Gender identity has become an increasingly prominent topic in recent years, including within the realm of behavioral and mental health. Generally, gender identify is defined as a personal sense of one’s own gender, which may or may not correlate to one’s biological sex. Regardless of sex, a person may have a separate, internal feeling of being male, female, a combination, or neither.
Starting in 2016, federally funded U.S. health centers have been collecting and entering sexual orientation and gender identity (SO/GI) data in electronic health records (EHRs). Health providers have increasingly included SO/GI data with a patient’s other demographic information.
HL7 International has created specific protocols for including gender identity in its FHIR standard for EHRs. The organization developed the FHIR standard to help share electronic healthcare information and improve interoperability. (If you’re curious about how FHIR works in general, you can check out our blog post that explains this EHR standard.)
The topic of gender identity can be a hot-button issue, and has been the subject of a lot of political, social, and health debate. In the midst of these discussions, all behavioral health providers should follow current standards in recording a client’s SO/GI data. This helps to maintain the reliable exchange and flow of a patient’s health data through the healthcare system.
FHIR and other standards can provide guidance for behavioral health providers when it comes to recording a client’s gender identity, without the need to enter contentious debates. However, providers who wish to contribute to the ongoing discussion of data standards for EHRs may still do so.
FHIR standards include the following codes for gender identity:
- Male: The patient identifies as male
- Female: The patient identifies as female
- Non-binary: The patient identifies with both female and male, or neither female nor male
- Transgender male: The patient identifies as transgender female-to-male
- Transgender female: The patient identifies as transgender male-to-female
- Other: The patient has another gender identity not listed
- Does not wish to disclose: The patient does not wish to disclose gender identity
In 2019, the Journal of the American Medical Informatics Association published an article with recommendations for incorporating high-quality SO/GI data in primary care and other health care practices. These recommendations include:
- Engaging leadership in the process of collecting SO/GI data
- Incorporating health IT staff from the beginning of the data collection process
- Providing educational brochures about SO/GI to clients and patients
All health stakeholders should remember that SO/GI data is sensitive personal information. All parties involved in exchanging SO/GI data should know and follow all local, state, and federal rules involving patient consent and information sharing.
Following all current standards for health data, interoperability, and privacy can be challenging. When your EHR does the work for you, it helps your behavioral health practice operate more efficiently and demonstrate greater value.
BestNotes offers EHR solutions tailored specifically for behavioral health and addiction treatment providers, with features that help you exchange important information while preserving client privacy. Contact us today to learn more or reach out to us to schedule your free demo.