READY, SET, GO! GUIDELINES AND TIPS FOR COLLECTING PATIENT DATA ON SEXUAL ORIENTATION AND GENDER IDENTITY January 2018 TABLE OF CONTENTS INTRODUCTION Why Collect Data on Sexual Orientation and Gender Identity? 1 How to Use This Guide 1 READY! Creating a Team and a Timeline 2 Fig 1. Sample Timeline 2 Developing a Workflow 3 Fig 2. Sample Process of Collecting SO/GI Data 3 Adding Questions to Registration Forms 4 Fig 3a. Recommended SO/GI Questions 4 Fig 3b. Definitions of SO/GI Categories 4 Translations of Questions 5 Definitions of SO/GI Categories 5 Names and Pronouns 6 Fig 4. Sample Registration Form 7 Considerations for Children and Adolescents 7 SET! Customizing the EHR 8 Fig 5. Sample Pronoun Color Code 9 Training Staff 9 Educating Patients 10 Patient Education Brochures 10 Fig 6. Sample SO/GI Patient Brochures 10 Privacy and Confidentiality 11 Responding to Patient Questions and Concerns 11 Discussing SO/GI during the Clinical Encounter 12 Responding to Staff Concerns 13 Creating a Welcoming and Inclusive Health Center 13 LGBTQ Cultural Competency Resources 14 GO! Piloting the Process 15 Analyzing and Applying SO/GI Data 15 Monitoring Data Quality 16 Fig 7. Sample Staff Roles in Data Quality Improvement 16 LESSONS FROM THE FIELD 17 ADDITIONAL RESOURCES 18 INTRODUCTION Why Collect Data on Sexual Orientation and Gender Identity? Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience significant health disparities and require preventive services and treatment interventions tailored to their unique needs. Yet health care pro- viders often do not know the sexual orientation or gender identity (SO/GI) of their patients, leading to missed screenings, less effective counseling, culturally insensitive remarks, and other missteps. The process of asking all patients about their SO/GI empowers health care organizations to get to know their patients better, and to provide them with the appropriate, patient-centered services they need. SO/GI data collection has been recommended by both the Institute of Medicine1,2 and the Joint Commission3 as a way to learn about which populations are being served, and to measure the quality of care provided to LGBTQ people. In recognition of the population health benefits of collecting SO/GI data, the Bureau of Pri- mary Health Care (BPHC), HRSA added SO/GI as required elements to be reported yearly by Health Center Program grantees (health centers) in the Uniform Data System (UDS) beginning in Calendar Year 2016.4 Although some have raised concerns that the process of identifying LGBTQ people could invite stigma or dis- crimination, in actual practice, SO/GI data collection has encouraged health centers to increase the cultural competence of their care delivery and environment. Patients have found that sharing SO/GI information has facilitated important health-related conversations with clinicians they trust. In sum, the reasons to collect SO/GI data are to: • Help clinicians provide more effective patient-centered care; • Encourage staff to provide more culturally-sensitive services to LGBTQ patients; • Facilitate the monitoring of quality of care to LGBTQ populations; and • Reduce health disparities. How to Use This Guide The following guide is designed to help your health center successfully collect SO/GI data, no matter where you are in the process. For those just beginning, the guide can be used from start to finish. If you have already created a system, but have encountered challenges and questions, this guide can help you address them. Even if your system is working smoothly, you will find resources and recommendations here that will help you move to the next level of data collection and analysis. 1 Institute of Medicine. The health of lesbian, gay, bisexual, and transgender (LGBT) people: building a foundation for better understanding. Washington, DC: National Academies Press; 2011. 2 Institute of Medicine. Sexual orientation and gender identity data collection in electronic health records: a workshop. Washington, DC: National Acad- emies Press; 2012. 3 The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, IL: Joint Commission; 2011. 4 Department of Health and Human Services, Health Resources and Services Administration. Program Assistance Letter (PAL 2016-02). Approved Uniform Data System Changes for Calendar Year 2016. March 22, 2016. 