Journal of Pathology Informatics Journal of Pathology Informatics
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TECHNICAL NOTE
Year : 2017  |  Volume : 8  |  Issue : 1  |  Page : 42

Preferred names, preferred pronouns, and gender identity in the electronic medical record and laboratory information system: Is pathology ready?


1 Department of Family Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
2 Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
3 Department of Ambulatory Care Services, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
4 Center of Excellence in Image Guided Radiation Therapy, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
5 Department of Health Care Information Services, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
6 Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
7 Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA

Correspondence Address:
Matthew D Krasowski
Department of Pathology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, C-671 GH Iowa City, IA 52242
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpi.jpi_52_17

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Background: Electronic medical records (EMRs) and laboratory information systems (LISs) commonly utilize patient identifiers such as legal name, sex, medical record number, and date of birth. There have been recommendations from some EMR working groups (e.g., the World Professional Association for Transgender Health) to include preferred name, pronoun preference, assigned sex at birth, and gender identity in the EMR. These practices are currently uncommon in the United States. There has been little published on the potential impact of these changes on pathology and LISs. Methods: We review the available literature and guidelines on the use of preferred name and gender identity on pathology, including data on changes in laboratory testing following gender transition treatments. We also describe pathology and clinical laboratory challenges in the implementation of preferred name at our institution. Results: Preferred name, pronoun preference, and gender identity have the most immediate impact on the areas of pathology with direct patient contact such as phlebotomy and transfusion medicine, both in terms of interaction with patients and policies for patient identification. Gender identity affects the regulation and policies within transfusion medicine including blood donor risk assessment and eligibility. There are limited studies on the impact of gender transition treatments on laboratory tests, but multiple studies have demonstrated complex changes in chemistry and hematology tests. A broader challenge is that, even as EMRs add functionality, pathology computer systems (e.g., LIS, middleware, reference laboratory, and outreach interfaces) may not have functionality to store or display preferred name and gender identity. Conclusions: Implementation of preferred name, pronoun preference, and gender identity presents multiple challenges and opportunities for pathology.


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