The American Medical Association has adopted a policy supporting the voluntary inclusion of a transgender patient’s preferred name and clinically relevant sex-specific anatomy in electronic health records.
At its interim meeting in San Diego this week, AMA’s House of Delegates called for creating EHR documentation that is fully inclusive of transgender patients.
“Failure of electronic health records to promote inclusive medical documentation is a major barrier to providing quality care to transgender patients,” contends the AMA, the nation’s largest physician group. “To fill the gap in needed information on transgender patients, the AMA today strengthened its existing policy promoting inclusive gender, sex and sexual orientation options in medical documentation for LGBTQ patients.”
According to the AMA, its new policy is in alignment with the recommendations of the World Professional Association for Transgender Health, which calls for medical documentation includes a patient’s preferred name, gender identity and pronoun preference, as well as the means to maintain an inventory of a patient’s medical transition history and current anatomy.
“The newly amended policy reinforces the importance of EHRs that contain inclusive information on transgender patients,” said AMA Board Member William Kobler, MD, in a written statement. “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 healthcare services may not be delivered.”
In 2011, the Institute of Medicine released a report recommending that information on patients’ sexual orientation and gender identity should be collected in EHRs. However, EHRs have been hamstrung with limitations in the way that they collect data on sexual orientation and gender identity.
Earlier this year, American Academy of Family Physicians delegates at their 2019 national conference adopted a resolution asking the AAFP to advocate that EHR vendors include sexual orientation and gender identity fields in their products.
In addition, AAFP delegates acknowledged that clinicians do not consistently document sexual orientation and gender identity information.
AAFP delegate Melissa Hidde, MD, co-author of the adopted resolution, explained that the intention of the measure was not only to get EHR developers and vendors to include fields for sexual orientation and gender identity, “but also that healthcare entities activate these fields, utilize them and train their staff appropriately to use them.”