Characterizing identifiers for immigrant populations in Electronic Health Records

Characterizing identifiers for immigrant populations in Electronic Health Records | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characterizing identifiers for immigrant populations in Electronic Health Records Preethi Ravi, Margaret Smith, Sabrina Bogović, Camille Lin, Anna Yaffee, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4941083/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 May, 2025 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted 9 You are reading this latest preprint version Abstract The current use of identifiers to describe immigrant patients in Electronic Health Records (EHRs) is poorly described and lacks standardization, but nevertheless has broad implications related to clinical care and research of this population. We conducted interviews with key informants to discern strong identifiers for use to identify patients who have immigrated to the United States (U.S.). Language, country of origin, time in the U.S., and race/ethnicity were identified as effective, ethical, and acceptable for use. Limitations of each of these identifiers were noted, highlighting the need to use multiple identifiers in combination when describing patients in EHRs. The processes used to collect these identifiers in clinical settings and the ethical implications of using these identifiers must also be carefully considered. Our results highlight the need for standards related to documentation of immigrant patients in EHRs. Further research is also needed to validate the identifiers we have outlined, discern additional identifiers that are useful and acceptable in specific clinical and research contexts, and explore how strong identifiers can be operationalized in EHRs for clinical, research, and community engagement purposes. immigrant health refugee health electronic health records patient identifiers population health health equity Background In the past 40 years, the number of individuals living in the United States (U.S.) who speak a language other than English has increased dramatically, now representing nearly one-fifth of the U.S. population [ 1 ]. Non-English Language Preference (NELP) individuals, many of whom identify as immigrants, face significant challenges in accessing and receiving health care in the U.S. [ 2 , 3 ]. Language barriers alone are associated with adverse outcomes during hospitalization, increased ED revisits, increased hospital length of stay, and higher readmission rate within 30 days [ 3 – 6 ]. Additionally, immigrants experience a relatively high burden of chronic disease with varying levels of health care access and utilization, yet the true extent of health disparities and interventions to address disparities faced by this population is still under investigation [ 7 – 11 ]. One of the difficulties in understanding health needs and addressing health inequities is the challenge of ethically and appropriately identifying this heterogeneous population in health care settings. Health systems have historically recorded patients’ race, ethnicity and primary language in Electronic Health Records (EHRs) [ 12 ]. However, previous studies have demonstrated underreporting and inaccuracies of these labels [ 13 , 14 ]. Additionally, there are increasing concerns over the collection of equity-centered demographic variables in EHRs [ 15 ]. Currently, there are no widely accepted EHR identifiers for immigrant populations, which makes identification in EHRs and national health datasets difficult [ 16 , 17 ]. Clinician scholars have recommended avoidance of documenting immigration status in the health record, but use of other variables has not been extensively explored [ 18 ]. While some proxy identifiers have been used (e.g., insurance status, insurability), these can vary by state and hospital [ 16 ]. Challenges with identification are problematic for clinicians and researchers and have resulted in exclusion of immigrants from published research studies [ 19 , 20 ]. Measures to identify immigrants in EHRs are important for clinical and research purposes but must also be acceptable and ethical. Our objective was to explore identifiers that could be used universally in EHRs from the perspectives of stakeholders involved in immigration-related research, clinical care, and community engagement. Methods Study Design This qualitative study included semi-structured interviews with key informants who work with immigrant populations. This approach was selected as prior data on EHR identifiers is limited, particularly data that incorporates the perspectives of those who care for, represent, and conduct research with this population. This approach also creates a flexible environment to explore a range of experiences and suggestions for identifiers that would accurately reflect this population and be ethical for utilization in EHRs widely. This study was approved by the university’s Institutional Review Board and aligns with Consolidated Criteria for Reporting Qualitative Research (COREQ) Reporting. Study Setting and Population Interviews were conducted with key informants, defined as clinicians, researchers and community leaders who work with immigrant populations. We use the term “immigrant populations” to be as inclusive as possible; it includes refugees, people seeking asylum, and those with other statuses. Key informants were recruited at a national level through the Society of Refugee Healthcare Providers (SRHP) Research Committee (which operates in the U.S. and Canada), locally through a refugee Community Advisory Board (CAB), and through contacts within the study team’s networks. We included both local and national key informants to understand if any site/region-specific themes emerged given the geographical variability of resettlement. Recruitment was conducted via an email from a study team member who is a member of both the SRHP Research Committee and CAB (AZ). Purposive sampling was utilized to balance the distribution of key informant professions/roles in the community. Study Protocol Study Protocol We conducted semi-structured interviews with key informants using an interview guide developed by the study team. The interview guide explored participants' knowledge of current systems of identification of refugees/immigrants in EHRs, the importance of identification, suggestions for possible identifiers, ethical issues accompanying identifiers, and logistics including potential locations identifiers are recorded within EHRs. The interview guide was piloted with two physicians who work with, conduct research with, and represent immigrant populations, and refined thereafter. All interviews were conducted one-on-one by a study team member who was a medical student at the time with prior experience working with a resettlement agency (MS) over a video conference platform (Zoom). The interviewer had no prior interactions with the key informants and was trained in qualitative interviewing. Demographic information was collected at the end of each interview. Interviews were recorded, professionally transcribed, and conducted until thematic saturation was reached. While there are no formal sample size recommendations for qualitative studies, thematic saturation is generally achieved with six to twelve interviews [ 21 ]. Data Analysis A thematic analysis approach was utilized to analyze interview data [ 22 ]. The study team initially reviewed all key informant transcripts and developed a preliminary code book. Two study team members trained in qualitative analysis then independently coded all transcripts using Dedoose (AZ, SB). The study team met regularly to refine the code book, resolve coding differences by consensus, and identify prominent themes from each group (AZ, SB, PR). Results Of the 13 key informants, six were based in the state where the study team is located, six resided elsewhere in the U.S., and one was based in Canada. All interviews were conducted in English; however the majority of participants (n = 10) also spoke a language other than English. The majority of participants were born in the U.S. (n = 11). The mean age of participants was 40.6 years and the mean years of working with refugee and immigrant populations was 11.8 years. Most of the participants identified as female (n = 12) and over half (n = 7) identified as a race/ethnicity other than white. Seven of the participants worked in clinical settings, two participants identified as educators, two participants identified as students, and five participants identified themselves as community leaders. Key Informant Themes Current use and implications of immigration-related identifiers We found no difference in key themes by site/region. There was general consensus among the key informants interviewed that there is no single most effective method to identify patients who are immigrants within EHRs at present; however, a significant need for this exists (see Table 1 ). Key informants described the importance of being able to identify immigrant patients in EHRs in a safe, confidential, and acceptable way in order to better characterize their health care needs, facilitate access to support services, and engender more robust research. Importantly, identifiers should also be collected in a systematic manner to ensure all immigrants are appropriately identified. Table 1 Themes and Representatives Quotes Theme Quote(s) Current use and implications of immigration-related identifiers Provider knowledge about immigration “the backgrounds that comes with [different] legal statuses and the benefits that are available to each of those legal statuses really impacts, again, what they need in the healthcare system, what their lives are like outside of their healthcare, and how we think about researching those different subpopulations” (Key Informant 8) “there should be a way to identify [refugees and immigrants], but in a safe way that maintains their confidentiality and protection, and that's acceptable to them” (Key Informant 7) “immigration status also impacts a lot of [individuals’] health behaviors, their level of fear and hesitation of interacting with the health care system and also the types