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Is it Unethical to Identify Patients as “Frequent Flyers” in Health IT Systems?

October 19, 2016
by Heather Landi
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Healthcare information technology tools, such as electronic medical records (EMRs), can enable physicians and clinicians to have timely access to important patient history information and medical records. However, several researchers from the University of Pennsylvania contend that when symbols or icons in the technology tools are used to identify certain patients, such as those with mental illnesses, it can be stigmatizing and can create a potentially harmful bias against the patients.

In a viewpoint article published in JAMA, Michelle Joy, M.D., of the University of Pennsylvania’s Perelman School of Medicine, department of psychiatry; Timothy Clement of the Thomas Scattergood Behavioral Health Foundation in Philadelphia and Dominic Sisti, Ph.D., with the University of Pennsylvania’s Perelman School of Medicine, department of medical ethics and health policy, addressed the ethics of behavioral health IT as it relates to “frequent flyer” icons and the potential for implicit bias.

Many healthcare providers are aware that individuals with serious mental health conditions often make repeated and frequent visits to emergency departments and psychiatric crisis centers. The individuals are considered super utilizers and may be labeled “frequent flyers” by clinical staff and other healthcare providers.

“A pejorative branding, ‘frequent flyers’ are often assumed to be problem patients. In psychiatric settings, these patients are sometimes said to be ‘borderlines,’ ‘drug seekers,’ ‘malingerers,’ or ‘treatment resistant’,” the researchers wrote.

Some emergency departments maintain lists or files of patients with frequent visits to identify the “frequent flyers.” According to the researchers, one EMR system provides an airplane icon, “which system administrators may elect to configure so that clinicians can identify a patient as a high utilizer. The icon appears near the patient’s name and various colors indicate strata of utilization,” the researchers wrote.

The researchers contend that this iconography is “ethically and clinically inappropriate for two interdependent reasons.” First, the researchers stated, 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.

“More broadly, the icon offers an example of how potentially harmful biases may be built into and reinforced by well-intentioned but ill-conceived information technologies, such as those deployed widely across all sectors of health care, and particularly in psychiatric treatment settings where clinical interactions are often more interpersonally sensitive,” the researchers stated.

While the researchers acknowledge that clinicians need to view a patient’s past visit history in order to learn how often and for what reasons the patient frequently presents in the emergency department or other healthcare settings, they argue that “for clinicians to properly construct this history requires a deeper examination of utilization, something that the high utilization icon—particularly when positioned on the initial page of the medical record—may discourage.”

The researchers are concerned that the icon provides a shortcut that can provoke assumptions and associations implicit in the concept of the “frequent flyer.”

Drilling down into the stigma of the terminology and clinical consequences, the researchers contend that stigmatizing terminology such as the “frequent flyer” phrase can enhance diagnostic overshadowing. “For example, diagnostic overshadowing can occur in patients with co-occurring mental illness and conditions such as cardiovascular disease or diabetes. These patients are less likely to receive appropriate medical care than patients without a mental health condition—their psychiatric conditions overshadow their other conditions,” they wrote.

“Seeing the high utilizer icon at the time of the patient encounter may increase the likelihood that a clinician will possibly fail to recognize medical problems. The notion that the patient is a “’frequent flyer’ may interfere with the assessment of legitimate somatic symptoms and may cause the clinician to withhold or delay needed tests and procedures, which could lead to serious negative outcomes,” the researchers wrote.

The researchers also argue for inclusive development of behavioral healthcare technology. They note that “algorithms and computer systems reflect the intentional or unintentional biases of their designers, and by extension, problematic iconography in health information technology could reflect the biases and stigmatizing beliefs held by clinicians who advise and influence system designers.” I

Moving forward, health information technologies should be developed and deployed in a way that minimizes the likelihood of potentially harmful implicit biases, they wrote.

“Electronic medical record systems and behavioral health care applications should be built and tested in collaboration with patients, consumers, clinicians, social scientists, and ethicists who are sensitive to the broader ramifications of iconography and language. Algorithms designed to identify patients who may present with a specific set of challenges should be carefully created to avoid reinforcing nontherapeutic biases.”

The researchers concluded that a system that “confusingly displays acronyms or medication names would be considered unsafe. Likewise, systems that use stigmatizing iconography should also be unacceptable.”

According to the researchers, the goal should be to improve health care by designing systems that encourage ethical behavior and respectful interactions between physicians and patients.




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As long as there are some discrete and realistic criteria for determining when to flag the person (and at what level, if any), then ‘Why not?’

These super utilizers are a major expense to our healthcare system and take scarce resources away from those who really need them. I bet most people know of someone in their immediate or extended family or network who is a ‘frequent flyer.’ I know of several. One relative, who’s seriously overweight, smokes, is rarely seen without a cream puff in her hand, who is often sitting around watching TV and moaning about her aches and pains. And she’s always running to the ER and urgent care and the doctor’s office. She has ‘good insurance’ through her husband who has a union job; but can often be heard moaning about the small co-pays she has to pay- co-pays that most people would love to have. I suppose that mental health does have an impact in this case but so what? No one will broach that subject. That;s taboo. It’s clear she’s bringing a lot – if not all – of her ‘medical issues’ on herself.

But the politically correct, bleeding hearts would have society pay for her poor habits, actions and laziness? NFW!


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