Efforts are underway to routinize the collection of patient data related to sexual orientation and gender identity (SOGI) as is practice for race and ethnicity information. The Institute of Medicine (IOM) has recommended this as the only way to end LGBT invisibility in healthcare as well measure quality and progress at eliminating disparities based on sexual orientation and gender identity. A number of healthcare providers are already doing this, or actively working on implementing SOGI data collection. These include Fenway Health in Boston, UC Davis Health System in Sacramento, Calif., Mt Sinai in New York City, and Partners Health Care in Boston.
Demonstrations have already shown ways to best collect this data and come to a consensus on how to do that, and researchers have shown that patients feel it is important to provide this information to their clinicians. But another critical step in this process will be figuring out how to incorporate all of this into electronic medical record (EMR) and insurance company billing systems.
EMRs have decision support systems built into them that can help providers do the right thing in a range of areas. For example, using established, evidence-based guidelines, a well organized EMR would remind a clinician examining a man in his sixties to conduct a prostate exam and recommend a blood cholesterol test. A doctor conducting an annual exam for a woman will be prompted to take a PAP smear to check for cervical cancer, and conduct a breast exam.
Along these lines, decisions will need to be made with regard to the questions and prompts that should be built into EMRs with regard to appropriate and sensitive care related to a patient’s sexual orientation and gender identity. Risks related to acquisition of HIV and sexually-transmitted infections (STIs) must be assessed for all patients. Clinicians must be comfortable discussing these issues. Additionally, they must be knowledgeable about these risks and recommended screenings as they relate to a patient’s sexual orientation and gender identity. While EMRs should remind clinicians that everyone between the ages of 15-65 should have an HIV test, men who have sex with men may need to be tested for HIV more frequently in addition to having screening for STIs based on their history.
Once it is clear in the EMR that a clinician is working with a transgender person, the system should remind the provider of the need to assess current anatomy. Transgender women, for example, need regular prostate exams. Many transgender men, meanwhile, retain their natal anatomy and thus need PAP smears. Clearly these issues have to be discussed sensitively.
We must also keep in mind that as more people are enrolled in health insurance or Medicaid, billing for services is critical, and providers must have billing codes that allow them to be honest about a patient’s care. Therefore, billing algorithms must be adjusted to ensure that the needs of patients whose gender identity may be incongruent with their sex assigned at birth are met. For example, it must be possible to bill for a PAP smear for a patient who is a transgender man with an intact cervix. Similarly, hormone therapy must be covered as essential care for someone experiencing gender dysphoria. Currently, it is common for clinicians to create a workaround and avoid using the proper code for gender dysphoria in order to ensure that insurers provide payment for hormone therapy. An adjunct to this work will be the need for advocacy with insurers and employers who determine reimbursement for healthcare.
Collecting data on these issues in the EMR will not remove the clinician from sensitive conversations. In many ways, decision support in EMRs related to sexual orientation and gender identity will highlight the need for better education for clinicians around the needs of LGBT people. This will take time, continued education and advocacy, and collaboration across the continuum of care. Ultimately, working to ensure that unique population health needs are met will result in improved health care for all.
Dr. Harvey Makadon is Director of the National LGBT Health Education Center at The Fenway Institute. He is also Professor of Medicine at Harvard Medical School, and a member of the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston.
