Provider Practices and Perspectives regarding Collection and Documentation of Gender Identity

ABSTRACT

Recent recommendations to include patient sexual orientation (SO) and gender identity (GI) in the electronic health record (EHR) aim to improve clinical care and address health disparities among sexual and gender minority patients. Collection and documentation of GI may be complex due to multiple clinically relevant components. This study explored provider practices in collecting and documenting GI across multiple specialties. Qualitative interviews with 25 healthcare providers were transcribed verbatim, and thematic analysis and principles of grounded theory were used to analyze the data. Without a protocol and absent dedicated locations in the EHR for collecting and documenting patient GI, provider practices were inconsistent and highlighted challenges for communication across clinical staff. Providers noted that patients’ disclosure of GI was typically unprompted, or was presumed through disclosure of gender affirming treatments. Findings indicate the need for provider training and appropriate EHR fields to support GI collection and documentation.

KEYWORDS:

• Gender identity
• documentation
• clinical care
• electronic health record
• LGBT health
• health disparities
• qualitative methods

Acknowledgments

The authors thank Kylee Clyatt, Benjamin Yu, and Lydia Ramharack for their contributions to data collection and coding.

The views expressed in this article do not necessarily represent those of the U.S. Department of Veterans Affairs or the United States Government.

Disclosure statement

The authors declare that there are no conflicts of interest.