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Health Data Systems: Decision Support and Coding

SO/GI data are relevant to numerous aspects of patient health. To support a wide range of actors in clinical settings in successfully collecting and using these data to promote patient health, developers of EHR software for hospitals, health centers, and other health systems should incorporate structured SO/GI data into decision support and coding.

Decision support needs to be built into the system to remind clinicians to do routine screenings that support the unique health needs of LGBT people. For example, it is important to screen for HIV and STDs as recommended by the CDC, and for cancer as appropriate, such as screening with anal cytology for anal cancer as appropriate. It is important to be mindful of the history of affirmation surgery in transgender people and recognize the need for screening based on an anatomical inventory reviewing current anatomy as recommended by Deutsch et al., 2013 (see Resource Bibliography section for full citation and URL) and doing breast, cervical and prostate cancer screening as appropriate.

The Electronic Medical Records Working Group of the World Professional Association for Transgender Health (WPATH) “recommends an individualized approach in the care of each transgender patient, based on a current inventory of organs as well as the patient’s own transgender status and sex- or gender-specific history.” (27) More detailed information about how to implement decision support and use appropriate coding for care provided to transgender individuals can be found in the following two articles, both publicly available:

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