Journal excerpt: CDI’s role in building a gender-inclusive EHR

Historically, EHRs have tended to only include one indication of gender: the gender a patient was assigned at birth. While many patients identify as their birth-assigned gender and are thus correctly represented by this indicator, this may not be the case for patients who are transgender or part of the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, plus) community. For patients who have transitioned their gender or are currently doing so, having a gender-inclusive EHR is important both to respect their identity and to ensure they receive proper, uncompromised care.

While gender-inclusive EHR settings often have little impact on CDI specialists’ workflow, CDI professionals should still aim to promote such inclusivity. Having an EHR system that is intentionally gender-inclusive helps paint a better picture of the patient as a whole, can improve their quality of care, and leads to a higher level of acceptance.

“Generally, people in CDI have a working relationship with their clinical informaticist or the person who does their EHR work, so they can open the door for conversation to see if anything is being done for [patients in the LGBTQIA+] community,” says Phyllis Lotus Stevenson, MSN, RN, CCDS, clinical informatics specialist—provider support at UnityPoint Health-Allen Hospital in Waterloo, Iowa. “Bring forth critical questions to get people thinking about if we’re creating a safer environment or whether we’re achieving a level of acceptance where we are calling people by their chosen name and addressing them by their preferred pronouns.”

Even though they’re not providing patient care, CDI professionals are actually on the front lines when it comes to pushing for these changes, as they are in the patient records day in and day out. Because they’re so close to the records, CDI professionals may be the first to notice areas for improvement.

“CDI specialists are the ones who can say, ‘Wait, I just reviewed a chart, and it looks like the provider is calling the patient a male, but they’re female—what’s missing here?’ and advocate for having that distinction in the EHR,” Stevenson says. “If they bring that forward to other people, others might say that’s a good point and is something we need to add. It might even be a circumstance where it poses a safety issue. With that chart review, CDI professionals can be all over that.”

Not having gender-inclusive EHRs can lead to patient dissatisfaction and add to health disparities for the transgender community. If patients are afraid they’ll be ridiculed in the doctor’s office or not have their preferred pronouns used, they may avoid healthcare encounters entirely and miss out on services they need.

“Gender-inclusive EHRs are better for these patients’ mental health and gives them a voice, and it’s good for the community for patient awareness, safety, and patient satisfaction,” says Stevenson. “We’re in the 21st century; we need to leave all the biased mindsets behind and evolve. We should be here for the community, not just to make money, and these people are what makes us who we are.”

Editor’s note: This article is an excerpt from an article in the May/June 2022 edition of the CDI Journal. Members can read the full edition here.