Every click you make, it is watching you…

When I close my eyes and imagine what it is I do for a living, I see a computer screen.

I mean, yes, I’m primarily a clinical researcher so much of what I do is looking at statistical software, or, more recently, writing grant applications. But even when I think of my clinical duties, I see that computer screen.

The reason? The electronic health record – the hot beating heart of medical care in the modern era. Our most powerful tool and our greatest enemy.

The EHR records everything – not just the vital signs and lab values of our patients. Not just our notes and billing codes. Everything – every interaction we have is tracked and can be analyzed. The EHR is basically Sting in “Every Breath You Take”. Every click you make it is watching you.

Researchers are leveraging that panopticon to give insight into something we don’t talk about frequently, the issue of racial bias in medicine. Is our true nature revealed by our interactions with the electronic health record?

We’re talking about this study appearing in JAMA Network Open.

Researchers leveraged huge amounts of EHR data from two big academic medical centers – Vanderbilt University Medical Center and Northwestern University Medical Center. All told, there is data from nearly 250,000 hospitalizations here.

The researchers created a metric for EHR engagement. Basically, they summed the total amount of clicks and other EHR interactions that occurred during the hospitalization and divided by the length of stay in days to create a sort of average “engagement per day” metric. This number was categorized into four groups – think low engagement, medium engagement, high, and very high engagement.

What factors would predict higher engagement? Well, at Vanderbilt there was less engagement with patients who identified as Black, Hispanic, or “other” race.  Similar differences were present at Northwestern, except among Black patients who actually got a bit more engagement.

So, ok, right away we need to be concerned about the obvious implications here. Less engagement with the EHR may mean lower quality care, right?  Less attention to medical issues.  And if that differs systematically by race, that’s a problem.

But we need to be careful here. Because engagement in the health record is not random – there are many factors that would lead you to spend more time in one patient’s chart versus another. Medical complexity is the most obvious one. The authors did their best to account for this, adjusting for patients’ age, sex, insurance status, comorbidity score, and social deprivation index based on their zip code. But they notably did not account for the acuity of illness during the hospitalization. If individuals identifying as a minority were, all else being equal, less likely to be severely ill by the time they were hospitalized, you might see results like this.

The authors also restrict their analysis to individuals who were discharged alive. I’m not entirely clear on why they made this choice. Most people don’t die in the hospital – the inpatient mortality rate at most centers is from 1-1.5%, but excluding those individuals could potentially bias these results, especially if race is, all else being equal, a predictor of inpatient mortality, as some studies have shown.

But the truth is, this data isn’t coming out of nowhere – it does not exist in a vacuum. There are numerous studies that demonstrate different intensity of care among minority versus non-minority individuals.  There is this study, which shows that minority populations are less likely to be placed on the liver transplant waitlist. 

There is this study, which founds that minority kids with Type 1 diabetes were less likely to get insulin pumps than their White counterparts. And this one, which showed that kids with acute appendicitis were less likely to get pain control medications if they were Black.

There is this study, which shows that although life expectancy decreased across all races during the pandemic, it decreased the most among minority populations.

This list goes on. It’s why the CDC has called racism a “fundamental cause of … disease”.

So yes, it is clear there are racial disparities in healthcare outcomes. It is clear that there are racial disparities in treatments. It is also clear that virtually every physician believes they deliver equitable care. Somewhere, this disconnect arises. Could the actions we take in the electronic health record reveal the unconscious biases we have? Does the all-seeing eye of the electronic health record see not only into our brains, but into our hearts? And if it can, are we ready to confront what it sees? 

A version of this commentary first appeared on Medscape.com.