of services that they receive” (Key Informant 7) “it's like this perfect conundrum that we say your immigrant identity or your immigration status confers extra health risks or disparities, and yet we cannot measure that. And so I just think it's a fundamental challenge that the immigrant health research discipline has. You can't measure the effect of something if you can't identify it” (Key Informant 6) “I just feel like you [have] to be really clear about why you're asking these questions, and what our health systems are doing with them... It's so tricky how to help people understand the motivation for asking without restigmatizing and kind of othering people” (Key Informant 6) “there is lack of information on the part of health care providers and health care systems about what that documentation [immigrant or refugee-related] can be used for” (Key Informant 7) “when you're trying to look population wide at a medical record, people's knowledge about immigration status is so varied. And I just find it to be dramatically inaccurate when people have written what they think is going on in the record” (Key Informant 6) Language “I would say primary language, like language spoken at home is probably the most important. It gives us a number of sort of implied data points... language becomes a really clear proxy for ethnicity and a lot of cultural background and differences” (Key Informant 8) “the health system has this one demographic field, which is for preferred language. But what we have in our social history, specifically in our new arrivals clinic [is] a question about what languages different people in the family speak...I found it's very well-accepted” (Key Informant 10) “I think it's always good to allow a patient if they prefer to speak in English to have that opportunity, but to also know where their other language proficiencies are because there may be a point in time where there is a barrier in communication where you would need to bring in a cultural or a language broker to help bridge that gap” (Key Informant 11) Country of origin I think when I think about implementing something across a health system, I find country of birth appealing because it is so concrete, and it's a question that can be asked of everybody... and also know if someone was born in one country but didn't spend most of their life there, they might have risk factors that are linked to where they lived subsequently that would be important to know about” (Key Informant 10) “different countries of origin have different disease profiles, and so it helps you to figure out like what type of health issues that person is at risk for” (Key Informant 7) “knowing where somebody is from, which country they identify with, they consider home, I think that is important in terms of caring for [that] population: knowing about certain cultural practices... knowing that there may have been a civil war recently and this individual may have been traumatized, knowing that the incidence of hepatitis B is much higher in certain countries” (Key Informant 4) Time in US/country of resettlement “I think it's more if being in the United States for a long time signifies that you're better able to navigate the health system. So I tend to think more about kind of what sort of support you would need to access care...there are some things where the importance of screening certainly seems less urgent after someone [has] been here a long time” (Key Informant 10) “acculturation has a really big impact on health, and somebody who has lived here for 20 or 30 years has a completely different health profile than somebody who has just arrived” (Key Informant 7) “It starts to be a complicated interplay with duration of residence and what your status was along those time points. Our newly arrived refugees who are on a pathway to citizenship do much better in general than our asylees who've been waiting for five years and are still insecure about their immigration status” (Key Informant 6) Race/ethnicity “Until we have a better system of appreciating and understanding diversity and providing precision patient-centric care that includes not only the social and structural determinants [of] health, but their biometric information as well, we're going to have to continue to collect [race] because that's, again, how money is appropriated. That's how the census counts individuals. That's how grants are funded” (Key Informant 11) “some countries have tribes or ethnic groups that are minor ethnic groups so sometimes people do not want to identify with their ethnic group in fear of... [being] profiled, targeted” (Key Informant 9) Key informants discussed the challenges associated with labels including “refugee” and “immigrant,” as they are defined inconsistently and pose material risk to patients, ranging from bias in clinical care to more extensive legal ramifications, including possible deportation. Documenting immigration status was described as egregiously unethical, as clinicians are unable to ensure that such information remains confidential within EHRs. Ethical implications related to potentially enabling bias or differential treatment resulting in disparities in care, and violating HIPAA were also discussed. Participants emphasized that immigration is a dynamic process that encompasses a multitude of experiences; using concrete identifiers has the potential to force people into categories that may not fully describe them, limiting our understanding of diverse populations in key clinical and research contexts. Key informants also described inconsistencies among health care providers regarding knowledge about the immigration process, including related policies and practices, leading to potential inaccuracies in documentation. Without understanding the effects of immigration on individuals’ access to health care, insurance, and other services, it is also difficult for providers to appreciate patients’ lived experiences, in addition to what certain immigration-related identifiers in EHRs may signify. Key informants named language, country of origin, time in the US, and race/ethnicity as potential identifiers for immigrant patients (see Table 1 ). Other surrogate identifiers including social vulnerability indices and engagement in social services (e.g., through refugee resettlement agencies) were also described as potential ways to identify immigrants within health systems; however, due to the diversity and lack of standardization of surrogate identifiers, participants expressed caution related to their use. Additionally, key informants stressed the importance of how questions about identifiers are asked and by whom. They recommended that sensitive questions be asked by a trusted member of the health care team with the assurance of confidentiality and a pre-emptive explanation regarding why these questions are being asked. Potential Identifiers: Language, Country of Origin, Time in the US, Race/Ethnicity Documenting language serves a practical purpose as it facilitates the involvement of interpreters to ensure that individuals are appropriately understood and represented in health care contexts. Languages spoken by very specific populations are most useful in identifying members of those populations; however, people of multiple cultural groups, ethnicities, and/or nationalities often speak a common language, making language less useful to understand individuals’ sociocultural backgrounds, including if and where they may have emigrated from. Key informants also underscored how identifying with a non-English primary language may contribute to disparities in care. Country of origin was generally accepted as an appropriate and ethical identifier that could improve clinician and researcher understanding of patients’ backgrounds. It yields information related to an individual’s sociocultural context that may affect their health or health care access; however, similar to language, country of origin does not distinguish between the different cultural, ethnic, or other sub-populations that may live in the same country. It may also elucidate disease risk based on disease epidemiology in one’s country of origin. Many patients have complex migration histories, however, which limit the utility of country of origin as an identifier. It is possible that these individuals have spent more time living in a host or transition country (e.g., in a refugee camp in a neighboring country) than in their documented country of origin, which would substantially decrease the utility of disease risk profiles formulated based on their countries of origin. Time in the United States (or other country of resettlement) bears the implication that an individual is an immigrant and also provides information related to health status. People who have spent more time in their country of resettlement are more likely to adopt health behaviors that match those of the majority where they live. Key informants described differences in health care needs, access to health care, and health behaviors between people who have spent less time versus more time in the U.S. Key informants emphasized the longstanding, pervasive use of race and ethnicity to identify patients in EHRs. While race and ethnicity can provide some information related to patients’ backgrounds and experiences, they are of limited value because, as identifiers, they fail to distinguish immigrants from individuals born in the U.S. Additionally, individuals of certain persecuted ethnic groups may hesitate to share this information due to fear of perceived repercussions. Discussion Our results highlight broad limitations in identifying immigrant populations within health systems, specifically through the use of EHRs. At present, there are no standards for the documentation of immigrants in EHRs which further highlights the critical need for this research. As emphasized by our findings, discerning strong identifiers is a complicated endeavor which involves several ethical considerations and important nuances; given this, participants in this study generally felt that language, country of origin, time in the U.S. (or other country of resettlement), and race/ethnicity were useful and acceptable variables to collect. The