Toward an inclusive digital health system for sexual and gender minorities in Canada

Improving radiology information systems for inclusivity of transgender and gender-diverse patients: what are the problems and what are the solutions? A systematic review

INTRODUCTION

In medical radiation science (MRS), radiology information systems (RISs) record patient information such as name, gender and birthdate. The purpose of RISs is to ensure the safety and well-being of patients by recording patient data accurately. However, not all RISs appropriately capture gender, sex or other related information of transgender and gender-diverse (TGD) patients, resulting in non-inclusive and discriminatory care. This review synthesises the research surrounding the limitations of RISs preventing inclusivity and the features required to support inclusivity and improve health outcomes.

METHODS

Studies were retrieved from three electronic databases (Scopus, PubMed and Embase). A quality assessment was performed using the Johns Hopkins Nursing Evidence-Based Practice Research and Non-Research Evidence Appraisal Tools. A thematic analysis approach was used to synthesise the included articles.

RESULTS

Eighteen articles were included based on the predetermined eligibility criteria. The pool of studies included in this review comprised primarily of non-research evidence and reflected the infancy of this research field and the need for further empirical evidence. The key findings of this review emphasise how current systems do not record the patient's name and pronouns appropriately, conflate sex and gender and treat sex and gender as a binary concept.

CONCLUSION

For current systems to facilitate inclusivity, they must implement more comprehensive information and data models incorporating sex and gender and be more flexible to accommodate the transient and fluid nature of gender. However, implementation of these recommendations is not without challenges. Additionally, further research focused on RISs is required to address the unique challenges MRS settings present to TGD patients.

Utilization of electronic health record sex and gender demographic fields: a metadata and mixed methods analysis

OBJECTIVES

Despite federally mandated collection of sex and gender demographics in the electronic health record (EHR), longitudinal assessments are lacking. We assessed sex and gender demographic field utilization using EHR metadata.

MATERIALS AND METHODS

Patients ≥18 years of age in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between January 8, 2018 and January 1, 2022 were included in this retrospective study. Metadata for all sex and gender fields (Legal Sex, Sex Assigned at Birth [SAAB], Gender Identity) were quantified by completion rates, user types, and longitudinal change. A nested qualitative study of providers from specialties with high and low field use identified themes related to utilization.

RESULTS

1 576 120 patients met inclusion criteria: 100% had a Legal Sex, 20% a Gender Identity, and 19% a SAAB; 321 185 patients had field changes other than initial Legal Sex entry. About 2% of patients had a subsequent Legal Sex change, and 25% of those had ≥2 changes; 20% of patients had ≥1 update to Gender Identity and 19% to SAAB. Excluding the first Legal Sex entry, administrators made most changes (67%) across all fields, followed by patients (25%), providers (7.2%), and automated Health Level-7 (HL7) interface messages (0.7%). Provider utilization varied by subspecialty; themes related to systems barriers and personal perceptions were identified.

DISCUSSION

Sex and gender demographic fields are primarily used by administrators and raise concern about data accuracy; provider use is heterogenous and lacking. Provider awareness of field availability and variable workflows may impede use.

CONCLUSION

EHR metadata highlights areas for improvement of sex and gender field utilization.

Analysis of Inclusive Gender, Sexuality and Sexual Orientation Data Elements in Academic Electronic Health Records

Findings from an analysis of three vended academic electronic health records used in health science education are presented in this article. The quality assurance project examined the lexical and semantic fit and content coverage of gender, sexuality, and sexual orientation data elements within the academic electronic health records. A semantic comparative content analysis using a cognitive walkthrough was conducted as a means of comparing the ideal set of gender, sexuality, and sexual orientation data elements with those found in the three vended academic electronic health records. The results indicated a need for alignment to the research literature, expert consensus, and technical standards similar to what is expected for electronic health records used in clinical practice because of a lack of ideal state data elements. The findings align with ongoing issues with bias and disparities seen in the care of the lesbian, gay, bisexual, and transgender population and a lack of diverse, inclusive media and teaching technologies in health science education. The quality project and findings can inform academic electronic health record vendors on how they can create more inclusive systems and bring awareness to healthcare educators about the potential for implicit and explicit bias in their teaching technologies.

