A paper published in the Journal of the American Medical Informatics Association provides detailed guidance for making changes in electronic health records that will improve the quality of care of patients who are transgender and gender diverse. Authored by leading educators and clinical experts on LGBTQIA+ health care from The Fenway Institute, Fenway Health, and Massachusetts General Hospital, the paper builds on previously published guidance from The Fenway Institute and Fenway Health on how to develop and integrate transgender health programs within existing primary health care practices and how to create culturally responsive health care environments for LGBTQIA+ people.
The paper, titled “Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems,” recommends creating an anatomical inventory form that captures organ diversity, and developing clinical decision support tools and population health management systems that consider each patient’s gender identity, sex assigned at birth, and anatomy.
“Clinicians use their best judgment based on experience and wisdom to provide quality care, but they also rely on clinical decision support tools derived from information in electronic health records,” said lead author Chris Grasso, MPH, Associate Vice President for Informatics and Data Services at Fenway Health. “Given the significant disparities in health that transgender and gender diverse people experience in comparison with their cisgender peers, it is incumbent upon health care systems and health information technology vendors, including electronic health records, to improve clinical care for these patients.”
Many transgender and gender diverse people undergo myriad medical and surgical interventions to affirm their gender identity, including hormone therapies, chest reconstruction, hysterectomy, genital surgeries, and breast augmentation. But a significant number of transgender and gender diverse people do not undergo any medical or surgical interventions. This makes it impossible for clinicians to know which organs a person has without asking the patient and reviewing their health records.
The paper includes an example of an anatomical inventory that can be included in electronic health records (EHR) that allow clinicians to document and track the presence or absence of specific organs along with any surgical procedures in order to guide patient-centered, preventive health screenings and post-surgical care plans.
“A clinician who is using an EHR system that does not include an integrated anatomical inventory may be prompted to recommend a Pap test to a transgender man who does not retain a cervix after gender-affirming surgery, because the only information in the EHR system about that patient’s organs may be based on a female sex assigned at birth,” said senior author Alex Keuroghlian, MD, MPH, Director of Education and Training Programs at The Fenway Institute. “These are the types of mistakes that can increase mistrust in doctors and the medical system in general among transgender and gender diverse patients and lead to patients simply avoiding care. This contributes to the disparities in health experienced by transgender and gender diverse people. The tools now exist to reduce these mistakes, and hospitals and community health centers should be using them.”
Health care systems with EHRs that include anatomical inventories can create internal dashboards that will detect disparities in care among different patient populations. For example, care teams can measure the rate of depression screening in primary care for transgender and gender diverse patients as compared with cisgender patients. If the internal dashboard shows that only 60 percent of transgender patients were screened for depression as compared with 85 percent of cisgender patients, care teams and organizational leaders can investigate the reasons for the disparity.
“Without these customizable dashboards, it can be very difficult to detect disparities in care among patient populations. If disparities exist but cannot be measured, it is often impossible to address them,” said paper co-author Hilary Goldhammer, SM.
“EHR systems that integrate gender identity and anatomical inventories, and reference those fields and forms to produce clinical recommendations, identify health disparities, and promote culturally responsive communication, will allow for more tailored, gender-affirming, and timely care for patients,” added paper co-author Julie Thompson, PA-C, Medical Director of Trans Health at Fenway Health.
“Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems,” was published June 21, 2021 by the Journal of the American Medical Informatics Association.