process by which identifiers are collected and documented was also recognized as important, with special consideration for how measures are gleaned and documented, and by whom. Notably, no single identifier can be used in isolation to effectively identify immigrant patients or fully understand their sociocultural contexts. As a starting point, using multiple strong identifiers, incorporated into universal screening within health systems, is an important way to improve clinical and research endeavors related to this population, emphasizing that the strength of these identifiers may vary across populations and with respect to the contexts in which they are collected. To our knowledge, this is among the first studies that utilizes qualitative methods to explore strong identifiers for immigrant populations. Existing studies have attempted to identify patients using other primarily data-based methods, without assessing the utility or acceptability of identifiers from the perspectives of key informants who closely interface with immigrant patients. Rule-based natural language processing algorithms and EHR-based algorithms that extract specific proxy variables to determine health status (e.g., HIV status) or immigration-related characteristics (e.g., documentation status) of immigrant patients have been used previously, though they vary in sensitivity and specificity [ 23 – 25 ]. Proxies used by these studies include race/ethnicity and language, affirming our finding that these are suitable identifiers for immigrant patients. However, utilizing proxy variables that are unique to a specific population and context may not be generalizable to or acceptable for use in all settings. As researchers have outlined previously, and as supported by our findings, there is an ethical obligation to minimize documentation of information that poses substantial risk to patients, including documentation status [ 18 ]. Clinicians are hesitant to ask immigration-related questions due to uncertainty about what should be asked, how information should be documented, and how documented information can and will potentially be used. Documentation status, like other individually identifiable health information, should be considered protected health information; however, due to the potential legal risk to patients— including the potential use of information related to documentation status for prosecution and deportation— it is not ethical to include documentation status in EHRs in any capacity [ 26 ]. The political climate in the U.S. and other parts of the world, characterized by long-standing and escalating anti-immigrant rhetoric and policy, not only informs what we are able to safely and ethically document in EHRs, but also underscores the need to use objective language and carefully evaluate the presence of implicit and explicit bias in how we document information about immigrant patients. Using indirect information, including the identifiers outlined by this study, potentially circumvents this risk by providing information about individuals’ backgrounds and social contexts without mention of documentation status. However, these identifiers should still be used with caution and with appropriate protections to ensure this information is used only for clinical and research purposes within the context of health care settings. Notably, there are several nuances to consider when using the identifiers suggested, especially if used in isolation. For example, primary/preferred language is currently recorded in most health care contexts but the method by which this information is collected and utilized (e.g., to provide interpretation-related services) varies greatly, affecting its utility as an identifier universally [ 27 ]. Immigrant patients may also identify English as their primary language and/or be multilingual, and therefore not identified by this variable. Race and ethnicity are widely recorded across health systems; however, there is also substantial variability in how this information is ascertained and documented, limiting its utility [ 28 ]. Country of origin fails to encompass details related to an individual's migration history and whether an individual belongs to a specific sub-population within a specific country. It also fails to capture persecution or discrimination experienced by individuals in their home countries; these individuals are more likely to experience worse outcomes related to both mental and physical health [ 29 , 30 ]. Additionally, an individual's country of origin may not align with their family history or ancestry, and may not reflect where they may have lived and for how long. Time in the U.S. may serve as a surrogate for acculturation, which influences health behaviors and access to health care. Immigrants who have lived in the U.S. for longer are more likely to have more robust social networks, greater access to material resources, and a better understanding of systems including health care [ 31 ]. Further research is needed to validate the identifiers we have suggested to ensure that they are effective and acceptable to use. Most importantly, it is essential that the perspectives of immigrant patients are obtained to not only validate these identifiers, but also discern other relevant identifiers and ensure that all identifiers used are population driven. Once potential identifiers are confirmed, additional research will be needed to evaluate best practices for implementation and operationalization of identifiers in EHRs. Limitations There are several limitations specific to this study. Interviews were conducted with key informants, some of whom identify as immigrants; however, we did not interview immigrant patients whose perspectives are of utmost importance. We decided to interview key informants first to discern a range of identifiers that could then be explored with immigrant patients. Key informants had significant knowledge of clinical care and research endeavors specific to immigrant populations, which was important in establishing potential identifiers; however, these identifiers may not fully reflect those used by clinicians in routine practice. Further, the perspectives of our key informants, though from across the U.S., may not be broadly applicable to different contexts across the country (e.g., rural vs. urban) due to substantial variability among immigrant populations by state, region, and even city. As such, identifiers should be explored in relation to the local context of a specific health system prior to application. Finally, we did not interview any hospital-based legal counsel who could potentially comment on the legal ramifications of identifiers and/or specific hospital-based legal policies and practices. Declarations No competing interests to disclose. Acknowledgements: Funding: [university] Global Health Institute New Contribution to the Literature This is one of the first studies to qualitatively explore useful, acceptable, and ethical identifiers for immigrant populations within health systems, as they are documented in EHRs. Currently there is no standardized or widely-accepted way to identify immigrant populations in EHRs, and improved recognition is critical for both clinical and research purposes. Through interviews with key informants, we established potential identifiers that were perceived as useful, acceptable, and ethical, including language, country of origin, time in the U.S., and race/ethnicity. As we have outlined, no single identifier perfectly encompasses the diverse, complex, and dynamic experiences of immigrants, and therefore, it may be more effective to utilize multiple identifiers in combination. Author Contribution A.Y., M.D., and A.Z. conceived and designed the study. M.S. and A.Z. recruited study participants. M.S. acquired data. P.R., M.S., S.B., and A.Z. analyzed data, and all authors interpreted data. P.R. and A.Z. drafted the manuscript and prepared table 1. All authors revised the manuscript, and A.Z. critically revised the manuscript. Data Availability Data is provided within the manuscript. Additional data (e.g., coded segments, unedited table 1) can be provided by the authors upon reasonable request. References Dietrich S, Hernandez E. Nearly 68 Million People Spoke a Language Other Than English at Home in 2019. In: What Languages Do We Speak in the United States? United States Census Bureau. 2022. https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html . Accessed 15 Aug 2023. Welty E, Yeager VA, Ouimet C, Menachemi N. Patient satisfaction among Spanish-speaking patients in a public health setting. J Healthc Qual. 2012;34(5):31–8. 10.1111/j.1945-1474.2011.00158.x . Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60–7. 10.1093/intqhc/mzl069 . Portillo EN, Stack AM, Monuteaux MC, Curt A, Perron C, Lee LK. Association of limited English proficiency and increased pediatric emergency department revisits. Acad Emerg Med. 2021;28(9):1001–11. 10.1111/acem.14359 . Castro MRH, Schwartz H, Hernandez S, et al. The Association of Limited English Proficiency With Morbidity and Mortality After Trauma. J Surg Res. 2022;280:326–32. 10.1016/j.jss.2022.07.044 . Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012;27(10):1294–9. 10.1007/s11606-012-2041-5 . Yun K, Fuentes-Afflick E, Desai MM. Prevalence of chronic disease and insurance coverage among refugees in the United States. J Immigr Minor Health. 2012;14(6):933–40. 10.1007/s10903-012-9618-2 . Lutsey PL, Diez Roux AV, Jacobs DR Jr, et al. Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Public Health. 2008;98(11):1963–70. 10.2105/AJPH.2007.123844 . Rodríguez RL, Elliott MN, Vestal KD, Suttorp MJ, Schuster MA. Determinants of health insurance status for children of Latino immigrant and other US farm workers: findings from the National Agricultural Workers Survey. Arch Pediatr Adolesc Med. 2008;162(12):1175–80. 10.1001/archpedi.162.12.1175 . Vargas Bustamante A, Fang H, Garza J, Carter-Pokras O, Wallace SP, Rizzo JA, Ortega AN. Variations in Healthcare Access and Utilization Among Mexican Immigrants: The Role of Documentation Status. J Immigr Minor Health. 2012;14:146–55. doi.org/10.1007/s10903-010-9406-9 . Bustamante AV, Chen J, McKenna RM, Ortega AN. Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act. J Immigr Minor Health. 2019;21(2):211–8. 10.1007/s10903-018-0741-6 . Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41(4 Pt 1):1501–18. 10.1111/j.1475-6773.2006.00552.x . Klinger EV, Carlini SV, Gonzalez I, St Hubert S, Linder JA, Rigotti NA, Kontos EZ, Park ER, Marinacci LX, Haas JS. Accuracy of race, ethnicity, and language preference in an electronic health record. J Gen Intern Med. 2015;30(6):719–23. 10.1007/s11606-014-3102-8 . Rajaram A, Thomas D, Sallam F, Verma AA, Rawal S. Accuracy of the Preferred Language Field in the Electronic Health Records of Two Canadian Hospitals. Appl Clin Inf. 2020;11(4):644–9. 10.1055/s-0040-1715896 . Leeies M, Grunau B, Askin N, et al. Equity-relevant sociodemographic variable collection in emergency medicine: A systematic review, qualitative evidence synthesis, and recommendations for practice. Acad Emerg Med. 2023;30(7):742–59. 10.1111/acem.14629 . Singh GK, Rodriguez-Lainz A, Kogan MD. Immigrant health inequalities in the United States: use of eight major national data systems. Sci World J. 2013;2013:512313. 10.1155/2013/512313 . Semere W, Yun K, Ahalt C, Williams B, Wang EA. Challenges in Identifying Refugees in National Health Data Sets. Am J Public Health. 2016;106(7):1231–2. 10.2105/AJPH.2016.303201 . Kim G, Molina US, Saadi A. Should Immigration Status Information Be Included in a Patient's Health Record? AMA J Ethics. 2019;21(1):E8–16. doi.org/10.1001/amajethics.2019.8 . Brodeur M, Herrick J, Guardioloa J, Richman P. Exclusion of Non-English Speakers in Published Emergency Medicine Research - A Comparison of 2004 and 2014. Acta Inf Med. 2017;25(2):112–5. 10.5455/aim.2017.25.112-115 . Zeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health. 2023;25(1):181–9. 10.1007/s10903-022-01368-y . Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. doi.org/10.1191/1478088706qp063oa . Wieland ML, Wu ST, Kaggal VC, Yawn BP. Tracking health disparities through natural-language processing. Am J Public Health. 2013;103(3):448–9. 10.2105/AJPH.2012.300943 . Levison J, Triant V, Losina E, Keefe K, Freedberg K, Regan S. Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record. Appl Clin Inf. 2014;5(2):557–70. 10.4338/ACI-2014-02-RA-0013 . Heintzman J, Marino M, Clark K, Cowburn S, Sosa S, Cancel L, Ezekiel-Herrera D, Cohen D. Using Electronic Health Record Data to Study Latino Immigrant Populations in Health Services Research. J Immigr Minor Health. 2020;22(4):754–61. 10.1007/s10903-019-00925-2 . Schweikart SJ. Should Immigration Status Information Be Considered Protected Health Information? AMA J Ethics. 2019;21(1):E32–7. doi.org/10.1001/amajethics.2019.32 . Duong LM, Singh SD, Buchanan N, Phillips JL, Gerlach K. Evaluation of primary/preferred language data collection. J Registry Manag. 2012;39(3):121–32. Cook L, Espinoza J, Weiskopf NG, Mathews N, Dorr DA, Gonzales KL, Wilcox A, Madlock-Brown C, N3C Consortium. JMIR Med Inf. 2022;10(9):e39235. https://doi.org/10.2196/39235 . Issues With Variability in Electronic Health Record Data About Race and Ethnicity: Descriptive Analysis of the National COVID Cohort Collaborative Data Enclave. Yun K, Mohamad Z, Kiss L, Annamalai A, Zimmerman C. History of Persecution and Health Outcomes Among U.S. Refugees. J Immigr Minor Health. 2016;18(1):263–9. 10.1007/s10903-015-0176-2 . Ziersch A, Due C, Walsh M. Discrimination: a health hazard for people from refugee and asylum-seeking backgrounds resettled in Australia. BMC Public Health. 2020;20:108. doi.org/10.1186/s12889-019-8068-3 . Allen JD, Caspi C, Yang M, et al. Pathways between acculturation and health behaviors among residents of low-income housing: the mediating role of social and contextual factors. Soc Sci Med. 2014;123:26–36. 10.1016/j.socscimed.2014.10.034 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 May, 2025 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted Editorial decision: Revision requested 04 Dec, 2024 Reviews received at journal 26 Nov, 2024 Reviewers agreed at journal 21 Nov, 2024 Reviews received at journal 07 Nov, 2024 Reviewers agreed at journal 29 Oct, 2024 Reviewers invited by journal 28 Oct, 2024 Editor assigned by journal 21 Sep, 2024 Submission checks completed at journal 21 Sep, 2024 First submitted to journal 19 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4941083","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":357274054,"identity":"a80d0e0e-5e94-44c3-ae65-ae5a776197f8","order_by":0,"name":"Preethi Ravi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYLACxgYJMH3gA0yEh5CWg1AtB2eQoAVCM8NV4tNiLn344OOPOywYzNvPGB62qdgmZz4jgfHB2zbcWiz70pINDp6RYJA5k2NwOOfMbWOZGwnMhnPxaDE4w2MmcbBNgkGCIS3hcG7b7cQZEgls0rx4tfB//wHWwv8s4bDlP7AW9t/4tfCwMYC1SCQfOMzYALGFGZ8Wyx42Y4mzbRI8EhKPDxzsOXbbWILnYbPknHO4tZjzMD/8UNlWJyfBn9j84UfNbTkJ9uSDH96U4XEYlEaKCIHEBtzqkbQgAf4DeHWMglEwCkbByAMAfRhRbSGWElUAAAAASUVORK5CYII=","orcid":"","institution":"Emory University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Preethi","middleName":"","lastName":"Ravi","suffix":""},{"id":357274055,"identity":"d973edf6-585f-49e6-a68a-e20a753d14e8","order_by":1,"name":"Margaret Smith","email":"","orcid":"","institution":"Department of Internal Medicine, University of California, San Diego","correspondingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Smith","suffix":""},{"id":357274056,"identity":"13e3044c-2222-4818-910c-a5dd2fa001da","order_by":2,"name":"Sabrina Bogović","email":"","orcid":"","institution":"Emory University Rollins School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Sabrina","middleName":"","lastName":"Bogović","suffix":""},{"id":357274057,"identity":"bd1cb70d-c36f-453e-b4ec-3cc68036e838","order_by":3,"name":"Camille Lin","email":"","orcid":"","institution":"Department of Family Medicine, Prisma Health Tuomey Hospital","correspondingAuthor":false,"prefix":"","firstName":"Camille","middleName":"","lastName":"Lin","suffix":""},{"id":357274058,"identity":"d29a057e-25dd-41bc-bd33-449b9ee724a5","order_by":4,"name":"Anna Yaffee","email":"","orcid":"","institution":"Department of Emergency Medicine, Emory University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Yaffee","suffix":""},{"id":357274059,"identity":"b939acd8-3e0e-4ca9-b5e8-c1ee16dbbb9c","order_by":5,"name":"Matthew Dudgeon","email":"","orcid":"","institution":"Department of Medicine, Emory University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Matthew","middleName":"","lastName":"Dudgeon","suffix":""},{"id":357274060,"identity":"b3cea525-1384-4d79-9016-593689a51e47","order_by":6,"name":"Amy Zeidan","email":"","orcid":"","institution":"Department of Emergency Medicine, Emory University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Zeidan","suffix":""}],"badges":[],"createdAt":"2024-08-20 00:20:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4941083/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4941083/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10903-025-01698-7","type":"published","date":"2025-05-24T15:58:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83460151,"identity":"d6bc9020-b4f9-448c-ac9c-50212cb1122c","added_by":"auto","created_at":"2025-05-26 16:11:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":486294,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4941083/v1/78159f7a-9415-42fa-ab73-b4ea404778bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characterizing identifiers for immigrant populations in Electronic Health Records","fulltext":[{"header":"Background","content":"\u003cp\u003eIn the past 40 years, the number of individuals living in the United States (U.S.) who speak a language other than English has increased dramatically, now representing nearly one-fifth of the U.S. population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Non-English Language Preference (NELP) individuals, many of whom identify as immigrants, face significant challenges in accessing and receiving health care in the U.S. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Language barriers alone are associated with adverse outcomes during hospitalization, increased ED revisits, increased hospital length of stay, and higher readmission rate within 30 days [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, immigrants experience a relatively high burden of chronic disease with varying levels of health care access and utilization, yet the true extent of health disparities and interventions to address disparities faced by this population is still under investigation [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. One of the difficulties in understanding health needs and addressing health inequities is the challenge of ethically and appropriately identifying this heterogeneous population in health care settings.\u003c/p\u003e \u003cp\u003eHealth systems have historically recorded patients\u0026rsquo; race, ethnicity and primary language in Electronic Health Records (EHRs) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, previous studies have demonstrated underreporting and inaccuracies of these labels [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, there are increasing concerns over the collection of equity-centered demographic variables in EHRs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Currently, there are no widely accepted EHR identifiers for immigrant populations, which makes identification in EHRs and national health datasets difficult [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Clinician scholars have recommended avoidance of documenting immigration status in the health record, but use of other variables has not been extensively explored [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While some proxy identifiers have been used (e.g., insurance status, insurability), these can vary by state and hospital [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Challenges with identification are problematic for clinicians and researchers and have resulted in exclusion of immigrants from published research studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Measures to identify immigrants in EHRs are important for clinical and research purposes but must also be acceptable and ethical. Our objective was to explore identifiers that could be used universally in EHRs from the perspectives of stakeholders involved in immigration-related research, clinical care, and community engagement.