A concrete step towards health equity is the active and accurate collection of ethnic identifiers. This has been a controversial subject for years. One school of thought believes ethnicity information has no place in medical records, while another suggests added value. A health equity stance encourages the latter, but not as a means of blaming clinicians or other health care providers for their medical care. Instead, it looks down and considers the various ways this vital information can improve the delivery of care for all patients.
We often assign identifiers in our data. They are drawn from indirect sources, existing notes, and other elements of the table (i.e., a 58-year-old Spanish-speaking male and the later assumption that this patient identifies as Latinx). Clarification is not requested in most cases. Entering ethnic IDs directly eliminates the guesswork and fills in the gaps in our data collection. More importantly, it plays a vital role in exposing our equity blind spots. The implementation of regular ethnic identity capture has revealed racial health disparities related to COVID-19, for example. This then informed statewide strategies related to testing, resource allocation, and vaccine distribution.
A caveat: ethnic identifiers should never be assigned. A patient must be autonomous in defining their own identity. The person capturing this data must write down exactly what this patient identifies based on the language they use. A similar approach is used to document gender.
Here are three reasons why we should enter ethnic identity in the ER:
Respect: Identity can be as important as a namesake. It provides insight into an individual’s culture, value systems, practices and perspectives. The inclusion of identity is consistent with the belief that physicians do not treat numbers or an entity, but rather a whole patient. We are unknowingly infringing on our patients’ right to present themselves as themselves by excluding this element. It does not mean augmenting or adjusting a patient’s approach based on this information. Rather, its inclusion cements that a medical record is indeed personal.
Improvement: One of the most recent advances within our specialty is to perform screening for social factors of health. An important parallel to this filtering would be the inclusion of ethnic identifiers. This would allow us to better understand how these social drivers affect different populations. They also have the potential to reveal and inform strategies around health disparities. Interventions that aim 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 assess whether these actions are equitably distributed among all patients. It is difficult to make this assessment with data limited to indirect measures of identity. Clinical operations teams have the potential to greatly benefit from true and accurate identifiers captured at the start of a patient visit. This is where the opportunity to follow equity lies. Consider the following questions: Are there differences in turnaround times? Are ESI levels awarded impartially? Do some groups experience a disproportionate amount of adverse events?
The direct entry of ethnic identifiers allows this type of analysis, in particular to better understand our own tendencies. Our prejudices get lost in the shuffle without having an anchor to understand them.
It can certainly be argued that capturing ethnic IDs could create bias, but bias lives for free in our medical education and health care systems and can already operate at its peak. Last names, language preferences, insurance status, flags in graphs (which denote violent behavior or psychiatric diagnoses), and total number of emergency room visits (as an indicator of heavy use emergencies) all have the capacity to activate implicit or explicit biases. They will thrive until we put measures in place that help us deconstruct our biases.
The next step will be to build consensus on the details of this process, particularly how we securely collect patient identities and who shares responsibility for collecting those details. It will be important to engage colleagues from social work, case management, nursing and registration as stakeholders as we develop a standard approach. By 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 assistant professor of social emergency medicine at Stanford Hospital. He is also the Impact Director of TRAP Medicine, a salon-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of men and boys. black. He has also worked with ABC News’ medical unit and contributed articles on health equity and wellness. The New York Times, USA Today, GQ, and The root. Follow him on Twitter@gr8vision. Read his past articles onhttps://bit.ly/DiversityMatters-EMN.