By Julie Dooling, MSHI, RHIA, CHDA, FAHIMA, director of HIM practice excellence for AHIMA

CHICAGO – November 21, 2019 – The American Medical Association (AMA) recently amended its policy to support the voluntary inclusion of a transgender patient’s preferred name and clinically relevant sex-specific anatomy in medical documentation.

The amendment reflects AHIMA’s long-standing position regarding the importance of inclusivity to deliver quality care and best outcomes for patients.

AHIMA fully supports AMA’s call for inclusivity in EHRs for the transgender patient population. AHIMA’s LGBTQ workgroup has been actively addressing operational and workflow issues pertaining to health information management (HIM) professionals for several years through articles, practice briefs, and presentations.

Further, the amended AMA policy aligns with the recommendations of the World Professional Association for Transgender Health that medical documentation should include a patient’s preferred name, gender identity, and pronoun preference, along with a means to maintain an inventory of a patient’s medical transition history and current anatomy.

HIM professionals struggle with overall data integrity, from collection to access, and management of sexual orientation and gender identity (SO/GI) data. As the AMA has stated, many health information systems today do not allow for standardized SO/GI data collection.

Electronic health record (EHR) vendors need to update their modules to capture sexual orientation and gender identity in addition to pronouns, preferred name, and sex assigned at birth, to drive coding and billing functions. In addition, we agree that a sex-specific anatomy or biological inventory must be documented in order to provide our patients with the best possible care.

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About AHIMA
AHIMA is a global nonprofit association of health information (HI) professionals. AHIMA represents professionals who work with health data for more than one billion patient visits each year. AHIMA’s mission of empowering people to impact health drives our members and credentialed HI professionals to ensure that health information is accurate, complete, and available to patients and providers. Our leaders work at the intersection of healthcare, technology, and business, and are found in data integrity and information privacy job functions worldwide.