For transgender and gender non-conforming patients, receiving medical care might include concerns like whether their gender identity will be respected and whether providers will know and use their preferred name—not to mention the usual concerns over diagnoses and medical bills. Making the best care decisions and providing a positive experience for patients requires both collecting detailed information about a patient’s identity, and being able to record that information in the EHR.
One challenge to documenting patients’ sex, gender, and care needs is providing a place for a conversation about them in standard workflows. Many Epic community members have incorporated questions about patients’ preferred pronouns, sex assigned at birth, and gender identity into each patient’s chart in Epic. The information a patient provides in response to these prompts can give providers a more nuanced understanding of a patient’s sex, gender identity, and healthcare needs, helping to prevent unwarranted assumptions and improve care. For example, a transgender patient’s sex assigned at birth—along with the patient’s current anatomy—might inform clinical decisions, while their legal sex might be relevant to identifying them in billing workflows.
Legal sex, sex assigned at birth, and gender identity can be stored separately for all patients in Epic, and considerations like the use of preferred names are standard across Epic development. According to Janet Campbell, Epic’s vice president of patient experience, Epic’s initiative to store this information separately rather than as a single “sex” item required rethinking thousands of areas of the EHR to avoid a one-size-fits-all approach to patient care. Epic continues working to expand our software to help provide an inclusive, personalized healthcare experience for all patients.