Gaps in the Identification of Child Race and Ethnicity in a Pediatric Emergency Department

Introduction Race and ethnicity are social constructs that are associated with meaningful health inequities. To address health disparities, it is essential to have valid, reliable race and ethnicity data. We compared child race and ethnicity as identified by the parent with that reported in the electronic health record (EHR). Methods A convenience sample of parents of pediatric emergency department (PED) patients completed a tablet-based questionnaire (February–May 2021). Parents identified their child’s race and ethnicity from options within a single category. We used chi-square to compare concordance between child race and ethnicity reported by the parent with that recorded in the EHR. Results Of 219 approached parents, 206 (94%) completed questionnaires. Race and/or ethnicity were misidentified in the EHR for 56 children (27%). Misidentifications were most common among children whose parents identified them as multiracial (100% vs 15% of children identified as a single race, P < 0.001) or Hispanic (84% vs 17% of non-Hispanic children, P < 0.001), and children whose race and/or ethnicity differed from that of their parent (79% vs 18% of children with the same race and ethnicity as their parent, P < 0.001). Conclusion In this PED, misidentification of race and ethnicity was common. This study provides the basis for a multifaceted quality improvement effort at our institution. The quality of child race and ethnicity data in the emergency setting warrants further consideration across health equity efforts.

demographics. 1,[5][6][7] This may be more likely in the emergency department (ED), where hospital registration staff must find time to collect patient information and sign consents to care without interrupting urgent and fragmented clinical care. Race and ethnicity that are determined based on staff observation may be particularly inaccurate for children, who may not have the same race and/or ethnicity as their caregiver. 8,9 Inaccuracies can be further compounded by limitations in available race and ethnicity categories. 1,9,10 Healthcare systems often restrict race and ethnicity data collection to the minimum standard categories required for federal reporting and rarely give the option to select "other" or to select multiple races or "multiracial." 11 Additionally, although the Institute of Medicine supports the option of presenting race and ethnicity within a single question, healthcare systems often separate these into distinct categories as used in federal reporting. 1 This format can lead to misidentification of Hispanic individuals who do not otherwise identify with the options listed in a distinct race category. 1,12 As part of a quality initiative to improve and standardize accurate demographic data collection, we sought to assess the accuracy of child race and ethnicity data in an academic pediatric emergency department (PED), and to identify risk factors for misidentification.

METHODS
We conducted a cross-sectional analysis comparing child race and ethnicity reported by the parent to that documented in the electronic health record (EHR). This study took place in a single, academic PED with an affiliated onsite children's hospital. The PED has an annual volume of approximately 26,000 patients. In the EHR (Epic Systems Corporation; Verona, WI), race and ethnicity data are documented separately using the minimum US Office of Management and Budget categories. 7 Both fields are required. In each field multiple options can be selected, including an option for "other." If not already documented from a prior visit within the hospital system, PED registration staff obtain patient race and ethnicity from patient or parent self-report or through staff observation.
Between February-May 2021, three trained research assistants (RA) approached a convenience sample of parents or caregivers ("parents"). Parents of critically ill children were excluded. The RAs were in the PED during afternoons and evenings. Sample size was determined by RA availability during the study period. Parents were approached at any time during the PED visit. The RAs explained the purpose of the study and asked parents to complete a brief, tablet-based questionnaire while the RA remained in the room. Parents who used a language other than English completed the questionnaire verbally with video interpretation. The parent was asked to identify the child's race and ethnicity from a single question ("What is your child's race and ethnicity? You can choose as many answers as you want to: American Indian/ Alaska Native; Asian; Black/African American; Hispanic/ Latino; Native Hawaiian/other Pacific Islander; White; other (free-text optional); I don't want to say; I don't know"). 1 We chose to use a single question with race and ethnicity presented together, an option suggested by the Institute of Medicine, so that parents were not compelled to make selections within a category with which they or their child did not identify. 1,8 Parents were also asked to identify their own race and ethnicity in a similar, single-question format. 1 Child race and ethnicity were abstracted from the EHR. This study was approved by the University of Florida Quality Improvement Project Registry and determined not to require institutional review board review.
Our primary outcome was EHR misidentification of child race and ethnicity. Child race and ethnicity was considered "misidentified" if the EHR record did not match the parent report. Misidentifications in the EHR included situations in which the parent selected multiple options but not all of those were selected in the EHR, or vice versa. This also included situations in which the parent selected "other" but "other" was not reported in the EHR, or vice versa. Finally, race and ethnicity data are often missing from EHRs, leading to the exclusion of those individuals from equity-focused analyses and research. 3 Thus, if EHR race and/or ethnicity was missing but the parent provided a response in the questionnaire, this was considered a misidentification. To assess this approach, we conducted sensitivity analyses in which we excluded those patients with missing race and/or ethnicity. We performed statistical analyses in R (R Core Team, 2021, R Foundation for Statistical Computing, Vienna, Austria). We performed chisquare and bivariate regression analyses to evaluate misidentification by child race and/or ethnicity and age, respectively. We assessed statistical significance at the P = 0.05 level.

