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Evolving Sex and Gender in Electronic Health Records

Claire Burgess¹, Michael R Kauth¹, Caroline Klemt¹

¹is a Clinical Psychologist at the National TeleMental Health Center at VA Boston Healthcare System (VABHS) and an Instructor at Harvard Medical School in Boston, Massachusetts. is Codirector, Veterans Health Administration (VHA) Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program in Washington, DC; staff member at the National Center for PTSD at VABHS; and Professor of Psychiatry at Boston University School of Medicine in Massachusetts. is Codirector of the VHA South Central Mental Illness Research, Education, and Clinical Center at the Michael E. DeBakey VA Medical Center in Houston, Texas. He is Codirector of the LGBT Health Program and a Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston. is a Clinical Psychologist and Assistant Professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. is a Physician Informacist in systems engineering at the VA National Center for Patient Safety in Ann Arbor, Michigan.

Federal Practitioner : for the Health Care Professionals of the VA, Dod, and PHS

|July 2, 2019

Summary

Implementing a self-identified gender identity field in electronic health records can enhance patient-centered care. This improves healthcare experiences for transgender and gender nonconforming individuals.

Area of Science:

Health Informatics
Patient-Centered Care
LGBTQ+ Health

Background:

Electronic health records (EHRs) are crucial for patient care.
Current EHR systems may lack inclusive fields for gender identity.
This can negatively impact care for transgender and gender nonconforming (TGNC) patients.

Purpose of the Study:

To explore the impact of implementing a self-identified gender identity field in EHR systems.
To assess improvements in patient-centered care for TGNC individuals.

Main Methods:

Development of an EHR field for self-identified gender.
Training healthcare staff on its use.
Documentation of implementation processes.

Main Results:

The implementation of a self-identified gender identity field shows potential.
Improved patient-centered care is a likely outcome for TGNC patients.

Conclusions:

EHR system modifications, including staff training and documentation, are vital.
Such changes can significantly enhance care quality for TGNC populations.

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