A rapid review of gender, sex, and sexual orientation documentation in electronic health records

Abstract

Objective The lack of precise and inclusive gender, sex, and sexual orientation (GSSO) data in electronic health records (EHRs) is perpetuating inequities of sexual and gender minorities (SGM). We conducted a rapid review on how GSSO documentation in EHRs should be modernized to improve the health of SGM. Materials and Methods We searched MEDLINE from 2015 to 2020 with terms for gender, sex, sexual orientation, and electronic health/medical records. Only literature reviews, primary studies, and commentaries from peer-reviewed journals in English were included. Two researchers screened citations and reviewed articles with help from a third to reach consensus. Covidence, Excel, and Atlas-TI were used to track articles, extract data, and synthesize findings, respectively. Results Thirty-five articles were included. The 5 themes to modernize GSSO documentation in EHRs were (1) creating an inclusive, culturally competent environment with precise terminology and standardized data collection; (2) refining guidelines for identifying and matching SGM patients with their care needs; (3) improving patient-provider relationships by addressing patient rights and provider competencies; (4) recognizing techno-socio-organizational aspects when implementing GSSO in EHRs; and (5) addressing invisibility of SGM by expanding GSSO research. Conclusions The literature on GSSO documentation in EHRs is expanding. While this trend is encouraging, there are still knowledge gaps and practical challenges to enabling meaningful changes, such as organizational commitments to ensure affirming environments, and coordinated efforts to address technical, organizational, and social aspects of modernizing GSSO documentation. The adoption of an inclusive EHR to meet SGM needs is a journey that will evolve over time.

Culturally Competent Gender, Sex, and Sexual Orientation Information Practices and Electronic Health Records: Rapid Review

“…Gender, sex, and sexual orientation are very different and unambiguous concepts that relate to one another in complex ways for all people [ 1 , 4 , 6 , 9 , 16 , 29 ]. SGM-competent GSSO information practices are rooted in the language and terminology used to communicate with, for, and about SGMs in health care [ 4 , 9 ].…”

“…Gender expression is the way people outwardly display their gender [ 1 , 4 , 17 , 26 , 30 ]. There is no single or correct way to express gender; gender expression is dynamic, situational, and individual.…”

“…Gender identity is a person’s inner sense or felt gender [ 1 , 4 , 6 , 8 , 17 , 26 , 30 ]. Gender identity is different from lived gender because a person may not feel comfortable living/presenting outwardly in their felt gender.…”

“…Anatomic inventories enable transparent and assumption-free therapeutic relationships between patients and providers. Safe therapeutic relationships lead to increased opportunities for prudent screening and prevention [ 1 , 2 , 4 , 5 , 9 ].…”

“…The rapid review method was chosen because rapid reviews have gained recognition in health care research as a suitable method for fast exploration of rapidly evolving topics [ 10 ] and because this work is a natural extension of and complement to our research team’s recent rapid exploration of peer-reviewed academic literature [ 1 ] and EHR systems in Canada [ 2 ]. This work expands the domain of inquiry to the body of grey literature that houses key institutional, professional, and technical knowledge of safe, quality, and inclusive health care for SGMs.…”