Evolving Sex and Gender in Electronic Health Records

Challenges

One difficulty in the development process for both SIGI fact sheets was addressing the issue of patient safety for veterans who may be at different points in their gender transition process. It was challenging for the patient safety education work group to not sound alarmist in discussing the safety implications of birth sex changes in the EHR, as this is just one factor in clinical decision making. The goal was to educate veterans from a patient safety perspective about the implications of having a state-of-the-art, automated EHR. However, text can be perceived differently by different people, which is why the patient safety education work group asked veterans to preview the patient document and clinical providers to preview the provider document.

Both work groups encountered technologic challenges, including a delay in the implementation of the SIGI field due to a systemwide delay of EHR updates. Although it released training and educational materials to the VHA, the patient safety education work group understood that at some point in the future, VA programmers will update the EHR to change the information clerks and HCPs can see in the EHR. Coordination of the fact sheet release alongside information technology has been an important part of the SIGI rollout process.

Conclusion

HCPs have a complex role in providing treatment to TGNC patients in the VHA: They must affirm a patient’s gender identity through how they address them, while openly communicating the health risks inherent in having their birth sex field be incongruent with the sex recorded on their original birth certificate. Accomplishing these tasks simultaneously is difficult without invalidating the veteran’s identity or right to choose their EHR demographic birth sex label. Furthermore, patients may ask HCPs to write letters of support for either medical or surgical intervention or other documentation changes (eg, changes to a patient’s legal name, passport changes, or a safe passage letter for TGNC patients). Navigating the dialectic of safety and validation requires strong rapport, trust, and effective communication in the patient-provider relationship and great empathy by the provider.

A future task for the SIGI patient safety education work group is to continue to communicate with the technical work group and providers in the field about how demographic fields in the EHR are utilized to enable future EHR changes. This hurdle is not easy because EHR updates change the infrastructure through which demographic content is delivered and incorporated into a patient’s treatment. The VA HCPs are tasked with thoroughly examining the results that automated systems produce to ensure safe and accurate medical services are always provided to all patients. An integral part of patient-centered care is balancing any computer-guided recommendations with an understanding that actual patient needs may differ due to presence/absence of anatomy and other factors (eg, weight, current medications).

From a systems perspective, a benefit of adding the SIGI demographic field is systemic improvement in calculating the number of transgender veterans under VA care and evaluating health outcomes for this population. SIGI is particularly important for signaling gender pronouns for veterans, regardless of whether they are receiving care for a gender-related diagnosis. In terms of scope, the SIGI project potentially will apply to > 9 million enrolled veterans and nearly 400,000 VA employees.

Improvements could be made in the SIGI field of the new EHR, such as expanding the options for self-labels. Additionally, a text field could be used to enhance the quality of personalization provided to veterans self-identifying in the EHR, including pronoun specification. Moreover, adding new fields such as “preferred name” could improve the health care experience of not only TGNC veterans but all veterans who use something other than their full legal name (eg, a nickname). It will be good practice to notify providers and staff of a veteran’s requested name and pronouns when the patient checks in at an electronic kiosk so that all staff immediately know how to address the patient. The VHA can continue to adjust the options for the SIGI field once the new EHR system is operational. Ideally, this new EHR will display birth sex and SIGI to clinicians or clerks engaged in patient interactions.

Technology will continue to automate medical care, meaning that HCPs must be vigilant about how computer programming and the accuracy of prepopulated information affect patient care. The concerns discussed in this report relating to patient safety are relatively absent in the medical literature, even though substantial health risks exist to patients who have birth sex listed incorrectly for any reason.^6,7 Additionally, administrative burden can be reduced if patients who do not need certain screenings based on their current anatomy are not contacted for unnecessary screenings. Future EHR systems might incorporate anatomical considerations from an inventory to assist in automating patient care in safe and accessible ways.