1 READY! Creating a Team and a Timeline The first step in setting up a successful SO/GI data collection system is to identify key staff who can meet reg- ularly, be champions, and provide feedback on how the process is going. Although having LGBTQ people on the team is very helpful, it is not essential. All people can do this work effectively. Ideally, one member of the team should be an executive (e.g., CEO, CFO) who can make sure the health cen- ter has the right resources to implement the process. Alternatively, the team can have regular meetings with senior management to update them on their progress. In addition, the team should have representatives from different departments, including clinical (e.g., medical, nursing), non-clinical (e.g., registration, patient ser- vices, billing), and health information technology (HIT) (e.g., electronic health record (EHR) building, data analysis). Figure 1 provides a sample implementation timeline for SO/GI teams. Keep in mind that the length and timing of steps will vary by organization; in many cases, several of the steps can occur in parallel. Figure 1. Sample SO/GI Implementation Timeline Months 1-3: Plan implementation Month 4: Conduct process mapping Month 4-6: Modify electronic health record (EHR) systems Month 6: Train staff; change forms, policies, and physical environment Month 7: Pilot SO/GI in one department; use Plan-Do-Study-Act (PDSA) cycle; analyze outcomes Month 8: Repeat process with another department; use PDSA cycle; analyze outcomes Month 9-10: Expand to all departments/sites; monitor progress through data feedback reports Month 14: Conduct first data summary report Ongoing: Monitor data quality 2 Developing a Workflow The most efficient and effective way to collect SO/GI data is during patient registration. SO/GI data can be gathered along with other demographic information, such as race, ethnicity, and employment. This normaliz- es the process and ensures more complete data collection. In addition, it allows health centers to collect the data at the first patient visit, as well as to update the information during routine check-ins. Providers can then follow-up with patients to discuss SO/GI during the clinical exam. There are various ways to integrate SO/GI into existing forms and protocols (see Figure 2): • Patients can electronically enter SO/GI data through a patient portal at home, or onsite at a kiosk or on a tablet. Electronic methods provide the most privacy. • Patients can complete paper or laminated registration forms. Patient services staff can then manually enter the data in the EHR. • If SO/GI data is not reported, providers can ask about SO/GI during the social or sexual history, and can manually enter the data during or after the patient encounter. SO/GI should be asked at the first clinical visit as well as at least annually, because this information can change over time. Figure 2. Sample Process of Collecting SO/GI Data 3 Adding Questions to Registration Forms SO/GI questions can be integrated into the demographics or social history section of the registration form. The SO/GI questions in Figure 3a have been studied in different health center populations and have been found to be acceptable by most patients.5 For definitions of SO/GI categories and terms, see Figure 3b on page 5. For information on how to code and report SO/GI data in the Uniform Data System (UDS), see the most up-to-date UDS manual reporting instructions from BPHC.6 Figure 3a. Recommended SO/GI Questions Do you think of yourself as (Check one): Straight or heterosexual Lesbian, gay, or homosexual Bisexual Something else Don’t know Choose not to disclose What is your current gender identity? (Check one): Male Female Transgender Male/Trans Man/ Female-to-Male (FTM) Transgender Female/Trans Woman/ Male-to-Female (MTF) Genderqueer, neither exclusively male nor female Additional gender category, please specify: _______________ Choose not to disclose What sex were you assigned at birth? (Check one): Male Female Choose not to disclose Important Note: the reason for asking both gender identity and sex assigned at birth is because some transgender people will identify their gender as ‘male’ or ‘female,’ and not as ‘transgender’ or ‘gender- queer’. 5 Cahill S, Singal R, Grasso C, King D, Mayer K, Baker K, et al. Do ask, do tell: High levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers. PLoS One. 2014;9(9):e107104. 6 Bureau of Primary Health Care, HRSA. 2017 UDS Manual. August 31, 2017. OMB Number: 0915-0193, Expiration Date 2/28/2018. Available at: https://bphc. hrsa.gov/datareporting/reporting/2017udsreportingmanual.pdf 4 Translations of SO/GI Questions Spanish and Chinese translations of SO/GI questions can be accessed from the National LGBT Health Education Center website. Health centers may want to first review these translations with people in their own communities before using them; in many cultures, LGBTQ terminology may not directly translate into a single word or phrase; and in some instances, the translations can be viewed as offensive. For trans- lation into other languages, health centers can work with their own translators, employees, and/or local LGBTQ community groups. Figure 3b. Definitions of SO/GI Categories Sexual Orientation: describes how a person characterizes their emotional and sexual attraction to others.