Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group

Abstract

Transgender patients have particular needs with respect to demographic information and health records; specifically, transgender patients may have a chosen name and gender identity that differs from their current legally designated name and sex. Additionally, sex-specific health information, for example, a man with a cervix or a woman with a prostate, requires special attention in electronic health record (EHR) systems. The World Professional Association for Transgender Health (WPATH) is an international multidisciplinary professional association that publishes recognized standards for the care of transgender and gender variant persons. In September 2011, the WPATH Executive Committee convened an Electronic Medical Records Working Group comprised of both expert clinicians and medical information technology specialists, to make recommendations for developers, vendors, and users of EHR systems with respect to transgender patients. These recommendations and supporting rationale are presented here.

Keywords: Electronic; Recommendation; Records; Transgender; Transsexual.

Figure 1

Implementation in Allscripts Professional EHR using the ‘Nickname’ field and a coding system. The preferred name (Michael) is seen in parentheses after the patient's legal name (Mary) in the heading of every screen by every viewer. The preferred pronoun (‘M’ for male) is indicated by a second-order parenthesized letter after the preferred name. Clinic staff are trained in this coding mechanism. EHR, electronic health record.