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The Many Layers of Healthcare’s EHR Gender Identity Problem

December 12, 2017
by Rajiv Leventhal
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For the transgender population, EHR vendors and patient care organizations must work together to ensure that the appropriate demographic data is being collected at the point of care

As healthcare providers have shifted from paper records to EHRs (electronic health records) over the years, one ongoing challenge, perhaps an unexpected one, has been meeting the needs of transgender patients—specifically being able to properly record their gender identity.

Indeed, a key problem in this area for patient care organizations has been caring for individuals who are in the process of transitioning, as they could have difficulties getting the suitable care due to how their gender identity is being inputted within the systems. For some, this has exposed organizations to potential privacy issues and other legal exposure points.

At Sidney Health Center in rural Eastern Montana, a small critical access hospital with a clinic attached to it, Sue Casperson is the health information director, privacy officer, and the compliance coordinator. At the core of the EHR gender identity problem at Sidney, and also at many other patient care organizations, is that within the Epic system, doctors have three options to document a patient’s sex: male, female, or other. The issue, explains Casperson, is that “There is no dropdown under the ‘other’ field. So if we put ‘other’ in our medical record, there is nothing under that field that describes what it means.”

She adds that the impact of this could be that for a doctor who has a patient who was male but is now female, versus a female who became male, when it comes to continued care, the change is not noted anywhere. “So when we go to provide continued care, there could be things that providers can easily miss if they don’t have that information available,” she says. And even if the original provider documented the gender identity change in his or her notes, Casperson says that if the patient goes to see another provider, the notes may not all be reviewed, whereas demographic information within the EHR would be more easily reviewed, especially if the new provider uses the same computer system.

Some 190 million patients have a current medical record in Epic’s EHR system, meaning something needed to be done on the vendor development front to remedy this problem. As explained in an in-depth Wired piece in June, titled, “The Battle to Get Gender Identity Into Your Health Records,” pressure from federal health regulators to build the capability within the EHR software to appropriately collect sexual orientation and gender identity information started to ramp up in 2015. First, Federally Qualified Health Centers (FQHCs) were mandated to collect data on sexual orientation and gender identity by 2016. And for outpatient clinics that were attesting to the meaningful use program, they will have to use software that collects sexual orientation and gender identity information by 2018.


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While noting sexual orientation can change the pattern of care, in the case of gender identity, doing so can actually change how care is delivered. As such, Epic, for one, created a workgroup to make sure that gender identity would be displayed consistently and correctly by including a two-item gender identity question, according to the Wired piece.

But that update doesn’t apply for every Epic user. Casperson says that her small hospital actually uses a version of the Epic EHR through another healthcare organization in Sioux Falls, South Dakota, a collaborative approach to IT that helps cut costs. But with those savings come problems that arise by not using the vendor’s original foundation package. For example, in Montana and in some of its surrounding states, people cannot change their genders on their drivers’ licenses until they have completed a sex reassignment. So at this point, explains Casperson, “We are not allowed to use ‘other,’ even though Epic does have the [updated] dropdowns available. But the version we are using through Epic doesn’t [even] have that as an option for us,” adding that many of her peers are in similar situations.

The issue is compounded in the Montana badlands, where Sidney Health Center is located, an area with several oil fields and where outsiders from other areas of the country come for short-term work purposes. “Providers do not have all of that information available to them, so if a transgender patient [from outside the area] comes into our ER, there is nothing in our records. So unless the patient tells the provider [that he or she is transgender], we wouldn’t know,” she says.

And this leads to another potential complication—how comfortable are providers with asking patients these kinds of sensitive questions? The Wired piece references a 2015 report which found that 33 percent of transgender people surveyed had at least one negative healthcare experience in the past year related to their gender identity.

Casperson says that she sent out a survey to Sidney Health Center doctors asking if they would feel comfortable using the dropdown to ask patients these questions about gender identity. “I got all kinds of responses, from a flat out ‘no’ to ‘yes we need to do this.’ The doctors who said no are concerned the patients might see it as disrespectful if they were to ask them this question,” she says.

After the survey results were in, Casperson presented the data to her leadership, asking if descriptors were needed and if there needs to be a standard developed, especially with a new patient. “We are simply asking the question so that [the doctor] can take the best possible care of you. That’s what it comes down to and that’s what the medical record information is there for. But they need to do it in a respectful way so that the patient knows it is about getting him or her the best care,” she says.

Casperson adds that some doctors simply don’t want to “push the envelope” and are concerned that they will upset the patient by asking. But from a privacy standpoint, the only thing that matters is needing to know everything about that patient, she contends. “To me, it’s the same as asking if they’re married or asking about something in their past medical history. This is all a part of the medical history. Is it different than needing to know if the patient had a prior knee replacement [procedure]? It impacts the tests you might order and how you treat the patient.”

