Using EHRs to eliminate rather than create health disparities for LGBTQ people: Landmark decision by U.S. DHHS

Via: Landmark Decision By Dept. of Health and Human Services Will Reduce Health Disparities Experienced By LGBT People | Fenway Focus (@FenwayHealth)

The finality in the way the rule is written reminds me of the R v North West Lancashire Health Authority Decision in 1999: “Appeals dismissed. Permission to to appeal to House of Lords Refused.”

That decision quashed forever the UK’s National Health Service policy of not covering transition-related care for its transgender or gender non-conforming residents.

When I visited Charing Cross, the world’s longest running gender identity clinic, in London in 2013, all of the medical records had to be managed on paper because their EHR systems were incapable of managing gender identity successfully and within policy.

This decision is pretty big one too, for the U.S. Health System, and one that might ultimately help our colleagues in the NHS as well.

The new rules released October 6 by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) will require EHR systems certified under Stage 3 of Meaningful Use to allow users to record, change, and access structured data on sexual orientation and gender identity.

And here’s what the final rule says:

We thank commenters for their feedback. Given this feedback, the clinical relevance of capturing SO/GI, and the readiness of the values and vocabulary codes for representing this information in a structured way, we require that Health IT Modules enable a user to record, change, and access SO/GI to be certified to the 2015 Edition “demographics” certification criterion. By doing so, SO/GI is now included in the 2015 Edition Base EHR definition. The 2015 Edition Base EHR definition is part of the CEHRT definition under the EHR Incentive Programs. Therefore, providers participating in the EHR Incentive Programs will need to have certified health IT with the capability to capture SO/GI to meet the CEHRT definition in 2018 and subsequent years.

I was at the convening mentioned in the Fenway Article and wrote about it in this blog post: Sexual Orientation and Gender Identity Data in EHRs, convening at Fenway Health, it matters to all patients, where we took this lovely photograph:

Sexual Orientation and Gender Identity Collection in EHRs Convening at Fenway Health 57914
Sexual Orientation and Gender Identity Collection in EHRs Convening at Fenway Health 57914 (View on

Even though I was there, I am not responsible for making this happen. There’s the Do Ask, Do Tell Project Team, supported by the Robert Wood Johnson Foundation (@RWJF). I’m thinking Kellan Baker (@KellanEBaker), Harvey Makadon, MD (@HMakadon), Sean Cahill, PhD. And many others (please add their names in the comments) who deserve your thanks.

Even though I didn’t make this happen, I and millions of other people are the beneficiaries. This work will create a world where electronic health record systems work for us, to eliminate rather than create disparities. Thank you!

Doctors, EHRs, and the Patient relationship on the Kojo Nnamdi Show, Washington, DC USA

It is the decade of the patient, when the local (Washington, DC) affiliate (@Wamu885) hosts a conversation about how electronic health records are affecting the relationship between patients and physicians (You, Your Doctor And A Computer: How Technology Impacts Personal Health Care | The Kojo Nnamdi Show).

There was a time when I would come to Washington, DC, and other physicians would say things to me like, “isn’t a patient e-mailing their doctor kind of like spam?”

I was joined by 3 (superstar) physicians:

  • William Yasnoff, MD, PhD, Managing Partner at National Health Information Infrastructure (NHII) Advisors; CEO and President at Health Record Banking Alliance
  • Nareesa A. Mohammed-Rajput, MD, Internal Medicine Physician and Physician Lead for Electronic Medical Records, Johns Hopkins Healthcare
  • Alice L. Fuisz, MD, Internal Medicine Physician, Washington Internist Group (DC); Governor, American College of Physicians, DC Chapter

as Nareesa Mohammed-Rajput, MD (@nmohamme) aptly stated, “across the spectrum from health care.” And guess what, we all want to perform well for our patients, which in 2013 includes using the best technology. The art, which is what the show was about, is making it work for our patients. The comments of the listeners confirmed that there’s optimism, and also some work to do.

You can view the transcript here, or if you are more about the audio, you can listen to the broadcast here.

