Evolving Sex and Gender in Electronic Health Records

Review Process

As part of reviewing and finalizing the SIGI patient fact sheet, the patient safety education work group previewed the document’s content with veterans who provided feedback on drafts to improve comprehension, patient-centered care, and clinical accuracy. For instance, several patients commented that the document should address many gender identities, including intersex identities. As noted in one of the case presentations earlier, individuals who identify as intersex may have changed their birth sex to be consistent with their gender and might benefit from being informed about the EHR’s autocalculation feature. The patient safety education work group adjusted the SIGI patient fact sheet to include individuals who identify as intersex and instructed them to have a conversation with their HCP regarding potential birth sex changes in the EHR.

Much of the veteran feedback to the patient safety education work group reflected veteran concerns, more broadly, about implementation of SIGI. Many veterans were interested in how federal policy changes might affect their benefits package or clinical care within the VA. The SIGI patient fact sheet was a tool for communicating that Department of Defense (DoD) policies, specifically, do not have a bearing on VA care for LGBT veterans. Therefore, SIGI information does not affect service connection or benefits eligibility and is not shared with the DoD. Veterans found this information helpful to see reflected in the SIGI patient fact sheet.

The patient safety education work group also shared the SIGI provider fact sheet with VHA providers before finalizing the content. PCPs gave feedback to improve the specification of patient safety concerns and appropriate readership language. The patient safety education work group adjusted the SIGI provider fact sheet to be inclusive of relevant literature and an e-consultation link for assisting HCPs who are unsure how to proceed with a patient.

Implementation

The patient safety education work group also developed several materials to provide information about the birth sex and SIGI fields in the EHR. Because the SIGI demographic field is new and collected by clerical staff, training was necessary to explain the difference between birth sex and SIGI before implementation in the EHR. The training sessions educated staff about the difference between birth sex and SIGI, how to ask and respond to questions respectfully, and how to update these fields in the EHR. These trainings included a 20-minute video demonstrating best practices for asking about SIGI, a frequently asked questions document responding to 7 common questions about the new fields, and a quick reference guide for administrative staff to have handy at their desks.

Dissemination of the SIGI patient and provider fact sheets is planned to occur, ideally, several weeks before implementation of the new patches updating the EHR fields in spring 2020. Building on existing resources, the patient safety education work group plans to disseminate the patient fact sheets via e-mail lists for the national mental health facility leaders as well as through e-mail lists for VA PCPs, nursing and clerical staff, privacy officers, facility LGBT veteran care coordinators, VISN leads, transgender e-consultation, the Office of Connected Care, the LGBT external homepage for the VA, and the training website for VA employees. The goal is to target potential points of contact for veterans who may have already changed their birth sex and might benefit medically from altering birth sex to be consistent with their original birth certificate.

The SIGI provider fact sheet will be disseminated using internal e-mails, announcements on routine LGBT veteran care coordinator calls, weekly Ask LGBT Health teleconferences, and announcements at LGBT health training events both internally and externally. Several dissemination tools have already ensured that VA employees are aware of the SIGI field in the EHR. Leadership throughout the VA will be encouraged to share SIGI trainings with clerical staff. Additionally, broad-based e-mails summarizing changes to the EHR will be provided concurrent to the SIGI patch implementation to VA staff as well as links to the resources and training materials.