VA Health Care: Better Data Needed to Assess the Health Outcomes of Lesbian, Gay, Bisexual, and Transgender Veterans

GAO-21-69 Published: Oct 19, 2020. Publicly Released: Oct 19, 2020.
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Fast Facts

Veterans Affairs researchers have found that LGBT veterans may experience higher rates of depression and more frequent thoughts of suicide. Yet the VA can't systematically analyze the health of these veterans because it doesn't consistently collect data on sexual orientation or self-identified gender identity. For example, according to the VA, 89% of veterans' records lack gender identity data. Without this data, the VA may miss opportunities to provide appropriate health screenings and identify disparities.

We recommended the VA improve its data collection and analysis to improve health equity and better understand the needs of LGBT veterans.

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Highlights

What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) analyzes national-level data by birth sex to assess health outcomes for women veterans. For example, it analyzes frequency data to identify their most common health conditions. However, VHA is limited in its assessment of health outcomes for the lesbian, gay, bisexual, and transgender (LGBT) veteran population because it does not consistently collect sexual orientation or self-identified gender identity (SIGI) data.

VHA officials stated that providers may record veterans' sexual orientation—which can be used to identify lesbian, gay, and bisexual veterans—in non-standardized clinical notes in electronic health records. However, without a standardized field, providers may not be consistently collecting these data, and VHA does not know the total number of these veterans in its system. VHA officials recognize the importance of consistently collecting these data, but have yet to develop and implement a field for doing so.

VHA collects SIGI data—which can be used in part to identify transgender veterans—in enrollment, administrative, and electronic health record systems. Although VHA has worked to improve the collection of these data, GAO found inconsistencies in how VHA records SIGI and, according to VA, 89 percent of veterans' records lack SIGI information. VHA added a field to collect this information in the administrative system; however, these data are not linked to electronic health records. As such, VHA providers cannot see the data during clinical visits when determining the appropriate services for transgender veterans, such as screening certain transgender men for breast and cervical cancers, as required by VHA policy. VHA's plan to link SIGI data across both systems has been postponed several times, and the data remain unlinked.

VHA Sexual Orientation and Self-Identified Gender Identity (SIGI) Data Collection Limitations, Fiscal Year 2020

VHA Sexual Orientation and Self-Identified Gender Identity (SIGI) Data Collection Limitations, Fiscal Year 2020

Until VHA can more consistently collect and analyze sexual orientation and SIGI data for the veteran population served, it will have a limited understanding of the health care needs of LGBT veterans, including any disparities they may face.

Why GAO Did This Study

VHA provides care to a diverse population of veterans, including women and LGBT veterans. These veterans may experience differences in health outcomes that are closely linked with social or economic disadvantage, and VA considers it important to analyze the services they receive as well as their health outcomes to improve health equity.

House Report 115-188 included a provision for GAO to review VA's data collection and reporting procedures for information on veterans' gender and sexual orientation. This report describes how VHA assesses health outcomes for women veterans and examines the extent to which VHA assesses health outcomes for LGBT veterans.

GAO reviewed VHA directives and VHA's Health Equity Action Plan. GAO interviewed officials from VHA's Women's Health Services and LGBT Health Program, VHA researchers who focus on women and LGBT veterans, and representatives from other health care systems with experience collecting gender and sexual orientation information.

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Recommendations

GAO is making four recommendations to VA to consistently collect sexual orientation and SIGI data, and analyze these data to assess health outcomes for LGBT veterans. VA concurred with GAO's recommendations and identified actions it is taking to address them.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Undersecretary for Health should consistently collect sexual orientation data in VHA's health record system, which could include adding a field for providers to input veterans' sexual orientation. (Recommendation 1)
Open
VHA concurred with this recommendation and provided updates. In September 2021, VHA's Diversity & Inclusion Committee formed the LGBTQ+ Data Collection Subcommittee, which is working with VA.gov administrators to build a portal for veterans to enter and edit their sexual orientation data. In addition, the Office of Information Technology (OIT) determined the Master Person Index (MPI) will be the authoritative source of sexual orientation data and a sexual orientation field is expected to go live in the MPI in fiscal year 2022. The VA.gov portal will feed into the MPI. A clinical reminder for the Computerized Patient Record System (CPRS) and Veterans Health Information Systems and Technology Architecture (VistA) has been developed for the collection of sexual orientation data and has been approved by the OIT Clinical Work Group. As of January 2022, the reminder is being tested at pilot sites, with an expected national release in March 2022 . Lastly, while still early on in its implementation, the Cerner Millennium system collects sexual orientation data, but does not share the data with MPI currently. Discussions are underway to identify a potential solution. VHA's target completion for these efforts is April 2022.
Department of Veterans Affairs The Undersecretary for Health should analyze veterans' sexual orientation data in order to assess health care outcomes for lesbian, gay, and bisexual veterans. (Recommendation 2)
Open
VHA concurred with this recommendation and provided updates. As of January 2022, a sexual orientation field is expected to go live in April 2022 and efforts are underway to create and populate a sexual orientation data field in CPRS/MPI/VistA. In addition, VHA's new health record system, Cerner Millennium, will collect sexual orientation data once it is fully implemented. Collection and analysis of sexual orientation data will begin following the implementation of the sexual orientation field, with initial data analysis occurring by October 2022. A preliminary report of the initial analysis and the targeted completion date is set for December 2022.
Department of Veterans Affairs The Undersecretary for Health should consistently collect veterans' self-identified gender identity data within and across record systems. (Recommendation 3)
Closed – Implemented
VHA concurred with this recommendation and has taken several steps to consistently collect self-identified gender identity (SIGI) data across enrollment, administrative, and health records systems. This includes ensuring consistent response options across these systems and that data can be viewed across systems. In January 2022, VHA provided evidence that enrollment forms have been updated to include standard SIGI responses and a patch has been implemented displaying SIGI data from VistA in CPRS.
Department of Veterans Affairs The Undersecretary for Health should analyze veterans' self-identified gender identity data in order to assess health care outcomes for transgender veterans. (Recommendation 4)
Open
VHA concurred with this recommendation and provided updates. As of January 2022, SIGI data is available in CPRS and is collected during enrollment and clinic visits. Initial analyses of SIGI data will begin by June 2022 with a preliminary report on this initial analysis anticipated to be available by late August 2022. Based on these timelines for initial data analysis, VHA's completion date is September 2022.

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