A game-changer for LGBT health
The Obama administration has done more than any other White House to advance LGBT health. In Healthy People 2020, a blueprint for improving the health of Americans over the next decade, the federal government not only acknowledged that LGBT people experience disparities in health as compared with the general population, but for the first time made a commitment to ending them. Now, the US Department of Health and Human Services is requiring all Electronic Health Record systems certified under the Meaningful Use program have the capacity to collect sexual orientation and gender identity information from patients.
This move is a game-changer. As a result of the decision last month, conversations that are not taking place in doctor's offices but should be ― because they are critical to the care of someone who is lesbian, gay, bisexual, or transgender ― are much more likely to happen.
Meaningful Use is a $20 billion payment-incentive program designed to improve the public's health by engaging patients more closely in their own care; reducing health disparities among various demographics; and improving population health and public health. The Centers for Medicare and Medicaid Services and the Office of the National Coordinator of Health Information Technology make recommendations about what to include in EHRs certified under the Meaningful Use program, which is to say most EHRs in use today.
Electronic Health Records, in turn, are used as tools by clinicians. For example, a well-organized record will prompt a doctor conducting an annual exam for a woman to take a Pap smear and perform a breast exam. It will remind a nurse who is examining a man in his 60s to do a prostate exam and recommend a blood cholesterol test. Yet despite the disparities in health experienced by LGBT people, they are, for the most part, not currently included in Electronic Health Records.
This exclusion means that LGBT people are, for all intents and purposes, invisible to the health care system. This invisibility has contributed to catastrophic consequences in health: Gay and bisexual men are at least 44 times more likely to become HIV positive than the general population. Lesbians are less likely to receive preventive services for cancer. Bisexuals have much higher rates of alcohol and tobacco use than people who are lesbian, gay, or straight. Transgender people have a high prevalence of attempted suicide, and are less likely to access health care.
While there are many clinicians who provide excellent care to LGBT people, many more do not. This is largely due to ignorance. As the new rule on EHRs noted, transgender men who retain a cervix should be offered a Pap test. The fact that EHRs will now include code sets for people who are lesbian, gay, bisexual, and transgender opens the door for conversations between patients and providers that will result in patients not only feeling comfortable about being out in the exam room, but also talking about their risks to health.
The only way to know that we are reducing health care disparities in the LGBT population is to collect data on patient's sexual orientation and gender identity. If we don't, we won't know, for example, if efforts to increase the rates at which lesbians and bisexual women access mammograms are working. Clinical staff will need to be trained in how to sensitively and appropriately collect this information; LGBT people will need to be further educated about the importance of being out to their health care providers; robust nondiscrimination protections must be put in place throughout the health care system; and clinical staff will also need training in the risks to health faced by LGBT people. But these new guidelines from the US Department of Health and Human Services are a remarkable and historic step forward in improving the health of LGBT people.
Sean Cahill is director of health policy research at the Fenway Institute. Dr. Harvey Makadon is director of education and training at the Fenway Institute.