Overcome Gender Identity Barriers in Healthcare
Part 1: Know the limitations of EMRs and the importance of quality data collection.
Patients with gender conflict have stereotyping and depression to overcome; don’t let staff and billing be another obstacle they must face when getting medical care. One way you can help them overcome challenges is by knowing the limitations of electronic medical records (EMRs) and the importance of good data collection and registration.
Editor’s Note: This is the first article in a series of gender identity articles. Part 2 and Part 3 in our gender identity series will discuss coding, standard criteria required for gender reassignment, insurance barriers, and what your facility can do to help.
What Makes Up Our Gender?
Bodies: How society genders our bodies, how we see our own body, and how others interact with us based on our bodies.
Identity: Who we internally know ourselves to be (i.e., male, female, both, or neither). Sex assigned at birth based on anatomy and gender identity are not necessarily the same. Identity is our internal experience and designation of our gender. People identify as:
- Cisgender – Identifies as sex at birth and on the birth certificate
- Binary – Identifies as male or female regardless of sex at birth and on the birth certificate
- Non-binary – Does not identify as strictly male/female
- A-gender – Does not identify as either gender
- Intersex – A set of congenital variations of the reproductive system. They are not considered typical for either male or female.
Expression: How we present our gender, how people perceive our gender, and gender roles. Gender expression comes in the form of choice in toys, clothes, colors, and activities, and the way a person walks, talks, and moves.
Each of these dimensions of gender can vary greatly across a range of possibilities. A person’s comfort in their gender is related to the degree to which these three dimensions feel in harmony.
EMR and Staff Obstacles and Possible Solutions
Transgender patients face stereotypes based on gossip, judgment, negativity, complaining, ignorance, and exaggeration. EMR systems add insult to injury by not painting a complete and accurate medical picture. Obstacles and solutions that should be addressed in your office/facility include:
|Patient is not being addressed as they wish, are uncomfortable seeking care, and feel their voice is not heard.||Educate staff on registration, communication, and compassion.|
|Patient ID wristband discrepancies: How do you address the patient?||Sex and gender identity can be added to the header of all reports.
Remove the label “Sex” from the patient wristband and keep other identifiers such as their name, date of birth, patient ID, and their picture on it.
|Data flow downstream is often not accurate due to EMR limitations.||Engage the IT department to review all programs used to ensure they are “communicating” to eliminate inaccurate data and denials.|
Gender Identity Terms and Definitions
Gender dysphoria: Conflict between a person’s physical or assigned gender and the gender they identify as. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):
For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized.
Cross-dresser: An individual who dresses and presents as a different gender.
Transgender: An individual who strongly identifies with the other sex and seeks hormones or gender-affirmation surgery, or both, to feminize or masculinize the body. This person may live full time in the cross-gender role.
Female-to-male: Someone identified as female at birth but identifies and portrays his gender as male. This term is often used after the individual has taken some steps to express his gender as male or after medically transitioning through hormones and/or surgery.
Male-to-female: Someone identified as male at birth but identifies and portrays her gender as female. This term is often used after the individual has taken some steps to express her gender as female or after medically transitioning through hormones and/or surgery.
EMR Limitations and Data Collection
Collecting data in an EMR is essential to providing high-quality care. It doesn’t matter how you view transgender patients — the bottom line is there are discrepancies in the EMR systems that don’t allow for accurate patient capture. For example, EMR language is inconsistent, and EMR fields are lacking the appropriate language to capture accurate data. These failings cause confusion for clinical and billing staff.
Most EMRs document sexual identity as a fixed, binary value, but classic designations such as “male” and “female” fail to capture transgender patients. The “Sex” field in an EMR has been misused in many ways, and at times it’s not even consistently used within an organization. EMR systems use the “Sex” field as a marker for the organs that the patient has now or sometimes as markers for the sex assigned at birth. Gender identity questions should instead have two parts:
- Current gender identity
- Sex assigned at birth
Together, these would replace “Sex: Male or Female?” Having two-part gender identity questions would provide a clearer, more clinically relevant representation of the patient. Staff would no longer have to ask awkward questions due to missing data, which helps with transgender patients feeling accepted for who they are.
Information that should be collected on the EMR clinical form includes:
- Patient’s sexual orientation
- Patient’s gender identity
- Patient’s sex assigned at birth
- Patient’s pronouns
- Steps the patient has taken to transition, if any
- Patient’s plans for transition
- Organs the patient currently has
- Organs present at birth or expected at birth to develop
- Organs hormonally enhanced or developed
- Organs surgically enhanced or constructed
See Figure 1 for an example of a thorough EMR clinical form.
Collection of Demographics Begins at Registration
Patient questionnaires may be completed upon check-in with online registration, through a kiosk during registration, paper, or during check-in. Ways to get gender demographic data include:
- Via the registration forms by filling out the demographics section
- Telephone calls prior to appointment to verify demographics
- Providers asking questions during the encounter
- Patients may self-disclose to providers as a response to open-ended questions, such as “Tell me about yourself.”
- Collecting data for the social or sexual history with a question such as “Do you have any concerns or questions about your sexual orientation or your gender identity?”
Remember: Some patients are not comfortable answering these questions on the phone, in front of others during registration, or at all. Educating registration staff is essential for getting this information. Putting a policy in place to address the proper questions to ask patients may eliminate inaccuracies in:
- Data entered in free text
- Drop-down selections
- Preferred name
- Chosen name
Data collection at registration is important because wristbands are put on a patient when they become an inpatient. These wristbands often have the patient’s name, date of birth, sex, and patient ID. When lab labels do not match what is in the chart, discrepancies are introduced, and the patient isn’t addressed properly.
Note: The chosen name will become the default, but this can potentially cause issues downstream with wristbands/lab work if it doesn’t match the patient’s name throughout the EMR.
Data Collection and Coding
In the EMR, you may not think you can assign a female ICD-10-CM code when the “other” sex field box has been checked, but you can. There are rules that a facility can change in the EMR. These rules can be changed to a “soft warning” when the patient’s legal sex and gender identity do not match. This soft warning allows the provider to know there are modifiers that should be added if a procedure is performed. There are also “hard warnings” your facility can set up to create a stop until the data is updated.
ICD-10-CM Coding Guidance
In an upcoming issue of Healthcare Business Monthly, we’ll discuss how DSM-5 is helping to remove gender identity stigma by choosing the right words and replacing “disorder” with “dysphoria” in the diagnostic label. It created appropriate and consistent clinical sexology terminology, as well as removed the connotation that the patient is “disordered.” We’ll see how this new labeling carries over into ICD-10-CM codes for proper diagnosis assignment.
For more information on gender definitions, conditions for gender reassignment, and the evolution of gender dysphoria read the article “Clear Up Misconceptions About Transgender Coding” on pages 22-24 in the June 2018 issue of Healthcare Business Monthly. It is also found on AAPC’s Knowledge Center.
About the authors:
Danielle Erickson, CPC, CCS, is a health information management educator with Optum360 with 15 years’ experience in auditing, education, and revenue management. She holds her Associate of Applied Science in Medical Billing and Coding from Northland College East Grand Forks, Minn. Erickson is a member of the Fargo, N.D., local chapter.
Litriana (Lee) Shimano, CPC, CMDP, CCP, PCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an educator with a 30-year background in the healthcare industry. She has had management roles in physician-based services in multiple settings, including private practice, academic health systems, and managed care companies. Shimano has extensive experience leading coding departments, development and delivery of coding education training for all audiences, quality audits for internal staff and external clients, workflow improvement, coding and billing support, and revenue cycle management. She is a member of the Loma Linda, Calif., local chapter.