The ethics of labeling 'frequent fliers' in the EHR

Hospitals often identify patients who make frequent, repeated visits to emergency departments as "frequent fliers," sometimes making a note of such in the EHR, but doing so may have clinical consequences and attach a stigma to these patients, according to a viewpoint in JAMA.

First, labeling patients as "frequent fliers" imposes preconceived notions on such patients, often suggesting they are problematic, according to the viewpoint.

"This iconography is ethically and clinically inappropriate for two interdependent reasons," according to the viewpoint. "First, the icon reinforces and encourages the use of disrespectful and stigmatizing terminology. Second, the icon may frame the initial clinical interaction in a way that inhibits good diagnostic judgment, potentially placing the patient at increased risk of a poor outcome."

According to the viewpoint, mental health patients already face stigma in everyday interactions, and identifying patients as frequent flyers in the ED furthers that stereotyping and marginalization.

Additionally, if clinical providers do carry these preconceived notions about mental health patients, especially after being alerted to their frequent flyer status in the EHR, it may color how they treat the individual. The viewpoint also discusses diagnostic overshadowing, where providers only identify and treat mental health issues when a patient may have a co-occurring clinical condition.

"These patients are less likely to receive appropriate medical care than patients without a mental health condition — their psychiatric conditions overshadow their other conditions, potentially biasing the clinician's judgment about diagnosis and treatment such that the clinician may attribute physical symptoms to mental health problems," according to the viewpoint.

However, the authors write that a patient's past visit history should be accessible to providers, as this information can help inform current treatments. An icon in the EHR, however, is not the way to do so, as it boils down the nuances of an individual to a small graphic.

Instead, EHRs and behavior healthcare care applications should be designed with patients, consumers, clinicians, social scientists and ethicists with a focus on iconography and language in efforts to minimize potentially harmful implicit biases, suggest the authors.

"Technological systems will always be value laden to a degree," the authors write. "Instead of trying to sanitize these technologies, the goal should be to improve healthcare by designing systems that encourage ethical behavior and respectful interactions between physicians and patients."

More articles on frequent fliers:

How Sutter, Alameda Health use data analytics to manage ED frequent fliers
Emergency rooms facing public health crisis
Technologies to supercharge your patient portal, workflow and data analytics

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