Blog Post

Behavioral Flags in the Emergency Department Risk Unintended Consequences

Flags in Electronic Health Records Are Rare But Exacerbate Racial Disparities

February 21, 2023

By:

Anish K. Agarwal, MD, MPH

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Droves of nurses and physicians are leaving the bedside as the health care workforce continues to face significant levels of burnout. One factor behind this trend is clinician concern about safety when caring for patients. An unfortunate fact is that many emergency nurses and physicians report experiencing physical, verbal, and sexual abuse while at work. In response to these experiences, clinicians can add a marker to a patient’s electronic health record (EHR) referred to as a “behavioral flag.” These flags are designed to alert future care teams about previous patient behavior. Behavioral flags make practical sense, yet they remain underexplored, especially within the context of another critically important area in health care — equity in care delivery.

We examined the prevalence of behavioral flags placed in patients’ EHRs during emergency department (ED) visits in order to understand the frequency of their use and to investigate if there was a difference in how often Black and white patients were flagged. We also were interested in whether the flags were associated with disparities in the care provided in the ED.

We found that flags are rarely used in ED settings, with only 0.3% of all patients having been flagged. Of the patients who were flagged, we found that Black patients received flags at almost double the rate of white patients. Additionally, these flags impacted the care that Black patients received. Black patients with flags spent more time in the waiting room, waited longer to see a clinician, and had fewer tests ordered as compared to white patients with a flag.

These outcomes show that change is needed to eliminate disparities and keep clinicians safe. Specific actions that health systems can take include:

Avoid “one-size fits all” approaches: Often in the health care field, we look for solutions that are scalable, but clinician safety and patient equity are nuanced issues that may be locally driven by culture and teams.
Attempt to remove biases: Current policies around placing flags are highly subjective and would benefit from the creation of a systematic and objective approach to regulate their implementation.
Elicit feedback: Dynamic and iterative approaches that include perspectives from front-line clinicians and patient advocacy groups would help to engage key stakeholders and to promote safe workplaces.

In today’s environment, health systems face many challenges related to workforce retention, clinician well-being, and health equity. Our work highlights that often, these avenues intersect, and without constant attention and evaluation, solutions designed with only one issue in mind may work at cross-purposes. My research team is beginning to dive deeper into this underexplored area to hear the lived experiences of clinicians and patients with regards to equity and safety in hopes of developing new strategies that keep the workforce safe and ensure equitable care.

The study “Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department” was published on January 19, 2023 in JAMA Network Open. Authors include Anish K. Agarwal, Emily Seeburger, Gerald O’Neill, Chidinma C. Nwakanma, Lillian E. Marsh, Kevin Alexander Soltany, Eugenia C. South, and Ari B. Friedman.