And if a doctor did not know that information, she adds, the treatment process could suffer.  “Let’s say a doctor has a patient who was a male but turned female. You might not even look for an issue with a prostate or order a PSA [prostate-specific antigen] test if you didn’t know that the patient was once male. You wouldn’t even thinking of it as a possibility. So you can potentially miss something such as prostate cancer,” she attests.

Moving forward, Casperson says the top priority at her organization is making sure that the “other” field in the EHR has a dropdown menu where more information could be collected. But for the time being, “plenty of gaps still exist and there is a stigma that needs to be reduced,” she says.




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Allscripts Sells its Netsmart Stake to GI Partners, TA Associates

December 10, 2018
by Rajiv Leventhal, Managing Editor
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Just a few months after Allscripts said it would be selling its majority stake in Netsmart, the health IT company announced today that private equity firm GI Partners, along with TA Associates, will be acquiring the stake held in Netsmart.

In 2016 Allscripts acquired Kansas City-based Netsmart for $950 million in a joint venture with middle-market private equity firm GI Partners, with Allscripts controlling 51 percent of the company. With that deal, Allscripts contributed its homecare business to Netsmart, in exchange for the largest ownership stake in the company which has now become the largest technology company exclusively dedicated to behavioral health, human services and post-acute care, officials have noted.

Now, this transaction represents an additional investment for GI Partners over its initial stake acquired in April 2016, and results in majority ownership of Netsmart by GI Partners.

According to reports, it is expected that this sale transaction will yield Allscripts net after-tax proceeds of approximately $525 million or approximately $3 per fully diluted share.

Founded 50 years ago, Netsmart is a provider of software and technology solutions designed especially for the health and human services and post-acute sectors, enabling mission-critical clinical and business processes including electronic health records (EHRs), population health, billing, analytics and health information exchange, its officials say.

According to the company’s executives, “Since GI Partners' investment in 2016, Netsmart has experienced considerable growth through product innovation and multiple strategic acquisitions. During this time, Netsmart launched myUnity, [a] multi-tenant SaaS platform serving the entire post-acute care continuum, and successfully completed strategic acquisitions in human services and post-acute care technology. Over the same period, Netsmart has added 150,000 users and over 5,000 organizations to its platform.”

On the 2018 Healthcare Informatics 100, a list of the top 100 health IT vendors in the U.S. by revenue, Allscripts ranked 10th with a self-reported health IT revenue of $1.8 billion. Netsmart, meanwhile, ranked 44th with a self-reported revenue of $319 million.

According to reports, Allscripts plans to use the net after-tax proceeds to repay long-term debt, invest in other growing areas of its business, and to opportunistically repurchase its outstanding common stock.

The transaction is expected to be completed this month.

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Study Links Stress from Using EHRs to Physician Burnout

December 7, 2018
by Heather Landi, Associate Editor
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More than a third of primary care physicians reported all three measures of EHR-related stress
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Physician burnout continues to be a significant issue in the healthcare and healthcare IT industries, and at the same time, electronic health records (EHRs) are consistently cited as a top burnout factor for physicians.

A commonly referenced study published in the Annals of Internal Medicine in 2016 found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day.

Findings from a new study published this week in the Journal of the American Medical Informatics Association indicates that stress from using EHRs is associated with burnout, particularly for primary care doctors, such as pediatricians, family medicine physicians and general internists.

Common causes of EHR-related stress include too little time for documentation, time spent at home managing records and EHR user interfaces that are not intuitive to the physicians who use them, according to the study, based on responses from 4,200 practicing physicians.

“You don't want your doctor to be burned out or frustrated by the technology that stands between you and them,” Rebekah Gardner, M.D., an associate professor of medicine at Brown University's Warren Alpert Medical School, and lead author of the study, said in a statement. “In this paper, we show that EHR stress is associated with burnout, even after controlling for a lot of different demographic and practice characteristics. Quantitatively, physicians who have identified these stressors are more likely to be burned out than physicians who haven't."

The Rhode Island Department of Health surveys practicing physicians in Rhode Island every two years about how they use health information technology, as part of a legislative mandate to publicly report health care quality data. In 2017, the research team included questions about health information technology-related stress and specifically EHR-related stress.

Of the almost 4,200 practicing physicians in the state, 43 percent responded, and the respondents were representative of the overall population. Almost all of the doctors used EHRs (91 percent) and of these, 70 percent reported at least one measure of EHR-related stress.

Measures included agreeing that EHRs add to the frustration of their day, spending moderate to excessive amounts of time on EHRs while they were at home and reporting insufficient time for documentation while at work.

Many prior studies have looked into the factors that contribute to burnout in health care, Gardner said. Besides health information technology, these factors include chaotic work environments, productivity pressures, lack of autonomy and a misalignment between the doctors' values and the values they perceive the leaders of their organizations hold.

Prior research has shown that patients of burned-out physicians experience more errors and unnecessary tests, said Gardner, who also is a senior medical scientist at Healthcentric Advisors.

