Behavioral Flags in Pediatric Records: Examining Their Use and Impact on Patient Care

Behavioral flags in electronic health records were initially developed to help identify patients at risk of behaviors that could affect safety in healthcare settings. However, new research from the Department of Pediatrics at UC San Francisco indicates that the way these flags are applied may have unintended consequences, particularly for young children and certain patient populations.

Published in JAMA Network Open, the study is the first to examine behavioral flags in a pediatric setting and provides insights into how they are assigned. The analysis, which reviewed over 50,000 pediatric encounters, found variation in flag application based on factors such as insurance status and demographic characteristics.

How Behavioral Flags May Affect Patient Care

“Having a behavioral warning flag pop up as soon as a patient’s chart opens can shape provider interactions and influence clinical decision-making,” said April Edwell, MD, first author of the study and assistant professor of pediatrics in the Division of Critical Care.

Beyond influencing clinician perceptions, behavioral flags can have significant consequences for patients and families. The study highlights concerns that these flags may contribute to delays in care, increased use of restraints, or escalated interactions with hospital security personnel.

Behavioral Flags in Young Patients

The study examined UCSF hospital data spanning nine years and found that most of the 236 applied behavioral flags were assigned during encounters with children younger than eight. Notably, even infants younger than one year had behavioral flags placed in their records.

“In these cases, behavioral flags may reflect interactions with a patient’s family rather than the child themselves,” explained Edwell. “This raises important questions about how such warnings are used and whether they are always aligned with best practices for pediatric care.”

Ensuring Fair and Appropriate Use of Behavioral Flags

To promote best practices, UCSF has implemented several initiatives aimed at refining how behavioral flags are assigned and reviewed:

• Code CARE Initiative: UCSF has launched a dedicated behavioral de-escalation response team that provides an alternative to security interventions. This team helps facilitate constructive, non-contentious resolutions in challenging situations.
• Enhanced Flag Review Process: Behavioral flags are now limited to a maximum of three years, and a committee reviews each new flag to ensure appropriate and consistent application.
• Ongoing Evaluation of Interventions: UCSF is assessing the impact of the Code CARE team to determine whether these efforts improve the experience of both patients and providers.

“It’s important for healthcare institutions to review their processes regularly to ensure that patient care decisions are data-driven and applied fairly across all groups,” said Edwell.

Looking Ahead

As part of its ongoing efforts to improve pediatric healthcare, UCSF is committed to evaluating how systems like behavioral flags affect clinical care. Future research will assess whether new approaches—such as real-time provider training and patient-centered review processes—can help support equitable and high-quality care for all children.

Other authors from UCSF: Jia Xin Huang, MD; Tasce Bongiovanni, MD, MPP, MHS; and Matthew Pantell, MD, MS.