|Submitted By: A. Taylor / ONC
|Data Element Information
|Rationale for Separate Consideration
|It is important for healthcare providers and staff to record patients’ administrative sex and gender identity separately and accurately. Although administrative sex may affect gender-specific care (e.g., mammograms), a patient's gender identity may also affect care and health outcomes. For example, transgender patients are known to face health disparities, and lack of adherence to preferred names and pronouns can lead to embarrassment and even discrimination in healthcare.
|Use Case Description(s)
|Use Case Description
|Technical outcome – A user can record a patient’s gender identity according to HL7® FHIR R4, HL7® version 3, SNOMED CT®, and LOINC codes specified in the “standard(s) referenced” column. The user must be able to record whether the patient declined to specify gender identity. Note that while gender identity was included in the 2015 Edition “demographics” certification criterion and the 2015 Edition Base EHR definition, it was not included in the Common Clinical Data Set definition. This means that gender identity is not required to be exchanged using certain standards, only that systems enable a user to record, change, and access gender identity. [see also 80 FR 62619].
|Estimate the breadth of applicability of the use case(s) for this data element
|Users of the 572 certified health IT products, out of 901 total products certified to ONC's 2015 Edition, that successfully tested to the 170.315(a)(5) demographics certification criterion has the ability to record, change, and access gender identity data within these products.
|Link to use case project page
|Maturity of Use and Technical Specifications for Data Element
|LOINC, SNOMED CT, HL7 version 3
|This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
|Extent of exchange
|Restrictions on Standardization (e.g. proprietary code)
|While it is required under the 2015 Edition 170.315(a)(5) demographics certification criterion to be able to record, change, and access gender identity data, it is not required for exchange. One restriction may be the ability to restrict exchange based on patient consent by element.
|Restrictions on Use (e.g. licensing, user fees)
|Privacy and Security Concerns
|Potential concern due to limited capacity to capture and enforce patient consent by element across the industry at this time.
|Estimate of Overall Burden
|Already implemented for record, change, and access, but not for exchange.
Data used to categorize individuals for identification, records matching, and other purposes.
A person’s internal sense of being a man, woman, both, or neither.
Applicable Vocabulary Standard(s)
Gender Identify must be coded in accordance with SNOMED CT® and HL7 Version 3 Standard, Value Sets for AdministrativeGender and NullFlavor, attributed as follows:
Adopted at 45 CFR 170.207(o)(2)