Readability of Epic's Obstetric Discharge Education

In obstetrics, patients with insufficient health literacy have a higher likelihood of adverse perinatal outcomes. The American Medical Association (AMA) recommends all patient-facing health information be written at or below a sixth-grade reading level. The reading level of standardized obstetric patient education materials embedded into Epic via "Patient Pass/Exit Care" package published by Elsevier is unknown. Since the Spanish versions of the materials have not been back-translated, the readability of those materials also requires further assessment. In this study, our aims were to (1) characterize overall readability of Epic's obstetric patient education documents, (2) assess differences in readability between English and Spanish materials, and (3) understand differences in readability by subject material, stratified by language.

Using the "Clinical References" tab in Epic, obstetric patient education materials were extracted in both English and Spanish. Materials were evaluated using metrics for assessing readability that have been validated in English and/or Spanish: Flesch-Kincaid Grade Level (FKGL), Fernandez-Heurta (FH), and Simple Measure of Gobbledygook (SMOG). Education was coded by content category. Paired t-tests were conducted to evaluate differences in readability scores (FKGL vs. FH) and SMOG scores across language pairs. Mean differences (95% confidence intervals [CIs]) and one-way ANOVA with Bonferroni-adjusted post hoc tests assessed language readability gaps across clinical categories.

Of 235 total texts analyzed, grade level for English was 6.2 (SD 1.0) using the FKGL metric versus 4.2 (SD 0.5) for Spanish content that used the validated FH. Overall, the English documents were 2.0 grade levels higher than the corresponding Spanish documents (95% CI, 1.8-2.1). SMOG mean grade level for English materials was 9.7 (SD 0.9) versus 6.2 (SD 0.6) for Spanish materials (p < 0.01). Across all perinatal topics, English texts scored significantly higher than Spanish texts on both SMOG and language-specific readability metrics. A total of 41.2% of Spanish materials were at or below a 6th grade level using SMOG, but none of the English materials were.

Existing obstetric patient education materials embedded in the Epic electronic medical record (EMR) do not meet AMA standards for readability and comprehension. Differences between English and Spanish materials highlight a potential for disparities in patient understanding of their plans of care.