Variation in Sexual Orientation Documentation in a National Electronic Health Record System

Abstract

Purpose: The purpose of this study was to determine variation in sexual minority (SM) sexual orientation documentation within the electronic medical records of the Veterans Health Administration (VHA). Methods: Documentation of SM sexual orientation was retrospectively extracted from clinical notes and administrative data in the VHA from October 1, 1999 to July 1, 2019. The rate of documentation overall and by calendar year was calculated, and differences across patient, provider, and clinic characteristics were evaluated. Results: Approximately 1.4% of all VHA Veterans (n = 115,911) had at least one documentation of SM sexual orientation, including 79,455 men and 36,456 women. The rate of documentation increased from 81.01/100,000 in 2000 to 568.84/100,000 in 2018. The majority of documentations (58.7%) occurred in mental health settings by non-MD mental health/social work counselors, whereas only 9.6% occurred in primary care settings. Although 99% of these Veterans had a primary care visit, only 19% had SM status recorded in that setting. Conclusion: Documentation patterns of SM sexual orientation varied considerably in the VHA with notable gaps in primary care. Diverse approaches to culturally competent training for primary care clinicians and patient-facing collection strategies could facilitate documentation of sexual orientation.

Keywords: Veterans/Department of Veterans Affairs/VA; administrative data or large data sets; natural language processing; sexual orientation.

FIG. 1.

Diagram of the clinic setting of sexual minority documentation by patient sex. Each clinical setting is represented by a separate slice of the figure. The area of each slice represents the number of documentations in the corresponding clinical setting. The change in color (gray to black or black to gray) represents the higher number of documentations for sexual minority males or females, respectively. ER, emergency room.

FIG. 2.

Documentation of sexual minority sexual orientation across time in the Veterans Health Administration, October 1, 1999 to July 1, 2019. Complete data for years 1999 and 2019 were not available. Therefore, rates and counts may not be reflective of the entire calendar year for those 2 years.