;)
Figure: social EM, health equity, ethnic identifiers, DEI, diversity
FigureA concrete step toward ensuring health equity is the active and accurate collection of ethnic identifiers. This has been a controversial topic for years. One school of thought believes that information about ethnicity does not belong in medical charts, while another suggests an added value. A stance of health equity encourages the latter, but not as a means to indict clinicians or other health care providers for their medical management. Instead, it is seeing downfield and considering the various ways this vital information can improve care delivery for all patients.
We often assign identifiers in our data. They are drawn from proxy sources, existing notes, and other components in the chart (i.e., 58-year-old Spanish-speaking man and the subsequent assumption that this patient identifies as Latinx). Clarification is not sought in most cases. Direct capture of ethnic identifiers removes the guessing and bridges gaps in our data collection. Most importantly, it plays an integral role in exposing our equity blind spots. The implementation of regular ethnic identity capture exposed racial health disparities related to COVID-19, for example. This went on to inform statewide strategies related to screening, resource allocation, and vaccine distribution.
One caveat: Ethnic identifiers should never be assigned. A patient should have autonomy in defining his own identity. The person capturing these data should write down exactly what that patient identifies based on the language he uses. A similar approach is used in documenting gender.
Here are three reasons we should be capturing ethnic identity in the emergency department:
Respect: Identity can be as important as a namesake. It gives insight to the culture, value systems, practices, and perspectives of an individual. The inclusion of identity is in alignment with the belief that physicians are not treating numbers or an entity but rather a complete patient. We unknowingly infringe on our patients' right to present as their full selves by excluding this element. This does not mean to augment or adjust the approach to a patient based on this information. Rather its inclusion cements that a medical chart is indeed personal.
Improvement: One of the most recent pushes within our specialty is to perform screening for social drivers of health. An important parallel to that screening would be the inclusion of ethnic identifiers. This would allow us special insight into the ways that those social drivers are affecting different populations. They also have the potential to reveal and inform strategies surrounding health disparities. Interventions that seek to improve health outcomes and reduce ethnic health disparities can be targeted based on standardized collection of this information.
Due Diligence: Precision medicine is now a guiding principle for most emergency departments, but we would be remiss not to evaluate whether those actions are equitably distributed among all patients. It is difficult to perform this evaluation with data limited to proxy measures of identity. Clinical operations teams have the potential to benefit greatly from true and accurate identifiers captured at the outset of a patient visit. Therein lies the opportunity to track equity. Consider the following questions: Are there differences in door-to-doc times? Are ESI levels assigned in a manner free of bias? Are certain groups experiencing a disproportionate amount of adverse events?
The direct capture of ethnic identifiers allows for these types of analyses, especially to better understand our own tendencies. Our biases get lost in the shuffle without having an anchor to understand them.
An argument can certainly be made that capturing ethnic identifiers could create bias formation, but biases live rent-free in our medical education and health care systems and may already be operating at a maximum. Surnames, language preferences, insurance status, flags in charts (that denote violent behavior or psychiatric diagnoses), and total ED visits (as an indicator of heavy ED utilization) all have the ability to activate implicit or explicit biases. They will flourish until we introduce measures that help us to deconstruct our biases.
The next step will be gathering consensus in the details of this process, particularly how we safely collect patient identity and who shares responsibility in collecting those details. It will be important to engage colleagues in social work, case management, nursing, and registration as stakeholders as we develop a standard approach. Working together, this data collection strategy can be operationalized and ultimately contribute to health equity in the emergency department.
Dr. Brownis an emergency physician and an assistant professor in social emergency medicine at Stanford Hospital. He is also the chief impact officer of T.R.A.P. Medicine, a barbershop-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of Black men and boys. He also served with the ABC News Medical Unit and has contributed health equity and wellness pieces to The New York Times, USA Today, GQ, and The Root. Follow him on Twitter@gr8vision. Read his past articles athttps://bit.ly/DiversityMatters-EMN.
