This paper, titled “Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters,” investigates how healthcare systems, despite efforts to address social determinants of health (SDHs), may inadvertently exacerbate existing health disparities. The authors, Jennifer M. Silva, T. Elizabeth Durden, and Annemarie Hirsch, published this work in Social Science & Medicine, volume 323, with the article ID 115837, in 2023.
The research addresses a critical gap in existing literature by comparing both clinicians’ documentation in Electronic Health Records (EHRs) and patients’ own narratives of clinical encounters. While current policy encourages integrating patients’ SDHs into EHRs to address clinical and social risks, this study argues that the way clinicians document and engage with patients’ social characteristics can actually contribute to health disparities. The study posits that healthcare systems committed to reducing health disparities need to recognize their own clinical interactions as SDHs in their own right.
The authors utilized a qualitative methodology, drawing upon 46 in-depth interviews with non-college-educated women in the United States. These patient narratives were then rigorously compared against their EHRs, which included discrete data and free-text notes from an integrated health system pseudonymously named “CentralHealth”. This comparative approach allowed the researchers to observe how SDHs appear from both the patient’s and clinician’s perspectives, revealing discrepancies that highlight how clinical encounters can either ameliorate or exacerbate health disparities.
The findings demonstrate that perceived negative interactions with the health system can lead some women to resist care, through self-treatment or by challenging clinician authority, which may result in poorer health outcomes. Specifically, the research identifies two key processes through which EHR documentation exacerbates health disparities:
- The translation of social suffering stemming from structural inequality into stigmatized risk factors. For example, socially-produced vulnerabilities are reduced to “problems” (e.g., via ICD-10 z-codes) which can be used to infer treatment adherence, discredit symptoms, or blame patients for their medical issues.
- The suppression of conflicts over diagnosis and treatment. This often involves framing observations of women’s social identities, such as their housing or family situation, as evidence of their unreliability as patients.
The study concludes that these experiences of the clinical encounter as a social determinant of health “administratively disappear” from the EHRs, meaning the source of suffering in clinical encounters and subsequent patient withdrawal from healthcare are not recorded or addressed. The authors suggest that acknowledging these dynamics is crucial and propose that allowing patients to co-construct their visit summaries and goals in EHRs could help reduce miscommunication and build trust, ultimately improving patient-clinician relationships and addressing health inequalities more effectively.
Reference for the Article:
Silva, J. M., Durden, T. E., & Hirsch, A. (2023). Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters. Social Science & Medicine, 323, 115837.
