EquiCare Toolkit

Overview: Biases and stigmatizing language in electronic health records (EHRs) often appear as negative physical or behavioral descriptors related to race and ethnicity. Such language can perpetuate inequalities and negatively impact patient care across providers. This tool offers practical guidance for writing EHR notes that foster patient-centered care and uphold dignity.

Casau, A., & Beach, M. C. (2022). Words matter: Strategies to reduce bias in electronic health records. Center for Health Care Strategies. https://www.chcs.org/media/Words-Matter-Strategies-to-Reduce-Bias-in-Electronic-Health-Records_102022.pdf

Abstract — Background: Clinician bias contributes to healthcare disparities, and the language used to describe a patient may reflect that bias. Although medical records are an integral method of communicating about patients, no studies have evaluated patient records as a means of transmitting bias from one clinician to another. Objective: To assess whether stigmatizing language written in a patient medical record is associated with a subsequent physician-in-training’s attitudes towards the patient and clinical decision-making. Design: Randomized vignette study of two chart notes employing stigmatizing versus neutral language to describe the same hypothetical patient, a 28-year-old man with sickle cell disease. Participants: A total of 413 physicians-in-training: medical students and residents in internal and emergency medicine programs at an urban academic medical center (54% response rate). Main Measures: Attitudes towards the hypothetical patient using the previously validated Positive Attitudes towards Sickle Cell Patients Scale (range 7–35) and pain management decisions (residents only) using two multiple-choice questions (composite range 2–7 representing intensity of pain treatment). Key Results: Exposure to the stigmatizing language note was associated with more negative attitudes towards the patient (20.6 stigmatizing vs. 25.6 neutral, p < 0.001). Furthermore, reading the stigmatizing language note was associated with less aggressive management of the patient’s pain (5.56 stigmatizing vs. 6.22 neutral, p = 0.003). Conclusions: Stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior. This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Attention to the language used in medical records may help to promote patient-centered care and to reduce healthcare disparities for stigmatized populations.

Goddu, A. P., O’Conor, K. J., Lanzkron, S., Saheed, M. O., Saha, S., Peek, M. E., Haywood, C., Jr., & Beach, M. C. (2018). Do words matter? Stigmatizing language and the transmission of bias in the medical record. Journal of General Internal Medicine, 33(5), 685-691. https://doi.org/10.1007/s11606-017-4289-2 

Abstract —  Purpose: Stigma related to mental health is well documented and a major barrier to using mental and physical health care. Integrated behavioral health (IBH) in primary care, in which behavioral/mental health care services are located within a primary care setting, may reduce the experience of stigma. The purpose of this study was to assess the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with IBH and to gain insight into strategies to reduce stigma, encourage discussion of mental health, and increase uptake of IBH care. Methods: We conducted semistructured interviews with 16 patients referred to IBH in a prior year and 15 health care professionals (12 primary care physicians and 3 psychologists). Interviews were transcribed and inductively coded separately by 2 coders for common themes and subthemes under the topic headings of barriers, facilitators, and recommendations. Results: We identified 10 converging themes from interviews with patients and the health care professionals, representing important complementary perspectives, with respect to barriers, facilitators, and recommendations. Barriers included professionals, families, and the public as sources of stigma, as well as self-stigma or avoidance, or internalizing negative stereotypes. Facilitators and recommendations included normalizing discussion of mental health and mental health care-seeking action, using patient-centered and empathetic communication strategies, sharing by health care professionals of their own experiences, and tailoring the discussion of mental health to patients’ preferred understanding. Conclusions: Health care professionals can help reduce perceptions of stigma by having conversations with patients that normalize mental health discussion, use patient-centered communication, promote professional self-disclosure, and are tailored to patients’ preferred understanding.

Phelan, S. M., Salinas, M., Pankey, T., Cummings, G., Allen, J.-S. P., Waniger, A., Miller, N. E., Lebow, J., Dovidio, J. F., van Ryn, M., & Doubeni, C. A. (2023). Patient and health care professional perspectives on stigma in integrated behavioral health: Barriers and recommendations. Annals of Family Medicine, 21(Suppl 2), S56-S60. https://doi.org/10.1370/afm.2924 

Overview: This evidence report underscores the consistent research findings on the benefits of having a usual source of care (USC), whether it’s a person or place you can rely on for health concerns—most often primary care. A strong evidence base shows that individuals with an ongoing relationship with primary care experience better health outcomes, more equitable care, and lower healthcare costs across all demographic groups. This continuity, often called the “secret sauce of primary care,” fosters trust, strengthens clinician-patient relationships, and enables providers to better understand patients’ needs and preferences, ultimately enhancing satisfaction and care quality.   

Primary Care Collaborative. (2022). Relationships matter: How usual is usual source of (Primary) Care? https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/pcc-evidence-report-2022.pdf