I also personally enjoy being in a room with other doctors who like taking pictures – they’re the ones that celebrate the human spirit 🙂

UC Davis Health asks LGBT patients to share info for tailored care

UC Davis Health asks LGBT patients to share info for tailored care – Business – The Sacramento Bee.

There’s a groundswell of concern in the medical community that lack of sexual orientation and gender identity information might be impacting care of lesbian, gay, bisexual and transgender patients.The UC Davis Health System responded to those concerns Thursday, saying it will become the first academic health system in the nation to incorporate that information as standard demographic elements within the electronic health records of its patients.

As I mentioned previously in this post (see: Now Reading: Electronic medical records and the transgender patient – to eliminate, not create, disparities | Ted Eytan, MD), there is work to be done to improve electronic health records’ abilities for vulnerable populations, including people who are trans. Nice to see UCDavis (@UCDavis) move ahead on this work.

For more information, you can access Ed Callihan, MD’s presentation to the Intitute of Medicine here.

Now Reading: Electronic medical records and the transgender patient – to eliminate, not create, disparities

WPATH recommends1—in concert with policy statements from the American Medical Association,2 the American Psychiatric Association,3 the American Psychological Association,4 the American College of Obstetricians and Gynecologists,5 and the Center of Excellence for Transgender Health at the University of California, San Francisco6—that the healthcare needs of transgender people should be openly and properly addressed, at the same level of quality and thoroughness as is afforded to any other person.

This just published paper (unfortunately behind a paywall, but(no longer behind a paywall, updated 8/11/14) you can access a summarized version at the website) explodes an inaccurate tenet within electronic health record systems – that a person’s sex and gender are tied together, and in turn fully inform a person’s medical destiny. This is not the case for a small percentage of patients.

It is recognized that the overwhelming majority of patients are not transgender, which has led to implementation of a binary male/female oriented system across multiple platforms such as EHR systems, billing and coding systems, and laboratory systems; however, this structure inhibits the collection of accurate medical information, and therefore such systems should be modified.

The paper describes a recommended two-step process to collect two pieces of information, gender identity and sex assigned at birth, that is already in use at the CDC. In addition, there are recommendations for recording preferred pronouns, common treatments and procedures, and status of a person’s transition and anatomy. In 2010 The Institute of Medicine recommended that gender identity be accurately collected in electronic health records and be part of meaningful use.

The Working Group producing the recommendations is EHR experienced and the ideas make sense in terms of what is doable in an electronic health record. The alternative today is not very healthful for this population – having to change the “sex” field back and forth to order necessary preventive exams, or to not have ready access to transition history or preferred pronouns in establishing a relationship.

As WPATH guidelines become followed more regularly and medically necessary services are covered and performed across health care (37 Universities and counting), the health of trans people will be more and more about ongoing preventive care, just like the population at large.

Why do this?

A recent non-peer reviewed report on transgender discrimination showed some 28% of respondents had experienced harassment in a clinic setting and that 2% had been subject to physical abuse.12

Electronic Health Records are for health, and should not codify or indirectly create misunderstanding in the clinical setting. The results can be devastating. Fortunately, health information technology can be used to eliminate disparities in health instead of creating them.

I love hearing about great things HIT “does” for people rather than what HIT “is,” don’t you? 🙂

Visit to a very paperless practice: Michael West, MD PhD – Washington Endocrine Clinic, Washington DC USA

I recently reconnected with Emily Peters (@PFPresscenter), who I asked “How is that Practice Fusion EHR doing?” (she’s the Senior Director of Communications).

I seem to associate Practice Fusion with San Francisco, where the company is based, but I realize that electronic health records, especially web based ones, know no bounds, so I asked if I could shadow in a practice local to me, in Washington, DC. And so I was connected to Michael West, MD, PhD, at The Washington Endocrine Clinic.

If I can walk to it, I’ll do it. So I did it.

Michael West, MD, PhD – click to enlarge

As the name of his practice implies, Michael is an endocrinologist and his practice has been open since 2009. Like so many physicians of his generation, he sought to enter practice without paper. He began with an electronic health record that was physically served within his practice, and then like so many humans in general, sought a system that didn’t require him to be a server technician at the same time he was building his professional career.

