scholarly journals Patient Perspectives on Gender Identity Data Collection in Electronic Health Records: An Analysis of Disclosure, Privacy, and Access to Care

2016 ◽  
Vol 1 (1) ◽  
pp. 205-215 ◽  
Author(s):  
Hale M. Thompson
Keyword(s):  
Data Collection ◽  
Gender Identity ◽  
Electronic Health Records ◽  
Access To Care ◽  
Patient Perspectives ◽  
Health Records ◽  
Electronic Health

scholarly journals Planning and implementing sexual orientation and gender identity data collection in electronic health records

2018 ◽  
Vol 26 (1) ◽  
pp. 66-70 ◽  
Author(s):  
Chris Grasso ◽  
Michal J McDowell ◽  
Hilary Goldhammer ◽  
Alex S Keuroghlian
Keyword(s):  
Health Care ◽  
Sexual Orientation ◽  
Data Collection ◽  
Gender Identity ◽  
Electronic Health Records ◽  
Current Evidence ◽  
Institute Of Medicine ◽  
Health Records ◽  
Electronic Health ◽  
And Gender

AbstractLesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience significant health disparities across the life course and require health care that addresses their unique needs. Collecting information on the sexual orientation and gender identity (SO/GI) of patients and entering SO/GI data in electronic health records has been recommended by the Institute of Medicine, the Joint Commission, and the Health Resources and Services Administration as fundamental to improving access to and quality of care for LGBTQ people. Most healthcare organizations, however, have yet to implement a system to collect SO/GI data due to multiple barriers. This report addresses those concerns by presenting recommendations for planning and implementing high-quality SO/GI data collection in primary care and other health care practices based on current evidence and best practices developed by a federally qualified health center and leader in LGBTQ health care.

scholarly journals Implementation of Gender Identity and Assigned Sex at Birth Data Collection in Electronic Health Records: Where Are We Now?

2021 ◽  
Vol 18 (12) ◽  
pp. 6599
Author(s):  
Hale M. Thompson ◽  
Clair A. Kronk ◽  
Ketzel Feasley ◽  
Paul Pachwicewicz ◽  
Niranjan S. Karnik
Keyword(s):  
Data Collection ◽  
Gender Identity ◽  
Electronic Health Records ◽  
Data Quality ◽  
Hospital Admissions ◽  
The United States ◽  
Patient Comfort ◽  
United States Department ◽  
Health Records ◽  
Electronic Health

In 2015, the United States Department of Health and Human Services instantiated rules mandating the inclusion of sexual orientation and gender identity (SO/GI) data fields for systems certified under Stage 3 of the Meaningful Use of Electronic Health Records (EHR) program. To date, no published assessments have benchmarked implementation penetration and data quality. To establish a benchmark for a U.S. health system collection of gender identity and sex assigned at birth, we analyzed one urban academic health center’s EHR data; specifically, the records of patients with unplanned hospital admissions during 2020 (N = 49,314). Approximately one-quarter of patient records included gender identity data, and one percent of them indicated a transgender or nonbinary (TGNB) status. Data quality checks suggested limited provider literacy around gender identity as well as limited provider and patient comfort levels with gender identity disclosures. Improvements are needed in both provider and patient literacy and comfort around gender identity in clinical settings. To include TGNB populations in informatics-based research, additional novel approaches, such as natural language processing, may be needed for more comprehensive and representative TGNB cohort discovery. Community and stakeholder engagement around gender identity data collection and health research will likely improve these implementation efforts.

scholarly journals Patient participation in electronic nursing documentation: an interview study among community nurses

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Kim De Groot ◽  
Elisah B. Sneep ◽  
Wolter Paans ◽  
Anneke L. Francke
Keyword(s):  
Data Collection ◽  
Electronic Health Records ◽  
Thematic Analysis ◽  
Patient Participation ◽  
Medical Condition ◽  
Nursing Documentation ◽  
Health Records ◽  
Technical Problems ◽  
Care Plans ◽  
Electronic Health

Abstract Background Patient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation. Methods A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting. Results Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment. Conclusions Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.

scholarly journals Comparing Automated vs. Manual Data Collection for COVID-Specific Medications from Electronic Health Records

2021 ◽  
pp. 104622
Author(s):  
Andrew L. Yin ◽  
Winston L. Guo ◽  
Evan T. Sholle ◽  
Mangala Rajan ◽  
Mark N. Alshak ◽  
...  
Keyword(s):  
Data Collection ◽  
Electronic Health Records ◽  
Health Records ◽  
Electronic Health

scholarly journals Electronic Health Records in Behavioral Research

2018 ◽  
Vol 3 (5) ◽  
Author(s):  
John Loft ◽  
Diana Greene
Keyword(s):  
Health Policy ◽  
Data Collection ◽  
Electronic Health Records ◽  
Medical Records ◽  
Recent Literature ◽  
Health Records ◽  
Administrative Record ◽  
Electronic Health ◽  
Access To Data ◽  
Evaluation Of Data

Medical records are a type of administrative record with rich potential for research of behavioral health and health policy. Developments in electronic health records (EHR) can increase access to data contained in medical records but also present some unusual challenges for research. This presentation summarizes recent literature describing the use of EHR in research and identifies issues for consideration in the preparation of research design and protocols for data collection and preparation. The discussion is presented in a framework for evaluation of data quality and fitness for use.

Identification of Transgender People With Cancer in Electronic Health Records: Recommendations Based on CancerLinQ Observations

2021 ◽  
Vol 17 (3) ◽  
pp. e336-e342
Author(s):  
Ash B. Alpert ◽  
George A. Komatsoulis ◽  
Stephen C. Meersman ◽  
Elizabeth Garrett-Mayer ◽  
Suanna S. Bruinooge ◽  
...  
Keyword(s):  
Gender Identity ◽  
Electronic Health Records ◽  
Total Population ◽  
Female Gender ◽  
The United States ◽  
Current Data ◽  
Health Records ◽  
Transgender People ◽  
Transgender Identity ◽  
Electronic Health

PURPOSE: Cancer prevalence and outcomes data, necessary to understand disparities in transgender populations, are significantly hampered because gender identity data are not routinely collected. A database of clinical data on people with cancer, CancerLinQ, is operated by the ASCO and collected from practices across the United States and multiple electronic health records. METHODS: To attempt to identify transgender people with cancer within CancerLinQ, we used three criteria: (1) International Classification of Diseases 9/10 diagnosis (Dx) code suggestive of transgender identity; (2) male gender and Dx of cervical, endometrial, ovarian, fallopian tube, or other related cancer; and (3) female gender and Dx of prostate, testicular, penile, or other related cancer. Charts were abstracted to confirm transgender identity. RESULTS: Five hundred fifty-seven cases matched inclusion criteria and two hundred and forty-two were abstracted. Seventy-six percent of patients with Dx codes suggestive of transgender identity were transgender. Only 2% and 3% of the people identified by criteria 2 and 3 had evidence of transgender identity, respectively. Extrapolating to nonabstracted data, we would expect to identify an additional four individuals in category 2 and an additional three individuals in category 3, or a total of 44. The total population in CancerLinQ is approximately 1,300,000. Thus, our methods could identify 0.003% of the total population as transgender. CONCLUSION: Given the need for data regarding transgender people with cancer and the deficiencies of current data resources, a national concerted effort is needed to prospectively collect gender identity data. These efforts will require systemic efforts to create safe healthcare environments for transgender people.

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