At its interim policy meeting this week, the American Medical Association’s (AMA) House of Delegates approved a policy that will encourage electronic health record (EHR) vendors to modify their systems to be more inclusive for transgender patients.
The AMA gathered physician and medical student leaders at its interim meeting to shape guiding policies on emerging healthcare topics. The AMA’s House of Delegates is the policy-making body at the center of these areas, aiming to work in a democratic process to create a national physician consensus on emerging issues in public health.
According to AMA officials, failure of EHRs to promote inclusive medical documentation “is a major barrier to providing quality care to transgender patients.” One key problem in this area for patient care organizations has been caring for individuals who are in the process of transitioning, as they could have difficulties getting the suitable care due to how their gender identity is being inputted within the systems.
In certain EHR systems, for example, doctors have three options to document a patient’s sex: male, female, or other. But issues may arise when there is no dropdown availability under the “other” field, meaning if “other” is entered into the medical record, there is nothing under that field that describes what it means.
The impact of this lack of functionality could be that for a doctor who has a patient who was male but is now female, for instance, when it comes to continued care, the change is not noted anywhere, potentially leading to misordered tests or care treatment plans.
To fill the gap in needed information on transgender patients, the AMA is aiming strengthen its existing policy promoting inclusive gender, sex and sexual orientation options in medical documentation for LGBTQ patients.
To create EHRs that are fully inclusive of transgender patients, the newly amended policy now supports the voluntary inclusion of a transgender patient’s preferred name and clinically relevant sex specific anatomy in medical documentation, according to the association.
“The newly amended policy reinforces the importance of EHRs that contain inclusive information on transgender patients,” said AMA Board Member William E. Kobler, M.D. “Without this information, transgender patients and their specific healthcare needs cannot be identified or documented, the health disparities they experience cannot be addressed, and the provision of important health care services may not be delivered.”
What’s more, the amended AMA policy aligns with the recommendations of the World Professional Association for Transgender Health that medical documentation include a patient’s preferred name, gender identity, and pronoun preference, along with a means to maintain an inventory of a patient’s medical transition history and current anatomy.