Three months in, then, he switched to an electronic health record that’s web-based. The advantage, especially for a physician building a practice, is to not have to worry about maintenance and upkeep of a software package, benefit from the improvements generated by a community of health care practitioners, and also to allow patients to access their data securely.

Michael has a good cadence to his use of the electronic health record. Information about the patients he’s seeing often comes from outside the practice, so it is scanned in or received electronically. What I thought was interesting is that much of the information comes in and goes out via secure electronic fax. In other words, there’s no machine printing out paper on Michael’s end but the protocol is the fax protocol.

Staff at the medical office then downloads the faxed PDFs, renames them, and uploads them to the correct patient file. (“As much as I wish this as an automatic process, we’re not there yet”) The good news is that the information is readable, the not as good news is that the information is not discrete data. There’s now direct lab interfaces to the system, which does populate the medical record.

The result is as the title of this post implies – this is a very paperless practice. I didn’t see much paper moving around, and the desk you see in the photograph pretty much looked like that during the entire session. To my eyes, the patients didn’t miss a beat, I didn’t hear complaints about the use of the electronic health record. In fact one patient said that they like to keep track of their lab values,  which prompted Michael to offer secure access to the information via the patient portal. Again, not a big deal, and this access is seen as a time saver. We’ve come a long way.

The electronic health record itself is steadily improving. I/we noticed there is some functionality that’s not present in this system that is present in other contemporary systems (yet). At the same time, there’s an ease of use and upkeep that’s extremely valuable in this situation.

I asked Michael about two things. First, the fact that this electronic health record is offered to physicians without cost, but with advertising. Second, about the sharing of lab result and pathology result information with patients. Here’s what he told me.

The ads are not really that bothersome.  They are in the periphery and so they don’t get in the way of me viewing the patient’s chart.  Regarding me being influenced to write prescriptions for those drugs, I generally have written those drugs even without being prompted by an advertisement in the EHR, and so I can’t say they have had much impact, if any, on my prescribing behavior.


Regarding patients accessing their lab results, I generally don’t release a specific set of results for viewing without meeting the patient in my office to discuss these in person first.  Pathology results are a different type of result.  Because this is unstructured data at the moment, I cannot release these to patients by using the personal health record (PHR).  Therefore they are either printed or emailed.  If emailing them, then the patient needs to request this and understand that most email is not HIPAA compliant.  If they understand that limitation and are comfortable with that, then I can email it to them.  I would never email patients a pathology report that was not clearly benign unless we had discussed this first in my office face-to-face.

Building a practice takes a lot of work, and I respect a physician who undertakes this challenge, especially today. To arrive at a state of good health, there needs to be enough patient volume and systems that allow people to feel well taken care of. On the particular day I shadowed Michael, he was seeing patients in follow-up, although he obviously does new consults and procedures. As a specialist, he also needs to be responsive to referring physicians, who expect to be notified about his findings in a professional and understandable way.

It’s good for physicians who make this practice choice (still the dominant form of medical practice today) to have the option to coordinate care using electronic health records. Also good to see a new generation of physicians embracing technology in our nation’s capital. Thanks again for having me, Michael, and Emily for the referral!

Why Dont More Hospitals Use Electronic Health Records? – Businessweek

Why Dont More Hospitals Use Electronic Health Records? – Businessweek.

When people in health care talk about the promise of digital medical records, they often point to Kaiser Permanente. The Epic system is integral to America’s largest nonprofit health maintenance organization. The Oakland-based operation’s doctors use it for everything from scheduling appointments to ordering lab results. Kaiser’s members seem to like it, too. They can log into the system, check their medical records, and correspond with doctors via Epic’s secure e-mail system

As of March, 2012, 1.2 million emails are being sent to physicians every month, as of May, 17 % of visits to are coming from mobile device, where people can get their test results, email their doctors, and make, view, cancel appointments.

This is what an EHR does for patients, in addition to what it does for nurses and doctors.