RESULTS
Of 219 approached parents, 206 completed a questionnaire (94%). Most parents identified their child as non-Hispanic White (51%) or non-Hispanic Black (26%) ( Table 1). Thirty-one parents (15%) identified their child as Hispanic, half of whom did not identify a separate race for their child. Seventeen parents (8.3%) identified their child as multiracial.
Fifty-six children (27%) had misidentified race and/or ethnicity in the EHR. Most misidentifications (89%) were misidentification of race. This includes all 17 multiracial children, most of whom were inaccurately reported as having a single race. Of the 16 Hispanic children who did not have separate race identified by the parent, 70% were misidentified as "other race," and 30% were misidentified as "White" in the EHR. Six children had misidentified ethnicity, all of whom were identified as Hispanic by the parent and in the EHR as "not Hispanic or Latino." A full list of misidentified EHR race and ethnicity data is found in Table 2.

Gaps in the Identifying Child Race and Ethnicity Gutman
Child race and ethnicity identified by the parent EHR misidentification

Multiracial
Black/African American + White "Not Hispanic or Latino + Black / African American + White" (1), "Hispanic + other race" (1) Table 2 Continued. Details of ethnicity listed in the electronic health record (EHR) compared to parent report of child race and ethnicity for children with misidentifications in the EHR. 1 Number in parentheses indicates the number of children for each listed EHR race and ethnicity combination. 2 Ethnicity not specified, as all were correctly identified as "not Hispanic or Latino" in the EHR. 3 One parent wrote in "Black white mixed." 4 One parent wrote in "Native American"; one parent wrote in "Indian." 5 Ethnicity not specified as all were correctly identified as "Hispanic" in the EHR. EHR, electronic health record; IQR, interquartile range.

DISCUSSION
Misidentification of child race and ethnicity was common in our PED, findings that remain similar to pediatric administrative-database analyses from the early 2000s. 8 Our findings demonstrate a clear need to develop strategies to enhance precise data collection within our EHR and to facilitate self-report of race and ethnicity. Importantly, such efforts to improve precision must be partnered with analyses that consider complex demographic subgroups. 6 Strategies applied in other healthcare systems have included the following: 1) staff training on self-report of race and ethnicity and education to increase patient awareness; 2) EHR systems that allow the selection of multiple races; 3) EHR alerts when race and/or ethnicity are missing; 4) use of granular race and ethnicity subcategories; and 5) a single-item question for race and ethnicity. 1,4,9,10 Our findings highlight the importance of this multifaceted approach. All multiracial children in our sample were misidentified in the EHR. Our EHR allows for the selection of multiple races, yet in most of these cases multiracial children were misidentified in the EHR as having a single race. Additionally, by intentionally using a single item for race and ethnicity, we found that half of Hispanic parents did not select an additional race option for their child. Most of these children were categorized in the EHR as "other race," an all-encompassing category that loses precision and is often excluded entirely from data analysis. 6 We assessed race and ethnicity as a single construct for two reasons. First, as we found in our sample, individuals who identify as Hispanic may not additionally identify with a distinct race category. 12,13 Second, this approach was pragmatic. 13 Race and ethnicity are often presented as a single construct in health equity research, which requires researchers to collapse the two variable data that are found in administrative and hospital databases. 14 Thus, our approach mirrors the practice of many health equity researchers. By offering choices that reflect the way data will be reported, we allow patients and parents greater selfdetermination in how precisely they will be identified.

LIMITATIONS
This study is subject to limitations. Questionnaires were completed by parents, which may not reflect child self-identification. Race and ethnicity categories used by the US Census Bureau are themselves limited and do not fully capture individual realities. We were unable to determine how EHR data was collected and could not determine which misidentifications occurred at the level of data entry (ie, if race and ethnicity were determined by

Gutman
Gaps in the Identifying Child Race and Ethnicity staff observation). Demographics may have been collected during prior visits within the hospital system, so our findings are not sufficient to identify misidentifications that are uniquely due to the PED registration process. Finally, we approached a convenience sample, and responses may have been influenced by the timing and methods of questionnaire administration. As part of a quality improvement initiative, our findings are not intended to be generalizable.

CONCLUSION
Despite representing arbitrary social constructs, accurate race and ethnicity data are essential to identifying and addressing health inequities. Although we found that rigidity within race and ethnicity items in the EHR was an important factor in many misidentifications (ie, the requirement for both a race and ethnicity response), we also found that some features of the EHR were not used (ie, the ability to select multiple responses within a category). This work provides the basis for a multifaceted quality improvement effort at our institution. The quality of child race and ethnicity data in the emergency setting warrants further consideration across health equity efforts.