Document Type


Degree Name



Dept. of Medical Informatics and Clinical Epidemiology


Oregon Health & Science University


Sex and gender are commonly thought to be synonymous, and both are generally classified using the binary categories of male and female. Existing standards applying to electronic health records (EHRs) all use, or until very recently have used, only these two categories plus “unknown” or “not-specified” with the latter options existing more for irretrievable or absent information than for purposes of documenting a diverse set of possible expected answers. Evidence is mounting that the binary options may not be adequate for many populations, including but not limited to intersex and transgendered patients. Insufficient granularity may result in insurance denials, documentation irregularities, or even medical misadventure. For example, a patient documented as male and appearing unremarkably in a masculine manner may present with pelvic pain and experience unnecessary delays and expense, possibly even harm, when the presence of an abnormally-behaving uterus is not discovered until a computerized tomography (CT) scan is performed.

The realization that more options might be needed crystallized in the recommendation by the Institute of Medicine (IoM) in March 2011 that more diverse categories for sex and/or gender classification be considered in developing Meaningful Use recommendations for EHRs. In March 2012, as part of Meaningful Use Stage 2 rule making, the Department of Health and Human Services (DHHS) solicited feedback regarding the need for, and appearance of, a new gender classification model. In Oct 2012, DHHS chose to defer a decision pending clearer guidance from stakeholders. This paper examines the supporting basis for more inclusive and clear gender and sex classifications in EHRs, provides an argument that Meaningful Use Stage 3 should include a requirement for such a classification scheme, and proposes a framework for such requirements that would meet the needs of the affected population, providers, and vendors taking into account the experiences gathered by trailblazing providers and vendors since the IoM report of 2011.




School of Medicine



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