In this latest study, researchers found that doctors with insufficient time for documentation while at work had 2.8 times the odds of burnout symptoms compared to doctors without that pressure. The other two measures had roughly twice the odds of burnout symptoms.

The researchers also found that EHR-related stress is dependent on the physician's specialty.

More than a third of primary care physicians reported all three measures of EHR-related stress -- including general internists (39.5 percent), family medicine physicians (37 percent) and pediatricians (33.6 percent). Many dermatologists (36.4 percent) also reported all three measures of EHR-related stress.

On the other hand, less than 10 percent of anesthesiologists, radiologists and hospital medicine specialists reported all three measures of EHR-related stress.

While family medicine physicians (35.7 percent) and dermatologists (34.6 percent) reported the highest levels of burnout, in keeping with their high levels of EHR-related stress, hospital medicine specialists came in third at 30.8 percent. Gardner suspects that other factors, such as a chaotic work environment, contribute to their rates of burnout.

"To me, it's a signal to health care organizations that if they're going to 'fix' burnout, one solution is not going to work for all physicians in their organization," Gardner said. "They need to look at the physicians by specialty and make sure that if they are looking for a technology-related solution, then that's really the problem in their group."

However, for those doctors who do have a lot of EHR-related stress, health care administrators could work to streamline the documentation expectations or adopt policies where work-related email and EHR access is discouraged during vacation, Gardner said.

Making the user interface for EHRs more intuitive could address some stress, Gardner noted; however, when the research team analyzed the results by the three most common EHR systems in the state, none of them were associated with increased burnout.

Earlier research found that using medical scribes was associated with lower rates of burnout, but this study did not confirm that association. In the paper, the study authors suggest that perhaps medical scribes address the burden of documentation, but not other time-consuming EHR tasks such as inbox management.


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HHS Studying Modernization of Indian Health Services’ IT Platform

November 29, 2018
by David Raths, Contributing Editor
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Options include updating the Resource and Patient Management System technology stack or acquiring commercial solutions

With so much focus on the modernization of health IT systems at the Veteran’s Administration and Department of Defense, there has been less attention paid to decisions that have to be made about IT systems in the Indian Health Service. But now the HHS Office of the Chief Technology Officer has funded a one-year project to study IHS’ options.

The study will explore options for modernizing IHS’ solutions, either by updating the Resource and Patient Management System (RPMS) technology stack, acquiring commercial off-the-shelf (COTS) solutions, or a combination of the two. One of the people involved in the analysis is Theresa Cullen, M.D., M.S., associate director of global health informatics at the Regenstrief Institute. Perhaps no one has more experience or a better perspective on RPMS than Dr. Cullen, who served as the CIO for Indian Health Service and as the Chief Medical Information Officer for the Veterans Health Administration

During a webinar put on by the Open Source Electronic Health Record Alliance (OSEHERA), Dr. Cullen described the scope of the project. “The goal is to look at the current state of RPMS EHR and other components with an eye to modernization. Can it be modernized to meet the near term and future needs of communities served by IHS? We are engaged with tribally operated and urban sites. Whatever decisions or recommendations are made will include their voice.”

The size and complexity of the IHS highlights the importance of the technology decision. It provides direct and purchased care to American Indian and Alaska Native people (2.2 million lives) from 573 federally recognized tribes in 37 states. Its budget was $5.5 billion for fiscal 2018 appropriations, plus third-party collections of $1.02 billion at IHS sites in fiscal 2017. The IHS also faces considerable cost constraints, Dr. Cullen noted, adding that by comparison that the VA’s population is four times greater but its budget is 15 times greater.

RPMS, created in 1984, is in use at all of IHS’ federally operated facilities, as well as most tribally operated and urban Indian health programs. It has more than 100 components, including clinical, practice management and administrative applications.


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About 20 to 30 percent of RPMS code originates in the VA’s VistA. Many VA applications (Laboratory, Pharmacy) have been extensively modified to meet IHS requirements. But Dr. Cullen mentioned that IHS has developed numerous applications independently of VA to address IHS-specific mission and business needs (child health, public/population health, revenue cycle).

Because the VA announced in 2017 it would sundown VistA and transition to Cerner, the assessment team is working under the assumption that the IHS has only about 10 years to figure out what it will do about the parts of RPMS that still derive from VistA. And RPMS, like VistA, resides in an architecture that is growing outdated.

The committee is setting up a community of practice to allow stakeholders to share technology needs, best practices and ways forward. One question is how to define modernization and how IHS can get there. The idea is to assess the potential for the existing capabilities developed for the needs of Indian country over the past few decades to be brought into a modern technology architecture. The technology assessment limited to RPMS, Dr. Cullen noted. “We are not looking at COTS [commercial off the shelf] products or open source. We are assessing the potential for existing capabilities to be brought into “a modern technology architecture.”

Part of the webinar involved asking attendees for their ideas for what a modernized technology stack for RPMS would look like, what development and transitional challenges could be expected, and any comparable efforts that could inform the work of the technical assessment team.




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