Stratifying Race and Ethnicity for SANER

Variation is the bane of standards.  Eliminating needless variation is part of my job.  Doing it in a way that doesn't increase provider (or developer) burden is an indication that it's been done right.

I've looked at a lot of state and national dashboards while working on the SANER Project, and one thing I notice is the variation in reporting for data with respect to race and ethnicity classifications (strata).  Often, when reported on publicly, these two different categories are combined into smaller sets, with groupings like multiple race, other and unknown.

ONC National Coordinator Micky Tripathi noted Health IT reporting variation for this kind of data in his keynote delivered at a recent Strategic Health Information Exchange Collaborative (SHIEC) conference.

Federal reporting uses separate fields for race and ethnicity, and allow for multiple values to be reported for race.  There are 5 possible values for race (not counting various flavors of unknown), and two values for ethnicity according to OMB Reporting requirements.

Reporting multiple races means that there are several ways to report none (flavors of null including unknown, refused to answer and did not ask), 5 ways to report one race, 10 to report two races, 10 ways report three races, 5 ways to report four, and 1 way to report all five, resulting in around than 33 categories.  

Combining that with the various ways to report ethnicity (again with flavors of none), that results in about 165 possible reporting categories.  Looking at the actual statistics, there are about 50 categories that would generally be needed for a given facility (e.g., frequency > a few tenths of a percent) to stratify populations according to race and ethnicity, if non-existing groupings are not reported on, and perhaps an even smaller number for smaller facilities.  It wouldn't be possible for example, for a 100 bed hospital to even use all of the category combinations.

The data is generally rolled up into a much smaller number of reporting categories which vary between states, and these often also vary with how federal dashboards report the same data.  Different states have different racial and ethnic makeups and the public reporting at race and ethnicity data at these levels is designed to address potential disparities relevant to the state.

Given that many state departments of health  also support reporting to federal agencies, how does one normalize reporting without having to have 51 separate specifications for reporting?

The best way to handle this is to stratify by the combination of race and ethnicity, and report all possible existing combinations.  In other words, don't report 0 values for combinations that don't exist, as that can be inferred from the data.  This enables states to roll up this data into a smaller set of categories for their public reporting, yet retain the data needed for federal reporting, and enable federal reporting to roll up differently.  When automatically computed, this level of stratification does not introduce a reporting burden on the reporting providers.