority of the study participants, totaling 77.7 percent at Vanderbilt and 69.2 percent at Northwestern.

They compared EHR engagement rates between white patients and those of all other minorities combined.

“When combining Black, Hispanic, or other race and ethnicity patients into one group, these patients were significantly less likely to receive a higher amount of EHR engagement compared with white patients,” the authors wrote.

Patients who were self-pay were also likely to have less EHR engagement over the three-year study period, Malin said.

The adjusted odds ratios for white patients versus all minorities combined was 0.86 at VUMC and 0.90 at Northwestern Medicine.

Engagement Matters

Studies suggest that patients have better outcomes when their health care professionals engage more with EHR. Measuring EHR engagement shows how much information was documented and how often patient records were reviewed.

Frequent EHR access can also influence care by affecting the timeliness and accuracy of diagnoses, updates to medication prescriptions, and scheduled execution of treatments, wrote Malin and colleagues. Health care organizations may also use EHR data to conduct clinical research and public health surveillance.

Reasons for Less Engagement

In their study, the researchers describe several potential causes for the differences in EHR engagement:

  • Less frequent access to health care services by minority patients, leading to differences in the integrity, complexity and precision of health information recorded in patients’ EHRs.
  • Language barriers, in which communication difficulties could trigger less engagement.
  • EHR use for research data collection and to inform interventions, which may omit minority patients, who are statistically less likely to participate.
  • Unintentional or subconscious racial discrimination by health care providers.

“While we aim to rid our medical system of racial disparities,” Malin said, “it may be that white patients have a stronger affinity to large academic medical centers and therefore have more information in their medical records.”

The race of the health care provider also may play a role.

“Patients are often more comfortable with providers with shared experiences or who look like them,” Malin said. “However, in this study we did not have documentation on the race of the care providers to test if such a relationship influenced our findings.”

Breaking it Down

The next step is to focus on different areas within the hospital.

“We have not studied whether differences in engagement are related to specific sections of the hospital, for example, the ICU or surgical step-down environment,” Malin said. “Do certain types of health care lead to more EHR engagement and correlation with race?”

The research also needs to be replicated in different institutions, he said. For example, comparing community hospitals to large Tier 1 academic medical centers, or West Coast sites to mid-South institutions, could shed more light on the causes.

Malin said his message to health care providers stresses the need to remain cognizant of the potential for racial bias in healthcare.

“They may be treating different populations differently, which may be correlated with race and insurance status,” Malin said. “Our study helps us recognize that we need to do better in terms of health equity.”

About the Expert

Bradley Malin, Ph.D.

Bradley Malin, Ph.D., is Accenture Professor of Biomedical Informatics, Biostatistics, and Computer Science, as well as vice chair for research affairs in the Department of Biomedical Informatics at Vanderbilt University Medical Center. He studies technologies applying artificial intelligence and machine learning in the context of organizational, political and health information architectures.