Providing Inclusive Care for Transgender Patients: Capturing Sex and Gender in the Electronic Medical Record

Abstract

Providing a positive patient experience for transgender individuals includes making the best care decisions and providing an inclusive care environment in which individuals are welcomed and respected. Over the past decades, introduction of electronic medical record (EMR) systems into healthcare has improved quality of care and patient outcomes through improved communications among care providers and patients and reduced medical errors. Promoting the highest standards of care for the transgender populations requires collecting and documenting detailed information about patient identity, including sex and gender information in both the EMR and laboratory information system (LIS). As EMR systems are beginning to incorporate sex and gender information to accommodate transgender and gender nonconforming patients, it is important for clinical laboratories to understand the importance and complexity of this endeavor. In this review, we highlight the current progress and gaps in EMR/LIS to capture relevant sex and gender information. Many EMR and LIS systems have the capability to capture sexual orientation and gender identity (SOGI). Fully integrating SOGI into medical records can be challenging, but is very much needed to provide inclusive care for transgender individuals.