Transgender Patients in the ED

Transgender Patients in the ED

POSTED IN: January/February 2017,

Written by Todd B. Taylor, MD, FACEP, Board Certified Emergency Medicine, ABEM , Board Certified Clinical Informatics, ABPM

Solutions (work-arounds) to this relatively new issue largely depend on which EMR you are using. Having said that, very few EMR vendors have addressed this issue to any great extent. 

See references below, as of 2014 only 13% of healthcare institutions had a way of addressing it in a structured way and less than half of providers did so in unstructured documentation.

These (other references available with an internet search) offer some general advice, but again specific solutions will depend on which EMR you use and what your IT and medical records department are willing to do.

Here are a few salient points:                

1)      Aside from cultural issues, this is a technical challenge, largely rooted in billing. Virtually all EMRs began as billing systems with binary gender fields (male or female). Most insurance company systems are also still binary. If the gender on the bill does not match the insurance company information it gets rejected.  The same holds true with the name (“legal name” vs “preferred name”). Some EMRs have the ability to list aliases, but usually only one name on the arm band. So, no matter how you address this, you must make sure the billing demographics match to avoid delay in payment. 

2)      The above issues may limit your ability to produce arm bands with preferred name and gender identity. This may also be a safety issue. As noted, genotypic females (regardless of gender identity) may retain the ability to get pregnant, so certain drugs may not be appropriate and pregnancy tests indicated. If listed as male, built-in warnings will not work, even if the provider is aware.  

3)      Most EMR databases have at most three fields for gender: male, female, unknown. Some EMRs may have a field for “Other” (either as an additional field or in place of “unknown”). But again, not matching the insurance plan expectation will cause issues.

4)      Finally, gender-specific pronouns create additional challenges with documentation. Which do you use, he or she?    

What to do?

Assuming your options are limited in the EMR (or perhaps even if they are not unless you have both “official” and “preferred” options) here is what I recommend.

1)      Registration must be done with the legal name and gender as noted on the insurance card and driver’s license. If different, they must be reconciled with preference for the insurance card due to billing implications.

2)      Arm band options may be limited based on registration data. A hand-written arm band can be added with the patient’s preferred name and gender identity. If this is a frequent issue, you may wish to create a policy and have a special arm band color for this purpose. If the patient objects to the official arm band, just explain it is for official billing so that they do not get stuck with the bill. If pressed, advise they need to change these things officially since you are required to reflect official records. 

3)      For personal interaction you can use whatever gender identification and name they wish, of course. 

4)      For medical documentation, here is my general rule. I use the genotypic gender (XY=”he” & XX=”she”) unless they have completed sex reassignment surgery. Having said that, if you are using a documentation system that automatically adds gender pronouns you are probably stuck with what has been listed in the registration. 

Bottom Line: Patient preference for gender identity and preferred name with regard to legal documentation (i.e. the medical record) has its limits. These limits are both practical and technical. You may wish to check with your legal department with regard to these choices. My sense is they will advise you to use the official (legal) name and gender, and patient preference only accommodated in unofficial interactions. Long term (definitive) solutions involve complicated (and expensive) EMR modifications.   


Health systems adapt EHRs, cultures to meet transgender patients’ needs
Modern Healthcare: January 30, 2016 

Perspective: Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group
J Am Med Inform Assoc. 2013 Jul; 20(4): 700–703.

 Adapting Hospital Records to the Needs of Transgender People
EMR & EHR: Jul 13, 2015