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AHIMA Leads the Way on Data Collection Best Practices for LGBTQ Patients

Practice Management


AHIMA Leads the Way on Data Collection Best Practices for LGBTQ Patients

Date Posted: Saturday, January 11, 2020

 

The American Health Information Management Association (AHIMA) welcomes and supports the November 2019 call by the American Medical Association (AMA) for fully inclusive electronic health records (EHRs) for transgender patients.  

AHIMA has long recognized this need and formed a LGBTQ volunteer work group in 2014 that has published articles and Practice Briefs to inform health information management (HIM) professionals on this important issue. The organization has also delivered presentations nationwide on the topic of best practices and known challenges when collecting and managing sexual orientation and gender identity (SOGI) data in the EHR.  

"How Inclusive Is Your Health Data?" in the January 2020 issue of Journal of AHIMA illustrates this need for change. Our HIM and clinical professionals struggle with data collection due to the fact that many systems do not allow for standardized SOGI data collection. EHRs must be inclusive and allow for the collection, processing, safeguarding, and managing of patients' protected health information (PHI). Some EHR vendors have updated their modules to capture data such as pronouns (he/him, she/her, they/them), preferred name, sex assigned at birth for transgender individuals, an anatomy or biological inventory to inform clinical decisions, and legal sex to inform workflows such as coding and billing. 

Since registration or patient financial services are typically the first point of entry for patients seeking care, the evaluation of collecting SOGI data is extremely important. Sensitivity training, including cultural competence for all members of the healthcare team, will assist with understanding why SOGI data must be collected. This area is known for high staff turnover rates, therefore iterative training is mandatory.  

The following example, adapted from an AHIMA LGBTQ work group article published in the Journal of AHIMA, aids in illustrating the need for staff training and inclusive EHRs : 
 
A transgender individual seeks medical care from a provider who does not have an inclusive EHR and staff have not been provided sensitivity and cultural competence training.  

On this day, the male-to-female (MTF) patient uses their new name, although it has not officially changed so there is no legal documentation such as a driver's license. The patient is registered under "male" using their "legal name." The patient asks the nurse to document their new name and pronoun in the chart. The nurse complies, although they do not relay the information to the physician as it is a very busy clinic day and they are moving on to see the next patient. The physician enters the room and uses the wrong name to address the patient because the information is not readily seen on the chart due to lack of inclusive data fields in the EHR. The patient asks the physician to please use this name and associated pronouns, but already feels uncomfortable and disrespected. 

Not only does this example show the wrong way of treating our patient populations due to lack of proper technology and training, but there is a clear potential for patient misidentification. If the patient presents for a follow-up visit and uses their new name and pronouns, the registrar could easily perform a search and not find the patient's unique health record and then proceed with creating a new record. Subsequently, this turns into a patient safety issue when the patient receives a service such as a scan or laboratory test under a new identity that correlates with a different sex at birth leading to the potential for false results or inadequate care.

Enhancing the healthcare environment for LGBTQ patients will contribute to improved patient care and safety where patients will be more willing to share their personal information in a welcoming, respectful, and confidential environment.  An inclusive EHR will advance the goal of delivering quality and safe healthcare for this patient population.      

Julie Pursley Dooling, MSHI, RHIA, CHDA, FAHIMA 



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