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis qualitative study included semi-structured interviews with key informants who work with immigrant populations. This approach was selected as prior data on EHR identifiers is limited, particularly data that incorporates the perspectives of those who care for, represent, and conduct research with this population. This approach also creates a flexible environment to explore a range of experiences and suggestions for identifiers that would accurately reflect this population and be ethical for utilization in EHRs widely. This study was approved by the university\u0026rsquo;s Institutional Review Board and aligns with Consolidated Criteria for Reporting Qualitative Research (COREQ) Reporting.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting and Population\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted with key informants, defined as clinicians, researchers and community leaders who work with immigrant populations. We use the term \u0026ldquo;immigrant populations\u0026rdquo; to be as inclusive as possible; it includes refugees, people seeking asylum, and those with other statuses. Key informants were recruited at a national level through the Society of Refugee Healthcare Providers (SRHP) Research Committee (which operates in the U.S. and Canada), locally through a refugee Community Advisory Board (CAB), and through contacts within the study team\u0026rsquo;s networks. We included both local and national key informants to understand if any site/region-specific themes emerged given the geographical variability of resettlement. Recruitment was conducted via an email from a study team member who is a member of both the SRHP Research Committee and CAB (AZ). Purposive sampling was utilized to balance the distribution of key informant professions/roles in the community.\u003c/p\u003e\n\u003ch3\u003eStudy Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eStudy Protocol\u003c/div\u003e \u003cp\u003eWe conducted semi-structured interviews with key informants using an interview guide developed by the study team. The interview guide explored participants' knowledge of current systems of identification of refugees/immigrants in EHRs, the importance of identification, suggestions for possible identifiers, ethical issues accompanying identifiers, and logistics including potential locations identifiers are recorded within EHRs. The interview guide was piloted with two physicians who work with, conduct research with, and represent immigrant populations, and refined thereafter. All interviews were conducted one-on-one by a study team member who was a medical student at the time with prior experience working with a resettlement agency (MS) over a video conference platform (Zoom). The interviewer had no prior interactions with the key informants and was trained in qualitative interviewing. Demographic information was collected at the end of each interview. Interviews were recorded, professionally transcribed, and conducted until thematic saturation was reached. While there are no formal sample size recommendations for qualitative studies, thematic saturation is generally achieved with six to twelve interviews [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eA thematic analysis approach was utilized to analyze interview data [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The study team initially reviewed all key informant transcripts and developed a preliminary code book. Two study team members trained in qualitative analysis then independently coded all transcripts using Dedoose (AZ, SB). The study team met regularly to refine the code book, resolve coding differences by consensus, and identify prominent themes from each group (AZ, SB, PR).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 13 key informants, six were based in the state where the study team is located, six resided elsewhere in the U.S., and one was based in Canada. All interviews were conducted in English; however the majority of participants (n\u0026thinsp;=\u0026thinsp;10) also spoke a language other than English. The majority of participants were born in the U.S. (n\u0026thinsp;=\u0026thinsp;11). The mean age of participants was 40.6 years and the mean years of working with refugee and immigrant populations was 11.8 years. Most of the participants identified as female (n\u0026thinsp;=\u0026thinsp;12) and over half (n\u0026thinsp;=\u0026thinsp;7) identified as a race/ethnicity other than white. Seven of the participants worked in clinical settings, two participants identified as educators, two participants identified as students, and five participants identified themselves as community leaders.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eKey Informant Themes\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eCurrent use and implications of immigration-related identifiers\u003c/h2\u003e \u003cp\u003eWe found no difference in key themes by site/region. There was general consensus among the key informants interviewed that there is no single most effective method to identify patients who are immigrants within EHRs at present; however, a significant need for this exists (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Key informants described the importance of being able to identify immigrant patients in EHRs in a safe, confidential, and acceptable way in order to better characterize their health care needs, facilitate access to support services, and engender more robust research. Importantly, identifiers should also be collected in a systematic manner to ensure all immigrants are appropriately identified.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and Representatives Quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote(s)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent use and implications of immigration-related identifiers\u003c/p\u003e \u003cp\u003e\u003cem\u003eProvider knowledge about immigration\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;the backgrounds that comes with [different] legal statuses and the benefits that are available to each of those legal statuses really impacts, again, what they need in the healthcare system, what their lives are like outside of their healthcare, and how we think about researching those different subpopulations\u0026rdquo; (Key Informant 8)\u003c/p\u003e \u003cp\u003e\u0026ldquo;there should be a way to identify [refugees and immigrants], but in a safe way that maintains their confidentiality and protection, and that's acceptable to them\u0026rdquo; (Key Informant 7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;immigration status also impacts a lot of [individuals\u0026rsquo;] health behaviors, their level of fear and hesitation of interacting with the health care system and also the types of services that they receive\u0026rdquo; (Key Informant 7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;it's like this perfect conundrum that we say your immigrant identity or your immigration status confers extra health risks or disparities, and yet we cannot measure that. And so I just think it's a fundamental challenge that the immigrant health research discipline has. You can't measure the effect of something if you can't identify it\u0026rdquo; (Key Informant 6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I just feel like you [have] to be really clear about why you're asking these questions, and what our health systems are doing with them... It's so tricky how to help people understand the motivation for asking without restigmatizing and kind of othering people\u0026rdquo; (Key Informant 6)\u003c/p\u003e \u003cp\u003e\u0026ldquo;there is lack of information on the part of health care providers and health care systems about what that documentation [immigrant or refugee-related] can be used for\u0026rdquo; (Key Informant 7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;when you're trying to look population wide at a medical record, people's knowledge about immigration status is so varied. And I just find it to be dramatically inaccurate when people have written what they think is going on in the record\u0026rdquo; (Key Informant 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I would say primary language, like language spoken at home is probably the most important. It gives us a number of sort of implied data points... language becomes a really clear proxy for ethnicity and a lot of cultural background and differences\u0026rdquo; (Key Informant 8)\u003c/p\u003e \u003cp\u003e\u0026ldquo;the health system has this one demographic field, which is for preferred language. But what we have in our social history, specifically in our new arrivals clinic [is] a question about what languages different people in the family speak...I found it's very well-accepted\u0026rdquo; (Key Informant 10)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think it's always good to allow a patient if they prefer to speak in English to have that opportunity, but to also know where their other language proficiencies are because there may be a point in time where there is a barrier in communication where you would need to bring in a cultural or a language broker to help bridge that gap\u0026rdquo; (Key Informant 11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI think when I think about implementing something across a health system, I find country of birth appealing because it is so concrete, and it's a question that can be asked of everybody... and also know if someone was born in one country but didn't spend most of their life there, they might have risk factors that are linked to where they lived subsequently that would be important to know about\u0026rdquo; (Key Informant 10)\u003c/p\u003e \u003cp\u003e\u0026ldquo;different countries of origin have different disease profiles, and so it helps you to figure out like what type of health issues that person is at risk for\u0026rdquo; (Key Informant 