Changes in Children and Youth's Mental Health Presentations during COVID-19: A Study of Primary Care Practices in Northern Ontario, Canada

Recent research suggests that children and youth are at increased risk of anxiety and depression due to the indirect effects of the COVID-19 pandemic. In Canada, children and youths may face additional hurdles in accessing mental health services in rural areas due to socioeconomic disadvantages and healthcare provider shortages worsened by the pandemic. Our study aimed to assess changes in primary healthcare utilization related to depression and anxiety among children and youth aged 10-25 years in Northern Ontario, Canada. We analyzed de-identified electronic medical record data to assess primary healthcare visits and prescriptions for depression and anxiety among children and youth aged 10-25 years. We used provider billing data and reasons for visits and antidepressant/antianxiety prescriptions compared with 21 months pre-pandemic (1 June 2018 to 28 February 2020) and 21 months during the pandemic (1 April 2020 to 31 December 2021). Our interrupted time series analysis showed an average increase in visits by 2.52 per 10,000 person-months and in prescriptions by 6.69 per 10,000 person-months across all ages and sexes. Females aged 10 to 14 years were found to have the greatest relative change in visits across all age-sex groups. The greatest relative increases in antianxiety and antidepression prescriptions occurred among females and males aged 10 to 14 years, respectively. These findings indicate that there were increased anxiety and depression presentations in primary healthcare among children and youths living in northern and rural settings during the COVID-19 pandemic. The increased primary healthcare presentations of anxiety and depression by children and youths suggest that additional mental health resources should be allocated to northern rural primary healthcare to support the increased demand. Adequate mental health professionals, accessible services, and clinical recommendations tailored to northern rural populations and care settings are crucial.

Advancing AI in healthcare: A comprehensive review of best practices

Artificial Intelligence (AI) and Machine Learning (ML) are powerful tools shaping the healthcare sector. This review considers twelve key aspects of AI in clinical practice: 1) Ethical AI; 2) Explainable AI; 3) Health Equity and Bias in AI; 4) Sponsorship Bias; 5) Data Privacy; 6) Genomics and Privacy; 7) Insufficient Sample Size and Self-Serving Bias; 8) Bridging the Gap Between Training Datasets and Real-World Scenarios; 9) Open Source and Collaborative Development; 10) Dataset Bias and Synthetic Data; 11) Measurement Bias; 12) Reproducibility in AI Research. These categories represent both the challenges and opportunities of AI implementation in healthcare. While AI holds significant potential for improving patient care, it also presents risks and challenges, such as ensuring privacy, combating bias, and maintaining transparency and ethics. The review underscores the necessity of developing comprehensive best practices for healthcare organizations and fostering a diverse dialogue involving data scientists, clinicians, patient advocates, ethicists, economists, and policymakers. We are at the precipice of significant transformation in healthcare powered by AI. By continuing to reassess and refine our approach, we can ensure that AI is implemented responsibly and ethically, maximizing its benefit to patient care and public health.

What's Next for Modernizing Gender, Sex, and Sexual Orientation Terminology in Digital Health Systems? Viewpoint on Research and Implementation Priorities

In 2021, Canada Health Infoway and the University of Victoria's Gender, Sex, and Sexual Orientation Research Team hosted a series of discussions to successfully and safely modernize gender, sex, and sexual orientation information practices within digital health systems. Five main topic areas were covered: (1) terminology standards; (2) digital health and electronic health record functions; (3) policy and practice implications; (4) primary care settings; and (5) acute and tertiary care settings. In this viewpoint paper, we provide priorities for future research and implementation projects and recommendations that emerged from these discussions.

