Evolving Sex and Gender in Electronic Health Records

Current Status of SIGI and EHR

Although having separate fields for birth sex and SIGI in the EHR is ideal, the VHA does not yet have a fully functional SIGI field, and several TGNC veterans have changed their birth sex field to align with their gender identity. Roughly 9,700 patients have diagnostic codes related to transgender care in the VHA, meaning thousands of current patients would potentially benefit from SIGI implementation (John Blosnich, written communication, March 2018). A possible action that the VHA could take with the goal of enhancing patient safety would be to revert the birth sex field of patients who had previously changed the field back to the patient’s original birth sex. However, if this alteration to the EHR were done without the patient’s consent, numerous additional problems would result—including invalidating a veteran’s wishes—potentially driving patients away from receiving health care.

Moreover, in the absence of updated SIGI information (which only the veteran can provide), making a change in the EHR would perpetuate the misgendering of TGNC veterans who have already sought an administrative fix for this problem. Thus, the agency decided to engage patients in a discussion about their decision to keep the birth sex field consistent with their original birth certificate. In cases in which the field had been changed previously, the recommendation is for HCPs to gain patient consent to change the birth sex field back to what was on their original birth certificate. Thus, decisions about what should be listed in the EHR are made by the veteran using an informed decision-making model.

Patient Safety Education Workgroup

To begin the process of disentangling birth sex and SIGI fields in the EHR, 2 work groups were created: a technical work group (coding the patches for SIGI implementation) and a SIGI patient safety education work group. The patient safety education work group was committed to promoting affirmative VA policies that require validation of the gender identity of all veterans and pursuing best practices through clinical guidelines to promote effective, efficient, equitable, and safe veteran care. The patient safety education work group included representatives from all 3 branches of the VA (VHA, Veterans Benefits Administration, and National Cemetery Administration), including clinical media, patient safety, information technology, and education specialists. The group developed trainings for administrative staff about the appropriate ways to ask birth sex and SIGI questions, and how to record veteran-driven responses.

SIGI Fact Sheet

The patient safety education work group examined clinical literature and developed tools for staff and veterans to facilitate effective discussions about the importance and utility of documenting both birth sex and SIGI in the EHR. The patient safety education work group along with media and educational experts created basic key term definition documents to address the importance, purpose, and use of the SIGI field. The patient safety education work group developed 2 documents to facilitate communication between patients and providers.

A 1-page veteran-facing fact sheet was developed that described the differences between birth sex and SIGI fields and how these fields are used in the VA EHR system (Figure 1). In addition, a 1-page HCP-facing fact sheet was designed to inform HCPs that patients may have changed their birth sex in their EHR or might still wish to change their birth sex field, and to inform HCPs of the importance of patient-centered, gender-affirmative care (Figure 2). An additional goal of both documents was to educate veterans and HCPs on how the EHR automatically calculates laboratory results and screening notifications based on birth sex.