7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;knowing where somebody is from, which country they identify with, they consider home, I think that is important in terms of caring for [that] population: knowing about certain cultural practices... knowing that there may have been a civil war recently and this individual may have been traumatized, knowing that the incidence of hepatitis B is much higher in certain countries\u0026rdquo; (Key Informant 4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime in US/country of resettlement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;I think it's more if being in the United States for a long time signifies that you're better able to navigate the health system. So I tend to think more about kind of what sort of support you would need to access care...there are some things where the importance of screening certainly seems less urgent after someone [has] been here a long time\u0026rdquo; (Key Informant 10)\u003c/p\u003e \u003cp\u003e\u0026ldquo;acculturation has a really big impact on health, and somebody who has lived here for 20 or 30 years has a completely different health profile than somebody who has just arrived\u0026rdquo; (Key Informant 7)\u003c/p\u003e \u003cp\u003e\u0026ldquo;It starts to be a complicated interplay with duration of residence and what your status was along those time points. Our newly arrived refugees who are on a pathway to citizenship do much better in general than our asylees who've been waiting for five years and are still insecure about their immigration status\u0026rdquo; (Key Informant 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace/ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;Until we have a better system of appreciating and understanding diversity and providing precision patient-centric care that includes not only the social and structural determinants [of] health, but their biometric information as well, we're going to have to continue to collect [race] because that's, again, how money is appropriated. That's how the census counts individuals. That's how grants are funded\u0026rdquo; (Key Informant 11)\u003c/p\u003e \u003cp\u003e\u0026ldquo;some countries have tribes or ethnic groups that are minor ethnic groups so sometimes people do not want to identify with their ethnic group in fear of... [being] profiled, targeted\u0026rdquo; (Key Informant 9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eKey informants discussed the challenges associated with labels including \u0026ldquo;refugee\u0026rdquo; and \u0026ldquo;immigrant,\u0026rdquo; as they are defined inconsistently and pose material risk to patients, ranging from bias in clinical care to more extensive legal ramifications, including possible deportation. Documenting immigration status was described as egregiously unethical, as clinicians are unable to ensure that such information remains confidential within EHRs. Ethical implications related to potentially enabling bias or differential treatment resulting in disparities in care, and violating HIPAA were also discussed. Participants emphasized that immigration is a dynamic process that encompasses a multitude of experiences; using concrete identifiers has the potential to force people into categories that may not fully describe them, limiting our understanding of diverse populations in key clinical and research contexts. Key informants also described inconsistencies among health care providers regarding knowledge about the immigration process, including related policies and practices, leading to potential inaccuracies in documentation. Without understanding the effects of immigration on individuals\u0026rsquo; access to health care, insurance, and other services, it is also difficult for providers to appreciate patients\u0026rsquo; lived experiences, in addition to what certain immigration-related identifiers in EHRs may signify.\u003c/p\u003e \u003cp\u003eKey informants named language, country of origin, time in the US, and race/ethnicity as potential identifiers for immigrant patients (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Other surrogate identifiers including social vulnerability indices and engagement in social services (e.g., through refugee resettlement agencies) were also described as potential ways to identify immigrants within health systems; however, due to the diversity and lack of standardization of surrogate identifiers, participants expressed caution related to their use. Additionally, key informants stressed the importance of how questions about identifiers are asked and by whom. They recommended that sensitive questions be asked by a trusted member of the health care team with the assurance of confidentiality and a pre-emptive explanation regarding why these questions are being asked.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePotential Identifiers: Language, Country of Origin, Time in the US, Race/Ethnicity\u003c/h3\u003e\n\u003cp\u003eDocumenting \u003cem\u003elanguage\u003c/em\u003e serves a practical purpose as it facilitates the involvement of interpreters to ensure that individuals are appropriately understood and represented in health care contexts. Languages spoken by very specific populations are most useful in identifying members of those populations; however, people of multiple cultural groups, ethnicities, and/or nationalities often speak a common language, making language less useful to understand individuals\u0026rsquo; sociocultural backgrounds, including if and where they may have emigrated from. Key informants also underscored how identifying with a non-English primary language may contribute to disparities in care.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCountry of origin\u003c/em\u003e was generally accepted as an appropriate and ethical identifier that could improve clinician and researcher understanding of patients\u0026rsquo; backgrounds. It yields information related to an individual\u0026rsquo;s sociocultural context that may affect their health or health care access; however, similar to language, country of origin does not distinguish between the different cultural, ethnic, or other sub-populations that may live in the same country. It may also elucidate disease risk based on disease epidemiology in one\u0026rsquo;s country of origin. Many patients have complex migration histories, however, which limit the utility of country of origin as an identifier. It is possible that these individuals have spent more time living in a host or transition country (e.g., in a refugee camp in a neighboring country) than in their documented country of origin, which would substantially decrease the utility of disease risk profiles formulated based on their countries of origin.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTime in the United States\u003c/em\u003e (or other country of resettlement) bears the implication that an individual is an immigrant and also provides information related to health status. People who have spent more time in their country of resettlement are more likely to adopt health behaviors that match those of the majority where they live. Key informants described differences in health care needs, access to health care, and health behaviors between people who have spent less time versus more time in the U.S.\u003c/p\u003e \u003cp\u003eKey informants emphasized the longstanding, pervasive use of \u003cem\u003erace and ethnicity\u003c/em\u003e to identify patients in EHRs. While race and ethnicity can provide some information related to patients\u0026rsquo; backgrounds and experiences, they are of limited value because, as identifiers, they fail to distinguish immigrants from individuals born in the U.S. Additionally, individuals of certain persecuted ethnic groups may hesitate to share this information due to fear of perceived repercussions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results highlight broad limitations in identifying immigrant populations within health systems, specifically through the use of EHRs. At present, there are no standards for the documentation of immigrants in EHRs which further highlights the critical need for this research. As emphasized by our findings, discerning strong identifiers is a complicated endeavor which involves several ethical considerations and important nuances; given this, participants in this study generally felt that language, country of origin, time in the U.S. (or other country of resettlement), and race/ethnicity were useful and acceptable variables to collect. The process by which identifiers are collected and documented was also recognized as important, with special consideration for how measures are gleaned and documented, and by whom. Notably, no single identifier can be used in isolation to effectively identify immigrant patients or fully understand their sociocultural contexts. As a starting point, using multiple strong identifiers, incorporated into universal screening within health systems, is an important way to improve clinical and research endeavors related to this population, emphasizing that the strength of these identifiers may vary across populations and with respect to the contexts in which they are collected.\u003c/p\u003e \u003cp\u003eTo our knowledge, this is among the first studies that utilizes qualitative methods to explore strong identifiers for immigrant populations. Existing studies have attempted to identify patients using other primarily data-based methods, without assessing the utility or acceptability of identifiers from the perspectives of key informants who closely interface with immigrant patients. Rule-based natural language processing algorithms and EHR-based algorithms that extract specific proxy variables to determine health status (e.g., HIV status) or immigration-related characteristics (e.g., documentation status) of immigrant patients have been used previously, though they vary in sensitivity and specificity [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Proxies used by these studies include race/ethnicity and language, affirming our finding that these are suitable identifiers for immigrant patients. However, utilizing proxy variables that are unique to a specific population and context may not be generalizable to or acceptable for use in all settings.