Epic Bias: Institutionalization of Racism in the Electronic Health Record

Introduction: This case aims to have learners 1) identify the role that the electronic health record (EHR) has in perpetuating racism 2) describe how children of color are overrepresented within the child welfare system and 3) employ strategies to minimize the perpetuation of biased documentation that may contribute to this racial disproportionality.

Case Description: A young Black patient with severe persistent asthma presented to urgent care for respiratory distress. The pediatrician recommended immediate transport to the Emergency Department (ED). The patient’s mother agreed to bring the child to the ED after picking up her other children from school, but the pediatrician warned against any delay. The mother expressed concern that the physician would file a child protective services report regarding the delay, but that the school would also file a report if she did not pick up her other children, since she just regained custody. The pediatrician ultimately filed a report for medical neglect. Since then, documentation of child protective services involvement and parent “escalation” appears throughout the patient’s chart, notably in flagged care coordination notes.

Discussion: Providers review the EHR prior to seeing patients to increase efficiency. The tradeoff is that initial impressions from the EHR may be at odds with a patient’s true narrative, risking perpetuation of biases. This case sparks a discussion about 1) testimonial injustice in the EHR, 2) institutional impact of biased documentation, and 3) structural racism within child welfare. Testimonial injustice refers to decreased credibility conferred to a patient based on pre-existing prejudice; it often manifests in biased documentation and occurs more often in charts of Black patients than white patients. Documentation in our patient’s chart emphasized, particularly through flagged documentation, medical neglect, parent escalation, and missed appointments rather than the lack of social support and barriers to housing and safety that played central roles in her life and disease course. In understanding the institutional impact of biased documentation, we explore structural racism within child welfare. While child welfare initially evolved with poverty alleviation programming, over time, surveillance for abuse and neglect cases increased and poverty alleviation policies declined. This occurred with racial disproportionality: children of color are overrepresented within the system, particularly in reports filed by mandated reporters. Documentation, therefore, is a likely pathway through which racial bias may become institutionalized, further perpetuating racial disproportionality in systems like child welfare.

Conclusion: The EHR can perpetuate and institutionalize bias. At an individual level, we encourage providers to learn about testimonial injustice, bias, and structural racism and be mindful about how their documentation can sustain and condone structural racism. Institutionally, we encourage formal anti-racist documentation training for all providers and standardized utilization of care coordination notes or patient flags in the EHR.