Q&A: EHR changes could improve care of LGBTQIA+ patients
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Research has shown that many patients in the LGBTQIA+ community experience health care discrimination and avoid health care out of fear of mistreatment.
Consequently, the LQBTQIA+ community has lower mammography and pap smear screening rates and higher rates of substance abuse, smoking, unhealthy weight control or weight perception, HIV and other STIs than the general population, according to a study in the American Medical Informatics Association Annual Symposium Proceedings.
Many LGBTQIA+ biases and health concerns could be abated by making changes to electronic health records, according to Chris Grasso, MPH, associate vice president for informatics and data services at Fenway Health in Boston.
“Technology has advanced very far, providing a real opportunity to care for LGBTQIA+ patients, who often have been very invisible in the health care system,” Grasso told Healio Primary Care.
Although the National Academy of Medicine has recommended that physicians collect information on patients’ sexual orientation and gender identity for nearly a decade in order to provide “patient-centered care for LGBTQ people,” most health care organizations have not carried out these recommendations, according to Grasso.
About two-thirds of health care institutions that were recognized for being leaders in LGBTQIA+ care said their EHR system “offers an explicit way to capture a patient’s sexual orientation,” according to the 2020 Healthcare Equality Index. One of these institutions, The Fenway Institute, said that it updated its EHR to be more sensitive to the needs of the LGBTQIA+ community. Healio Primary Care asked Grasso and Alex Keuroghlian, MD, MPH, director of education and training programs at The Fenway Institute, to provide ways other health care organizations can do the same.
Healio Primary Care: You have previously published papers that indicate taking anatomical inventories is one thing health systems can do to help meet the health needs of the LQBTQIA+ community. How can institutions do this?
Grasso: The benefit of having an anatomical inventory is that it removes assumptions such as, for example, a male patient must have a penis. It is very possible that a trans male or genderqueer person could have retained their cervix.
Keuroghlian: Clinicians are trained in a paradigm that assumes everyone is cisgender and has a binary gender identity and predictable anatomy based on their sex assigned at birth, which we know is not true. Clinicians are not systematically trained to ask patients necessary questions and to provide primary and preventive care that is comprehensive and affirming for transgender and gender-diverse individuals.
To take an anatomical inventory, physicians can ask all patients “May I ask you a list of questions about which body parts you have?” and follow up with, “You do not need to answer questions if you do not feel comfortable doing so.”
It is really important for the health care community to not make assumptions about what anatomy, transgender and gender-diverse people or intersex people have based on the binary sex listed in their chart or in their medical records.
There have been a lot of problems in the past, such as an EHR missing key information that a transgender man may retain a cervix and require a cervical Pap test, or that a transgender woman may retain a prostate, for example, and require a prostate exam. Once the anatomical inventory is linked up with clinical decision support functionality, the care team can receive alerts and notifications regarding preventive screening and follow-up interventions through the system based on the anatomy that the patient has.
Healio Primary Care: How often should physicians conduct an anatomical inventory?
Grasso: Utilizing an anatomical inventory is ongoing and can be updated at any time. Once these data are part of the EHR, clinical decision support can be programmed to prompt a clinician to have individualized clinical conversations with patients.
Healio Primary Care: Which EHR vendors offer standardized forms for anatomical inventories?
Grasso: This is not widespread across all EHR vendors at this point, so there is a lot of work to be done in this area. Here at Fenway Health, we currently use a product called AthenaHealth Practice, which allows users to create individual forms or customizable forms that have allowed us to create an anatomical inventory form.
The only other EHR vendor who has modified their systems to adapt to the LGBTQIA+ community is Epic. In the past, it has been really helpful to have a federal policy or mandate that requires such updates. If this could happen here regarding modifying systems to adapt to the LGBTQIA+ community, it would push the functionality forward. We want LGBTQIA+ patients, wherever they may live or get care, to have the same clinical experience as everyone else.
Healio Primary Care: How can practices create and integrate clinical decision support tools within their existing EHRs that incorporate information relevant to transgender and gender‐diverse patients?
Grasso: There is so much variability by EHR vendor. In many instances. the data and functionality within the EHR are already there, so it is just a matter of taking the technology to the next step and pushing vendors to do so.
Healio Primary Care: What else can physicians do to create a culturally appropriate health care environment for LGBTQIA+ patients?
Keuroghlian: This can start by training your staff in basic concepts related to sexual orientation, gender identity and sex development, and ensuring they understand how the stigma LGBTQIA+ communities experience is related to health disparities and health inequities. Staff also need to understand how to engage in sensitive, effective communication with LGBTQIA+ patients. Many resources to help physicians do this can be found on the website of the National LGBTQIA+ Health Education Center at The Fenway Institute, which is www.lgbtqiahealtheducation.org.
Staff also need to make members of LGBTQIA+ communities feel welcome. Think about the physical environment of your office. What posters, pamphlets and brochures do you have in the waiting room, for example, that are affirming to these patients? What are your marketing materials like? Are your office policies within the organization written so that it feels welcoming, inclusive and safe? Are you hiring, training and building a workforce that is culturally responsive? It is also very important that physicians utilize community input while conducting needs assessments to understand what LGBTQIA+ patients are looking for. Many resources to assist in this process can also be found on the National LGBTQIA+ Health Education Center website.
Healio Primary Care: What are the costs, staffing needs and equipment associated with all these strategies?
Grasso: Each EHR vendor can create the anatomical inventory and push it out at very little cost to their customers and make their systems benefit LQBTQIA+ patients. Initiating this process by EHR vendors avoids confusion that could occur with each health system in the U.S. having its own process or developing their own inventory form or functionality.
Keuroghlian: Sometimes making your practice more LGBTQIA+ affirming starts as a specialty program with just one or two providers within a practice or within the institution. Sometimes the specialty practice goes on to become mainstreamed, whereby all its primary care providers have skills serving transgender and gender-diverse people and the patient panel from this population builds. That’s what happened at Fenway.
Gender-affirming medical care is considered medically necessary and increasingly covered by health insurances and thus, often reimbursable. We have found it very helpful to have a transhealth program manager who ensures this delivery is happening smoothly and can coordinate reimbursement with the insurance companies. The other really important thing is to have representation of transgender and gender-diverse people working within the practice. That may mean recruiting outside the channels you typically recruit from, but it is really important to have members of these communities on your staff.
You can have the best technology in the world, but if your staff is not trained to address and mitigate their own implicit bias towards these populations and to engage in sensitive and effective communication and provide culturally responsive care, that technology is going to fall flat. On the other hand, if you have staff who are really well-trained and culturally responsive but do not have the right technology, they will be constrained in their ability to serve LGBTQIA+ patients well.
References:
Chittalia AZ, et al. AMIA Annu Symp Proc. 2021:303-310.
Fenway Health. New paper provides strategies for optimizing gender-affirming medical care by changing electronic health records. https://fenwayhealth.org/new-paper-provides-strategies-for-optimizing-gender-affirming-medical-care-by-changing-electronic-health-records/. Accessed Aug. 9, 2021.
Grasso C, et al. J Am Med Inform Assoc. 2021;doi:10.1093/jamia.ocab080.
Grasso C, et al. J Am Med Inform Assoc. 2019;doi:10.1093/jamia/ocy.137.
Human Rights Campaign Foundation. Healthcare Equality Index 2020. https://www.hrc.org/resources/healthcare-equality-index. Accessed Aug. 9, 2021.