A rapid review of gender, sex, and sexual orientation documentation in electronic health records
Date
2020
Authors
Lau, Francis
Antonio, Marcy
Davison, Kelly
Queen, Roz
Devor, Aaron
Journal Title
Journal ISSN
Volume Title
Publisher
Journal of the American Medical Informatics Association
Abstract
Objective: The lack of precise and inclusive gender, sex, and sexual orientation (GSSO) data in electronic health
records (EHRs) is perpetuating inequities of sexual and gender minorities (SGM). We conducted a rapid review
on how GSSO documentation in EHRs should be modernized to improve the health of SGM.
Materials and Methods: We searched MEDLINE from 2015 to 2020 with terms for gender, sex, sexual orientation,
and electronic health/medical records. Only literature reviews, primary studies, and commentaries from
peer-reviewed journals in English were included. Two researchers screened citations and reviewed articles with
help from a third to reach consensus. Covidence, Excel, and Atlas-TI were used to track articles, extract data,
and synthesize findings, respectively.
Results: Thirty-five articles were included. The 5 themes to modernize GSSO documentation in EHRs were
(1) creating an inclusive, culturally competent environment with precise terminology and standardized data collection;
(2) refining guidelines for identifying and matching SGM patients with their care needs; (3) improving
patient-provider relationships by addressing patient rights and provider competencies; (4) recognizing technosocio-
organizational aspects when implementing GSSO in EHRs; and (5) addressing invisibility of SGM by
expanding GSSO research.
Conclusions: The literature on GSSO documentation in EHRs is expanding. While this trend is encouraging,
there are still knowledge gaps and practical challenges to enabling meaningful changes, such as organizational
commitments to ensure affirming environments, and coordinated efforts to address technical, organizational,
and social aspects of modernizing GSSO documentation. The adoption of an inclusive EHR to meet SGM needs
is a journey that will evolve over time.
Description
Keywords
sex and gender minorities, documentation practices, electronic health record, electronic medical record, health information standards, rapid review, gender, sex, sexual orientation
Citation
Lau, F., Antonio, M., Davison, K., Queen, R., & Devor, A. (2021). A rapid review of gender, sex, and sexual orientation documentation in electronic health records. Journal of the American Medical Informatics Association, 27(11), 1774-1783. https://doi.org/10.1093/jamia/ocaa158.