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Standing AFFIRM

Standing AFFIRM

Another EMR Pitfall—Propagating Provider Bias

Wiesendanger, Kathryn

doi: 10.1097/01.EEM.0000734608.66717.f3
    implicit bias, EMR

    As an emergency department scribe in California, I listened to medical providers protest the intricacies of electronic medical records (EMRs) for years. I watched seasoned physicians throw up their hands in frustration, reminiscing about the good old days when they could focus on patients, not the computer.

    EMRs have been successful in addressing issues such as illegible handwriting, medication errors, and lost records, but they have significantly complicated physicians' work processes, undermining morale and contributing to physician burnout. I am now working in the Irish health care system, where most hospitals continue to utilize paper records, and I have learned about yet another potential unintended negative consequence of EMR adoption that affects our ability to care for patients: implicit bias.

    We are spoiled by the intricacies of the modern-day EMR, often so detailed that we can begin to form a differential diagnosis even before entering a patient's room. We review prior ED visits, chief complaints, medical history, prescription refill dates, and substance abuse records. This information shapes our view of the patient, often determining our approach. An unkempt 55-year-old man presenting with alcohol intoxication for the umpteenth time, for example, may be addressed differently from a 55-year-old businessman presenting with a headache.

    Focusing on social determinants of health, even subconsciously, rather than the patient's presentation can negatively affect patient care. I'll never forget that intoxicated 55-year-old man who frequented our ED. On his last visit, his confusion, drowsiness, and slurred speech were mistakenly attributed to his known chronic alcoholism, he never received a proper triage evaluation, and he subsequently died from hypothermia that would have otherwise been detected upon arrival.

    Not unlike those suffering from alcoholism, patients with mental health conditions are often affected by implicit bias in the ED. Many of the most difficult patients we see on a regular basis, whose disruptive behaviors challenge us, are products of adverse childhood experiences. By failing to acknowledge the root cause of these conditions and instead relying on EMR documentation, we fail as providers.

    Stigmatizing Language

    As I began to consider the role of the EMR in how implicit bias negatively affects patient care, I was shocked to find almost no research about this association. One paper examined the prevalence and effects of cherry-picking among EM residents in a single ED by examining the time interval between patient rooming and resident self-assignment. The authors hypothesized that more routine chief complaints would be picked up more quickly than unusual or unfamiliar ones. (Acad Emerg Med. 2016;23[6]:679; This paper didn't specifically look at the relationship between pre-interview EMR review and provider bias in patient care, but it did suggest that reviewing the EMR before seeing a patient influenced how providers perceived and predicted how a case would go.

    Another study found that stigmatizing language (e.g., “narcotic dependent,” “frequent ED visitor,” or emphasis on social factors) documented in the EMR influenced physicians in training in their patient approach and management, especially in prescribing pain relief. (J Gen Intern Med. 2018;33[5]:685; It is important to consider one's training and education in shaping the type of clinicians these trainees will become.

    Documentation about a patient's race, social status, or health literacy, for example, influences the provider's assessment and has the potential to stigmatize certain patients. We know the role that social determinants of health and health inequities play in medicine, especially in the emergency department, but how have we failed to consider the impact of EMR documentation in propagating these negative views?

    As a medical student in Ireland preparing for a career in emergency medicine, I have experienced the challenges and inefficiencies of health care on paper. We start each patient encounter from scratch, unable to view prior ED visits, investigations, or referrals unless the patient brings them along. This initially requires us to do more on the front end of each patient encounter through detailed sleuthing and comprehensive histories, but it may also add to our ability to understand and comprehensively treat the patient by diminishing the negative influence of implicit bias. Had the 55-year-old man presented without an EMR riddled with stigmatizing language, his vitals would have been checked and his hypothermia discovered.

    During my first ED rotation in Dublin, I often felt frustrated by the lack of information I was given before the patient interview, but I also felt grateful for the opportunity to practice taking a detailed patient history, performing a thorough physical exam, and creating a differential diagnosis without any preconceived notions or biases clouding my judgment.

    EMRs have undoubtedly revolutionized the accuracy and efficiency of medical care, but how much information is too much? How can we ensure adequate and appropriate information is documented while simultaneously minimizing the risk of provider bias? How can we optimize medical education so that students reap the benefits of EMRs without falling victim to the dangers of implicit bias?

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    Ms. Wiesendangeris a California native and third-year medical student at the Royal College of Surgeons in Ireland. She is dedicated to pursuing a career in emergency medicine and, as a survivor of a mass shooting, tofighting the gun violence epidemic with AFFIRM. Follow her on Twitter@k_wiesendangerand read more at

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