\u003c/p\u003e \u003cp\u003eAs researchers have outlined previously, and as supported by our findings, there is an ethical obligation to minimize documentation of information that poses substantial risk to patients, including documentation status [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Clinicians are hesitant to ask immigration-related questions due to uncertainty about what should be asked, how information should be documented, and how documented information can and will potentially be used. Documentation status, like other individually identifiable health information, should be considered protected health information; however, due to the potential legal risk to patients\u0026mdash; including the potential use of information related to documentation status for prosecution and deportation\u0026mdash; it is not ethical to include documentation status in EHRs in any capacity [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The political climate in the U.S. and other parts of the world, characterized by long-standing and escalating anti-immigrant rhetoric and policy, not only informs what we are able to safely and ethically document in EHRs, but also underscores the need to use objective language and carefully evaluate the presence of implicit and explicit bias in how we document information about immigrant patients. Using indirect information, including the identifiers outlined by this study, potentially circumvents this risk by providing information about individuals\u0026rsquo; backgrounds and social contexts without mention of documentation status. However, these identifiers should still be used with caution and with appropriate protections to ensure this information is used only for clinical and research purposes within the context of health care settings.\u003c/p\u003e \u003cp\u003eNotably, there are several nuances to consider when using the identifiers suggested, especially if used in isolation. For example, primary/preferred language is currently recorded in most health care contexts but the method by which this information is collected and utilized (e.g., to provide interpretation-related services) varies greatly, affecting its utility as an identifier universally [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Immigrant patients may also identify English as their primary language and/or be multilingual, and therefore not identified by this variable. Race and ethnicity are widely recorded across health systems; however, there is also substantial variability in how this information is ascertained and documented, limiting its utility [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Country of origin fails to encompass details related to an individual's migration history and whether an individual belongs to a specific sub-population within a specific country. It also fails to capture persecution or discrimination experienced by individuals in their home countries; these individuals are more likely to experience worse outcomes related to both mental and physical health [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Additionally, an individual's country of origin may not align with their family history or ancestry, and may not reflect where they may have lived and for how long. Time in the U.S. may serve as a surrogate for acculturation, which influences health behaviors and access to health care. Immigrants who have lived in the U.S. for longer are more likely to have more robust social networks, greater access to material resources, and a better understanding of systems including health care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther research is needed to validate the identifiers we have suggested to ensure that they are effective and acceptable to use. Most importantly, it is essential that the perspectives of immigrant patients are obtained to not only validate these identifiers, but also discern other relevant identifiers and ensure that all identifiers used are population driven. Once potential identifiers are confirmed, additional research will be needed to evaluate best practices for implementation and operationalization of identifiers in EHRs.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are several limitations specific to this study. Interviews were conducted with key informants, some of whom identify as immigrants; however, we did not interview immigrant patients whose perspectives are of utmost importance. We decided to interview key informants first to discern a range of identifiers that could then be explored with immigrant patients. Key informants had significant knowledge of clinical care and research endeavors specific to immigrant populations, which was important in establishing potential identifiers; however, these identifiers may not fully reflect those used by clinicians in routine practice. Further, the perspectives of our key informants, though from across the U.S., may not be broadly applicable to different contexts across the country (e.g., rural vs. urban) due to substantial variability among immigrant populations by state, region, and even city. As such, identifiers should be explored in relation to the local context of a specific health system prior to application. Finally, we did not interview any hospital-based legal counsel who could potentially comment on the legal ramifications of identifiers and/or specific hospital-based legal policies and practices.\u003c/p\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003eNo competing interests to disclose.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements: \u003c/h2\u003e\n\u003cp\u003eFunding: [university] Global Health Institute\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNew Contribution to the Literature\u003c/h2\u003e \u003cp\u003eThis is one of the first studies to qualitatively explore useful, acceptable, and ethical identifiers for immigrant populations within health systems, as they are documented in EHRs. Currently there is no standardized or widely-accepted way to identify immigrant populations in EHRs, and improved recognition is critical for both clinical and research purposes. Through interviews with key informants, we established potential identifiers that were perceived as useful, acceptable, and ethical, including language, country of origin, time in the U.S., and race/ethnicity. As we have outlined, no single identifier perfectly encompasses the diverse, complex, and dynamic experiences of immigrants, and therefore, it may be more effective to utilize multiple identifiers in combination.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.Y., M.D., and A.Z. conceived and designed the study. M.S. and A.Z. recruited study participants. M.S. acquired data. P.R., M.S., S.B., and A.Z. analyzed data, and all authors interpreted data. P.R. and A.Z. drafted the manuscript and prepared table 1. All authors revised the manuscript, and A.Z. critically revised the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript. Additional data (e.g., coded segments, unedited table 1) can be provided by the authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDietrich S, Hernandez E. Nearly 68 Million People Spoke a Language Other Than English at Home in 2019. In: What Languages Do We Speak in the United States? United States Census Bureau. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html\u003c/span\u003e\u003cspan address=\"https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 15 Aug 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWelty E, Yeager VA, Ouimet C, Menachemi N. Patient satisfaction among Spanish-speaking patients in a public health setting. J Healthc Qual. 2012;34(5):31\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1945-1474.2011.00158.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1945-1474.2011.00158.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDivi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/intqhc/mzl069\u003c/span\u003e\u003cspan address=\"10.1093/intqhc/mzl069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePortillo EN, Stack AM, Monuteaux MC, Curt A, Perron C, Lee LK. Association of limited English proficiency and increased pediatric emergency department revisits. Acad Emerg Med. 2021;28(9):1001\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/acem.14359\u003c/span\u003e\u003cspan address=\"10.1111/acem.14359\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastro MRH, Schwartz H, Hernandez S, et al. The Association of Limited English Proficiency With Morbidity and Mortality After Trauma. J Surg Res. 2022;280:326\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jss.2022.07.044\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2022.07.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012;27(10):1294\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-012-2041-5\u003c/span\u003e\u003cspan address=\"10.1007/s11606-012-2041-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYun K, Fuentes-Afflick E, Desai MM. Prevalence of chronic disease and insurance coverage among refugees in the United States. J Immigr Minor Health. 2012;14(6):933\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-012-9618-2\u003c/span\u003e\u003cspan address=\"10.1007/s10903-012-9618-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLutsey PL, Diez Roux AV, Jacobs DR Jr, et al. Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis. Am J Public Health. 2008;98(11):1963\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2007.123844\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2007.123844\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodr\u0026iacute;guez RL, Elliott MN, Vestal KD, Suttorp MJ, Schuster MA. Determinants of health insurance status for children of Latino immigrant and other US farm workers: findings from the National Agricultural Workers Survey. Arch Pediatr Adolesc Med. 2008;162(12):1175\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archpedi.162.12.1175\u003c/span\u003e\u003cspan address=\"10.1001/archpedi.162.12.1175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVargas Bustamante A, Fang H, Garza J, Carter-Pokras O, Wallace SP, Rizzo JA, Ortega AN. Variations in Healthcare Access and Utilization Among Mexican Immigrants: The Role of Documentation Status. J Immigr Minor Health. 