Use of Flags in the Electronic Medical Record: A Retrospective Analysis

Implicit bias in patient care and outcomes is well documented. However, the presence of bias in hospital security interactions is a relatively new area of research. Flags placed on the electronic medical record identify patients considered high risk for negative outcomes, including those with security interactions.

We sought to explore the types of flags and their frequency, differences among patients with flags, and their pattern over time.

We conducted a retrospective chart review of flags placed on electronic medical records over 13 years of adults 18 years or older who were patients at a Midwest, tertiary, academic medical center. Descriptive statistics were used to explore patient demographic data. Chi-square tests were executed to compare patients with different flag types.

Three flag types were investigated: "communication alert," "vulnerable/unsafe, behavior" and "risk management." The communication alert flag was most common, although Black male patients were more likely to receive a vulnerable/unsafe behavior flag than a communication alert flag (P = 0.001). Patients who were prescribed anti-anxiety medications, antidepressants, antipsychotics, and psychotherapeutics also were more likely to receive a vulnerable/unsafe behavior flag than a communication alert flag (P = 0.001). The highest number of flags was placed during quarter 3 - the months of July, August, and September.

Records of patients with certain demographics and on certain medications were more likely to be labeled with vulnerable/unsafe behavior flags. There is no clear protocol to determine what behaviors elicit which flag. Standardized procedures could help provide transparency to this issue.