Walking the Fine Line: Using the EHR to Promote Patient-Centered Care for Sexual and Gender Minorities

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By: Keisa Bennett, MD, MPH, assistant professor in the Department of Family and Community Medicine at the University of Kentucky. She is the chair of the GLMA faculty subcommittee of education and the immediate past chair of the Society of Teachers of Family Medicine Group on LGBT Health.

As a first year medical student, I finally worked up the courage to get my first Pap test. I had been avoiding doctors for at least 10 years due to what I eventually identified as my own “questioning” status with regard to sexual orientation. At student health, I was confronted with an intake form emblazoned with a question I couldn’t answer: “Are you heterosexual, homosexual, or bisexual?” At the time, I didn’t identify with any of these categories; this clinic didn’t know that people like me existed. I left it blank, and neither the doctor nor any nurse asked. An important part of my life and health remained invisible.

That experience happened 14 years ago, yet coming out to physicians hardly seems easier today. Health care providers are not trained [1,2] to ask anything beyond the gender of current sexual partners, and the majority don’t even ask that question routinely. [3] Do modern electronic health records (EHRs) hold promise in making our invisible patients visible in a way that benefits their care? This question underlies the work of a task force at the University of California, Davis (UCD) whose ultimate goal was to reduce health disparities by introducing sexual orientation and gender identity (SO/GI) measures into their EHR. UCD took on all the questions and concerns raised by this change, and ended up with a comprehensive plan involving interprofessional collaboration, training of staff and providers, patient outreach, and continuous quality improvement.

The UCD task force met resistance to the SO/GI incorporation, including genuine concern for the best interest of patients. The largest degree of resistance to change, however, was likely related to defensiveness–the difficulty in acknowledging that our current practice is not ideal. In health care, this defensiveness often manifests as a strong claim of objectivity–that we are effectively managing diversity by treating everyone “the same.” This superficial version of equality, however, often works against our expressed goal of patient-centered care, in which every patient is treated with an equal degree of respect but also as a unique individual. Practically speaking, physicians simply can’t treat a person with limited income the same as someone with wealth. They can’t help a patient with severe obesity and knee pain using the same methods they would use to treat an extreme athlete with knee pain. Care must be tailored to the patient’s real, lived experience, resources, and practical barriers. The line between discrimination and patient-centered care might be fine, but when all patients are treated with dignity and respect, acknowledging differences in culture and context can result in care that is more personal, meaningful, and effective. [4,5]

The prerequisite to patient-centered care for LGBTQ* people is therefore visibility or at least open invitation for visibility. We cannot pretend that SO/GI status does not matter for patient care when it is an integral part of the identity or life of LGBTQ people and the way they fit into the world. The new world of the EHR holds promise in finally being able to see and know these people and understand their health on a large scale.  The invisible has the potential to become visible.

It is a brave new world, however, one in which lurks that fine line bordering discrimination. Kudos belong to the UCD task force for not only embarking on a complex and sensitive project to include SO/GI meaningfully in their entire health care system but also for publishing their process as a guide for the rest of us. Luckily, multiple resources now exist to guide institutions in asking appropriate and sensitive questions on intake forms and during clinical encounters. The Joint Commission has a field guide to cultural competence with the LGBT community, and the Human Rights Campaign conducts the Healthcare Equality Index survey that assists hospitals in assessing and improving their outreach to and recognition of LGBT patients and employees. Replacing even subtle discrimination and stigma with patient-centeredness starts with acknowledging differences instead of glossing over them. The work of the UCD task force should inspire all of us as advocates to help our organizations promote the visibility and personhood of LGBTQ people inside the 21st century clinic or hospital.

*Lesbian, gay, bisexual, transgender, queer/questioning, in this blog post meant to represent the full range of sexual and gender minority spectrum including identities, orientations, and experience.

  1. Allison R ea. GLMA-AMA Collaborative Survey on Physician Experiences Caring for LGBT Patients (Survey on Physician Experiences) 2010.
  2. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306:971-977.
  3. Kitts RL. Barriers to optimal care between physicians and lesbian, gay, bisexual, transgender, and questioning adolescent patients. J Homosex. 2010;57:730-747.
  4. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9:100-103.
  5. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood). 2010;29:1489-1495.

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