Research: 7 Strategies for Documentation Practices to Improve Equity in Patient Care.

Published in the New England Journal of Medicine, our team’s research identified seven strategies to support antiracist documentation policies and improve equity in clinical encounters.

Documentation is an essential and time-consuming part of modern healthcare, shaping how providers and patients interact and influencing critical treatment decisions. Our research, a collaboration between Georgetown University and MedStar Health published in the New England Journal of Medicine, identifies strategies to support antiracist documentation practices and improve equity in clinical encounters.

Documentation, which is almost always a part of a patient’s Electronic Health Record (EHR), plays many important roles, including:

• Communicating medical decisions
• Determining reimbursement
• Educating trainees
• Recording essential clinical data

A patient’s record isn’t just a place for the clinician to keep notes; it’s an influential part of treatment decisions. A 2018 study found that documentation can communicate bias between providers. Exposure to stigmatizing language in records, the study found, was associated with more negative attitudes toward the patient and with less aggressive management of the patient’s pain.

Moreover, documentation is a huge part of healthcare providers’ time. A 2017 study of residents’ work time found that more than 50% was spent using a computer, and more than half was spent on documentation. By comparison, the study found residents spent less than 10% of their time interacting with patients.

Documentation is influential and universal within medical encounters, so our team set out to understand how documentation of race, specifically, impacts care and recommend practices supporting antiracism – the active process of identifying and dismantling racism.

Confronting biological and cultural stereotypes.

Race is often recorded in documentation without apparent reason, lacking the social context important for treatment. Instead, reflexively documenting a patient’s racial category can perpetuate racist myths that suggest people have biological differences based on the color of their skin.

It’s crucial to confront biological and cultural stereotypes. For example, evidence shows that the commonly held stereotype that Black patients have a higher tolerance for pain than their white counterparts is harmful to patients. But biases aren’t always so obvious. Implicit or unconscious bias can lead to discriminatory behaviors, too.

We all have implicit biases from our experiences, upbringing, and preferences. Acknowledging these biases is critical to working against the negative impacts of inequity in patient care. Conversations about spotting and stopping it are one way to disarm bias.

In addition to implicit bias, clinicians often confuse the relevance of race and geographic ancestry. While information about geographic ancestry can be pertinent to certain genetic predispositions, race is not a genetic category.

Related reading: Walking the Walk: How MedStar Health Research Leads to Action on Patient Safety.

Seven strategies for antiracist documentation.

It’s no secret clinicians are busy, and staffing shortfalls make implementing change even more challenging. Yet, we believe changing documentation habits can be accomplished efficiently and make a real difference for patients.

1. As a reader, question the relevance of race.

When reading a medical chart, providers should consider the relevance of race when it appears in documentation. Race is often included in the opening of the history of the present illness, known as the one-liner. This means anyone reading the documentation learns a patient’s racial category (for example, “Black”) before learning anything else about them. This practice is often unnecessary and can impact treatment decisions, even among well-intentioned clinicians.

2. Allow self-identification when needed.

When a patient’s identity is relevant to their care, clinicians should allow them to disclose their racial identity or ancestry as appropriate for documentation. Racial identity is not a natural fact; it is often recorded this way, as providers categorize patients based on their appearance. Instead, allowing patients to identify themselves can reveal fundamentally different information, such as social, cultural, familial, and political affiliations.

3. Ask about patients’ experiences of racism.

Clinicians can inquire directly about and document patients’ experiences of racial discrimination and other racism-related factors when deemed relevant. Conversations about race can be critical when addressing mistrust and hesitancy with healthcare engagement. Tools such as the structural vulnerability assessment tool and the cultural formulation interview can help facilitate these vital conversations.

4. Remove race from the one-liner.

Clinicians should avoid using race in the one-liner, the brief opening section of the medical record, which can steer readers away from critical reflection in favor of cognitive shortcuts. Race should be documented in appropriate sections if it is relevant to patient care. For example, in these “social history” sections, providers can include social, historical, and cultural information details.

5. Ask about social needs directly.

Clinicians should ask about and document health-related social needs rather than using race as a proxy for social or economic factors. To provide high-quality care, it’s critical to avoid race-based medicine practices like assuming social risk based on skin color. Instead, asking patients about their social needs can allow care providers to understand the full context of risks (such as lack of access to healthy food) and protective factors (such as a solid social support system) influencing health.

6. Foster patient choice in incorporating identity.

Clinicians should work with patients to choose how their identities and perspectives are incorporated. Traditionally, only clinicians decide what is included in the medical record. Empowering patients to select and incorporate their perspectives and disclosing the intended purpose of documenting identity information can help shift toward antiracist practices.

7. Routinely practice debiasing strategies.

Besides identifying a racial category, bias can be communicated in documentation in multiple ways. For example, Black patients’ race is cited more often than others, and clinicians are more likely to use negative words to describe personality, like “aggressive,” “angry,” or “non-compliant” in these patients’ records. Clinicians should also avoid using judgmental words that might cast doubt on a patient’s subjective experience; for example, a statement such as the patient “apparently” is having a side effect can cast skepticism regarding the legitimacy of the patient’s complaints.

It’s important for individual clinicians and health systems leaders to regularly examine their use of language and patient labels for implicit bias that could influence colleagues’ expectations about a patient and diagnostic and treatment decision.

Related reading: Research Commentary: Black Students’ Mental Health Suffers From School Policing and Policies.

Implementation: Education and accountability are essential.

There isn’t an easy answer for implementing the abovementioned strategies to root out racism in documentation practices. True systemic shifts will take time, resources, and leadership committed to building longstanding change.

Two primary methods that can help are education and accountability.

It is critical to reform how we educate healthcare professionals about race, racism, and its impacts on patient health. Over time, a new generation of clinicians can dismantle policies and practices that support racist mythologies. But change is needed now.

Accountability is one way to bring an antiracist mission to the fore. Staff at all levels care about how their supervisor evaluates their work and whether they meet expectations. Faculty evaluations can be revised to include questions related to antiracist documentation, participation in trainings that focus on cultural humility, and contributions to an environment of antiracism.

Documentation is just one part of how race inequitably influences patient care. Wait times, triage mechanisms, and hiring practices are all areas where antiracism frameworks can be applied to benefit patients. We hope this publication will be part of a broader conversation that will help spark more dialogue about examining our biases and implementing policies and practices to improve the patient experience and support community health.