2012;14:146\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1007/s10903-010-9406-9\u003c/span\u003e\u003cspan address=\"10.1007/s10903-010-9406-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBustamante AV, Chen J, McKenna RM, Ortega AN. Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act. J Immigr Minor Health. 2019;21(2):211\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-018-0741-6\u003c/span\u003e\u003cspan address=\"10.1007/s10903-018-0741-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41(4 Pt 1):1501\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1475-6773.2006.00552.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1475-6773.2006.00552.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlinger EV, Carlini SV, Gonzalez I, St Hubert S, Linder JA, Rigotti NA, Kontos EZ, Park ER, Marinacci LX, Haas JS. Accuracy of race, ethnicity, and language preference in an electronic health record. J Gen Intern Med. 2015;30(6):719\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11606-014-3102-8\u003c/span\u003e\u003cspan address=\"10.1007/s11606-014-3102-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajaram A, Thomas D, Sallam F, Verma AA, Rawal S. Accuracy of the Preferred Language Field in the Electronic Health Records of Two Canadian Hospitals. Appl Clin Inf. 2020;11(4):644\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0040-1715896\u003c/span\u003e\u003cspan address=\"10.1055/s-0040-1715896\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeeies M, Grunau B, Askin N, et al. Equity-relevant sociodemographic variable collection in emergency medicine: A systematic review, qualitative evidence synthesis, and recommendations for practice. Acad Emerg Med. 2023;30(7):742\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/acem.14629\u003c/span\u003e\u003cspan address=\"10.1111/acem.14629\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh GK, Rodriguez-Lainz A, Kogan MD. Immigrant health inequalities in the United States: use of eight major national data systems. Sci World J. 2013;2013:512313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1155/2013/512313\u003c/span\u003e\u003cspan address=\"10.1155/2013/512313\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemere W, Yun K, Ahalt C, Williams B, Wang EA. Challenges in Identifying Refugees in National Health Data Sets. Am J Public Health. 2016;106(7):1231\u0026ndash;2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2016.303201\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2016.303201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim G, Molina US, Saadi A. Should Immigration Status Information Be Included in a Patient's Health Record? AMA J Ethics. 2019;21(1):E8\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1001/amajethics.2019.8\u003c/span\u003e\u003cspan address=\"10.1001/amajethics.2019.8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrodeur M, Herrick J, Guardioloa J, Richman P. Exclusion of Non-English Speakers in Published Emergency Medicine Research - A Comparison of 2004 and 2014. Acta Inf Med. 2017;25(2):112\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5455/aim.2017.25.112-115\u003c/span\u003e\u003cspan address=\"10.5455/aim.2017.25.112-115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health. 2023;25(1):181\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-022-01368-y\u003c/span\u003e\u003cspan address=\"10.1007/s10903-022-01368-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWieland ML, Wu ST, Kaggal VC, Yawn BP. Tracking health disparities through natural-language processing. Am J Public Health. 2013;103(3):448\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/AJPH.2012.300943\u003c/span\u003e\u003cspan address=\"10.2105/AJPH.2012.300943\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevison J, Triant V, Losina E, Keefe K, Freedberg K, Regan S. Development and validation of a computer-based algorithm to identify foreign-born patients with HIV infection from the electronic medical record. Appl Clin Inf. 2014;5(2):557\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4338/ACI-2014-02-RA-0013\u003c/span\u003e\u003cspan address=\"10.4338/ACI-2014-02-RA-0013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeintzman J, Marino M, Clark K, Cowburn S, Sosa S, Cancel L, Ezekiel-Herrera D, Cohen D. Using Electronic Health Record Data to Study Latino Immigrant Populations in Health Services Research. J Immigr Minor Health. 2020;22(4):754\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-019-00925-2\u003c/span\u003e\u003cspan address=\"10.1007/s10903-019-00925-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchweikart SJ. Should Immigration Status Information Be Considered Protected Health Information? AMA J Ethics. 2019;21(1):E32\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1001/amajethics.2019.32\u003c/span\u003e\u003cspan address=\"10.1001/amajethics.2019.32\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuong LM, Singh SD, Buchanan N, Phillips JL, Gerlach K. Evaluation of primary/preferred language data collection. J Registry Manag. 2012;39(3):121\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook L, Espinoza J, Weiskopf NG, Mathews N, Dorr DA, Gonzales KL, Wilcox A, Madlock-Brown C, N3C Consortium. JMIR Med Inf. 2022;10(9):e39235. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/39235\u003c/span\u003e\u003cspan address=\"10.2196/39235\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Issues With Variability in Electronic Health Record Data About Race and Ethnicity: Descriptive Analysis of the National COVID Cohort Collaborative Data Enclave.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYun K, Mohamad Z, Kiss L, Annamalai A, Zimmerman C. History of Persecution and Health Outcomes Among U.S. Refugees. J Immigr Minor Health. 2016;18(1):263\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10903-015-0176-2\u003c/span\u003e\u003cspan address=\"10.1007/s10903-015-0176-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZiersch A, Due C, Walsh M. Discrimination: a health hazard for people from refugee and asylum-seeking backgrounds resettled in Australia. BMC Public Health. 2020;20:108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.1186/s12889-019-8068-3\u003c/span\u003e\u003cspan address=\"10.1186/s12889-019-8068-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen JD, Caspi C, Yang M, et al. Pathways between acculturation and health behaviors among residents of low-income housing: the mediating role of social and contextual factors. Soc Sci Med. 2014;123:26\u0026ndash;36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2014.10.034\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2014.10.034\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"immigrant health, refugee health, electronic health records, patient identifiers, population health, health equity","lastPublishedDoi":"10.21203/rs.3.rs-4941083/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4941083/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe current use of identifiers to describe immigrant patients in Electronic Health Records (EHRs) is poorly described and lacks standardization, but nevertheless has broad implications related to clinical care and research of this population. We conducted interviews with key informants to discern strong identifiers for use to identify patients who have immigrated to the United States (U.S.). Language, country of origin, time in the U.S., and race/ethnicity were identified as effective, ethical, and acceptable for use. Limitations of each of these identifiers were noted, highlighting the need to use multiple identifiers in combination when describing patients in EHRs. The processes used to collect these identifiers in clinical settings and the ethical implications of using these identifiers must also be carefully considered. Our results highlight the need for standards related to documentation of immigrant patients in EHRs. Further research is also needed to validate the identifiers we have outlined, discern additional identifiers that are useful and acceptable in specific clinical and research contexts, and explore how strong identifiers can be operationalized in EHRs for clinical, research, and community engagement purposes.\u003c/p\u003e","manuscriptTitle":"Characterizing identifiers for immigrant populations in Electronic Health Records","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-07 08:08:31","doi":"10.21203/rs.3.rs-4941083/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-04T18:50:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-26T17:28:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17510423858539631291330427290578621238","date":"2024-11-21T21:25:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-08T03:48:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191018687225695895611276561394573202457","date":"2024-10-29T19:42:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-29T02:07:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-21T17:13:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-21T17:13:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2024-08-20T00:18:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2941d702-5d60-4a4b-8264-3979bde8a99c","owner":[],"postedDate":"October 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:04:59+00:00","versionOfRecord":{"articleIdentity":"rs-4941083","link":"https://doi.org/10.1007/s10903-025-01698-7","journal":{"identity":"journal-of-immigrant-and-minority-health","isVorOnly":false,"title":"Journal of Immigrant and Minority Health"},"publishedOn":"2025-05-24 15:58:37","publishedOnDateReadable":"May 24th, 2025"},"versionCreatedAt":"2024-10-07 08:08:31","video":"","vorDoi":"10.1007/s10903-025-01698-7","vorDoiUrl":"https://doi.org/10.1007/s10903-025-01698-7","workflowStages":[]},"version":"v1","identity":"rs-4941083","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4941083","identity":"rs-4941083","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}