Barriers in Dental Care Utilization-An Explorative Study among Transgender Community of Bhubaneswar, Odisha

Introduction

Transgenders (TGs) are one of the vulnerable groups in our society. Trans people experience substantial health disparities and barriers to appropriate health care services that keep them from achieving the highest possible health status.

Methodology

The study was conducted over the course of 12 months at the Transgender Shelter Home. Focus group discussion (FGD) took place with 6-12 participants and the researcher acted as moderator. The questions were asked under four domains; sociodemographic variables, behavioral variables, medical and health status variables, and access and utilization of dental services barrier variables. Transcripts were coded and data analysis was concurrent with data collection to allow to know new insights. The data analysis was done by MAXQDA software 2022.0.0. It is being developed and distributed by VERBI Software based in Berlin, Germany.

Results

The barriers and facilitators explored were categorized at three levels: (1) the personal level, relating to those barriers and facilitators that the individual faced for their oral health care, and the perspectives regarding the delivery of care; (2) the inter-personal level; and (3) the system level, for identifying the wider elements and their influence.

Discussion

Social stigma and marginalization have been linked to adverse health effects, including personal attributes, structural and environmental factors, and personal perceptions of stigmatization.

Conclusion

It is evident that lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities have specific but varied health care needs, and the greatest way to treat these necessities is via exposure to professional, health care coverage.

Findings From a Scoping Review: Presumptive Treatment for Chlamydiatrachomatis and Neisseria gonorrhoeae in the United States, 2006-2021

ABSTRACT

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common reported sexually transmitted infections in the United States. Current recommendations are to presumptively treat CT and/or GC in persons with symptoms or known contact. This review characterizes the literature around studies with presumptive treatment, including identifying rates of presumptive treatment and overtreatment and undertreatment rates. Of the 18 articles that met our inclusion criteria, 6 pertained to outpatient settings. In the outpatient setting, presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 12% to 100%, and the percent positive of those presumptively treated ranged from 25% to 46%. Three studies also reported data on positive results in patients not presumptively treated, which ranged from 2% to 9%. Two studies reported median follow-up time for untreated, which was roughly 9 days. The remaining 12 articles pertained to the emergency setting where presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 16% to 91%, the percent positive following presumptive treatment ranged from 14% to 59%. Positive results without presumptive treatment ranged from 4% to 52%. Two studies reported the percent positive without any treatment (6% and 32%, respectively) and one reported follow-up time for untreated infections (median, 4.8 days). Rates of presumptive treatment, as well as rates of overtreatment or undertreatment vary widely across studies and within care settings. Given the large variability in presumptive treatment, the focus on urban settings, and minimal focus on social determinants of health, additional studies are needed to guide treatment practices for CT and GC in outpatient and emergency settings.

Equitable Research PRAXIS: A Framework for Health Informatics Methods

OBJECTIVES

There is growing attention to health equity in health informatics research. However, the literature lacks a comprehensive framework outlining critical considerations for health informatics research with marginalized groups.

METHODS

Literature review and experiences from nine equity-focused health informatics conducted in the United States and Canada. Studies focus on disparities related to age, disability or chronic illness, gender/sex, place of residence (rural/urban), race/ethnicity, sexual orientation, and socioeconomic status.

RESULTS

We found four key equity-related methodological considerations. To assist informaticists in addressing equity, we contribute a novel framework to synthesize these four considerations: PRAXIS (Participation and Representation, Appropriate methods and interventions, conteXtualization and structural competence, Investigation of Systematic differences). Participation and representation refers to the necessity for meaningful participation of marginalized groups in research, to elevate the voices of marginalized people, and to represent marginalized people as they are comfortable (e.g., asset-based versus deficit-based). Appropriate methods and interventions mean targeting methods, instruments, and interventions to reach and engage marginalized people. Contextualization and structural competence mean avoiding individualization of systematic disparities and targeting social conditions that (re-)produce inequities. Investigation of systematic differences highlights that experiences of people marginalized according to specific traits differ from those not so marginalized, and thus encourages studying the specificity of these differences and investigating and preventing intervention-generated inequality. We outline guidance for operationalizing these considerations at four research stages.

