Registrars may ask patients for information about race, ethnicity, and language. But if patients ask why, registrars may not be prepared to answer that question because they do not know either.
“The more the staff know, understand, and care about it themselves, the better they’ll do at explaining the data collection to patients and family members,” says David Nerenz, PhD, director emeritus of the Center for Health Policy and Health Services Research at Henry Ford Health System in Detroit.
Many patient access departments are examining their practices for collecting race, ethnicity, and language data. “We have all been reminded of the importance of equity, given the evidence of racial and ethnic disparities in COVID incidence and mortality, and the broad discussions of racism in society and in healthcare more specifically,” Nerenz observes.
Hospitals want to show care processes and outcomes are not different based on patient race or ethnicity. “The only way to do that is to collect the data, and then stratify the whole range of hospital quality measures by race/ethnicity,” Nerenz offers.
If disparities are identified, then those disparities become important targets for quality improvement initiatives. At Henry Ford Health System, “we generally collect the information at registration or at outpatient visit check-in,” Nerenz reports. He says patient access should use two key documents:
- The Health Research and Educational Trust Disparities Toolkit.
- The 2009 Institute of Medicine report: Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement.
“Both provide good, tangible examples of how and when to ask questions of patients,” Nerenz says.
Some patients are worried the data could be used against them in some way. It is important for registrars to tell these patients, with confidence, how the data are not going to be used. “This is not about finding people with immigration or visa problems. This is not about findings ways to discriminate against people,” Nerenz stresses.
The data are needed for a simple and important reason, according to Nerenz: “It’s about working to achieve health and healthcare equity.” Consistent data collection allows the hospital to compare itself to other hospitals, in terms of race, ethnicity, and language. Accuracy is important, but most uses of the data can tolerate a small amount of error or inaccuracy.
“Getting perfect data is the ideal goal. But getting good data is better than not getting any data at all,” Nerenz suggests.
Which specific ethnicities and languages are offered as likely options varies by the hospital’s geographic location. “Hawaii is not the same as Montana in this regard,” Nerenz notes.
Standardized scripting is recommended to explain the reasons for collecting these data. “Hospitals using these approaches have had success in gathering data, and then in using the data to work to reduce or eliminate disparities in care,” Nerenz says.
Without good data on race, ethnicity, and language, it is impossible to analyze differences in healthcare outcomes. “There is no other way to get these data than by getting it from patients themselves,” says Tara Oakman, a senior program officer with the Robert Wood Johnson Foundation in Princeton, NJ.
Asking sensitive questions requires a certain amount of skill and expertise. “It is very important that the patient be asked for this information in a way that builds trust,” Oakman stresses.
Registrars should make eye contact, and give clear answers on how the information will be used. “In the current environment, where there is a lot of mistrust of institutions, patients may be unwilling to provide it in a way that is useful or accurate,” Oakman cautions.
Victoria Warren-Mears, PhD, RDN, FAND, director of the Northwest Tribal Epidemiology Center in Portland, OR, recommends these processes:
- Design tools and processes that allow patients to accurately self-report their identity. “Allow patients to report their racial and ethnic background separately, with the option of choosing multiple races,” Warren-Mears says.
- Develop written policies for race/ethnicity/language data collection. “These policies should clearly state the reasons why this information is being collected, and how the information will be used,” Warren-Mears explains.
- Provide adequate and regular training on the importance of collecting the data. This is particularly important if the information is collected verbally. “Training should provide staff with scripts and opportunities for practice,” Warren-Mears adds.
Some registrars make assumptions about an individual’s racial/ethnic background. For example, in the Pacific Northwest, American Indian last names are confused with similar family names for those of white ancestry. In the Southwest, individuals may be misclassified as Hispanic, when in fact they are American Indian.
“Hospitals can address these concerns by investing in staff training, developing educational materials, and working to support a culture of inclusion for patients and staff,” Warren-Mears offers.
Some registration systems include hard stops that will not allow registrars to continue without completing the data field. “If staff are not trained to collect the data, it’s easy to click ‘other’ or ‘unknown’ to complete the registration,” says Romana Hasnain-Wynia, MS, PhD, chief research officer at Denver Health.
Registrars are more likely to do this if they think the question is just one more administrative burden. “It’s not supposed to be just ‘The feds require that we record this.’ It’s being on the front lines of reducing known disparities,” says Hasnain-Wynia, former director of the Addressing Disparities program at the Patient-Centered Outcomes Research Institute.
Most hospitals will say they are mission-driven. “But can they say that as part of our core mission, we are going to be on the front lines of reducing the known disparities?” Hasnain-Wynia asks.
Seeing this bigger picture motivates registrars to do more than just complete a data field. “What we do in our jobs differs. But patient registration staff is an important partner in this.”
Even so, some registrars dread confrontations over why they are asking about race. Hasnain-Wynia estimates this probably happens only about 3% of the time. If and when it does, scripting can provide registrars with a good response, such as, “Thank you very much. We appreciate that you don’t want to answer the question.”
In the vast majority of cases, the registrar completes the registration without incident. Yet as with any initiative, to get results, patient access leadership must address concerns of frontline staff. “Just saying, ‘Collect the data’ — we know that doesn’t work,” Hasnain-Wynia adds.