CONCLUSIONS

This framework can assist informaticists in systematically addressing these considerations in their research in four research stages: project initiation; sampling and recruitment; data collection; and data analysis. We encourage others to use these insights from multiple studies to advance health equity in informatics.

Digital Health Equity: Addressing Power, Usability, and Trust to Strengthen Health Systems

BACKGROUND

Without specific attention to health equity considerations in design, implementation, and evaluation, the rapid expansion of digital health approaches threatens to exacerbate rather than ameliorate existing health disparities.

METHODS

We explored known factors that increase digital health inequity to contextualize the need for equity-centered informatics. This work used a narrative review method to summarize issues about inequities in digital health and to discuss future directions for researchers and clinicians. We searched literature using a combination of relevant keywords (e.g., "digital health", "health equity", etc.) using PubMed and Google Scholar.

RESULTS

We have highlighted strategies for addressing medical marginalization in informatics according to vectors of power such as race and ethnicity, gender identity and modality, sexuality, disability, housing status, citizenship status, and criminalization status.

CONCLUSIONS

We have emphasized collaboration with user and patient groups to define priorities, ensure accessibility and localization, and consider risks in development and utilization of digital health tools. Additionally, we encourage consideration of potential pitfalls in adopting these diversity, equity, and inclusion (DEI)-related strategies.

Digital health systems-let's talk about sex (and gender)

Historically, within digital health information systems, sex and gender have been conflated as a single concept and often have been limited to a binary answer. This has led to inappropriate care, erosion of client trust and avoidance of the healthcare system. Health leaders can improve care for all clients with technical and clinical information practice initiatives. While procurement processes could require digital health systems that utilize modern Gender, Sex, and Sexual Orientation (GSSO) terminology, for most health leaders, technical initiatives will focus on modernizing existing systems to the maximum extent possible. Terminology updates may not be immediately visible to clients, but providing the correct information to clinicians will support respectful client encounters. Simultaneously, clinical information practice initiatives can directly affect clinical encounters. Change management strategies need to include all levels of employees and redesign tools and workflows to support modernized information handling practices.

Special Section on Inclusive Digital Health: Notable Papers on Addressing Bias, Equity, and Literacy to Strengthen Health Systems

OBJECTIVE

To summarize significant research contributions on addressing bias, equity, and literacy in health delivery systems published in 2021.

METHODS

An extensive search using PubMed and Scopus was conducted to identify peer-reviewed articles published in 2021 that examined ways that informatics methods, approaches, and tools could address bias, equity, and literacy in health systems and care delivery processes. The selection process comprised three steps: (1) 15 candidate best papers were first selected by the two section editors; (2) external reviewers from internationally renowned research teams reviewed each candidate best paper; and (3) the final selection of three best papers was conducted by the editorial committee of the Yearbook.

RESULTS

Selected best papers represent studies that characterized significant challenges facing biomedical informatics with respect to equity and practices that support equity and literacy in the design of health information systems. Selected papers represent the full spectrum of this year's yearbook theme. In general, papers identified in the search fell into one of the following categories: (1) descriptive accounts of algorithmic bias in medical software or machine learning approaches; (2) enabling health information systems to appropriately encode for gender identity and sex; (3) approaches to support health literacy among individuals who interact with information systems and mobile applications; and (4) approaches to engage diverse populations in the use of health information systems and the biomedical informatics workforce CONCLUSIONS: : Although the selected papers are notable, our collective efforts as a biomedical informatics community to address equity, literacy, and bias remain nascent. More work is needed to ensure health information systems are just in their use of advanced computing approaches and all persons have equal access to health care and informatics tools.