Why ‘Name to Use’ Is About Patient Safety, Not Just Courtesy (HTI-5 Article 1)

Is HHS Actively Trying to Hurt People?

Not me, but I understand the feeling

“My name is John.”

My legal first name is Earl, and I go by John. I was born on my father’s 39th birthday and was named after him. So we shared both a name and a birthday (and our birthday was just one day after my oldest brother). My mother used to joke, although I am not sure she was joking, that the first sentence I spoke was “My name is John.” That is the first thing that people learn about me.

Next month, I will visit my primary care physician for a routine annual checkup. He knows my name. Most of the office staff know my name and use it. But occasionally, I’ll be in the waiting room when a staff member comes to take me for the standard health screening at the start of the visit. I know if they are a new staff member by what they call me. The staff who have been there a while will come in and confidently call out, “John? We’re ready for you.” A new staff member will come into the waiting room and say, “Earl? Earl? OH! John!” as they glance down at the record, which clearly states that I prefer to be called “John”.

I know it is not true, but every time that happens, I feel discarded. It is as if that person didn’t even bother to do the bare minimum to learn about me before coming to retrieve me. It says, very clearly, that “I don’t know you; I haven’t prepared for this; you are just another slot on the appointment list.”

The federal Department of Health and Human Services (HHS), Office of the National Coordinator (ONC) has a Health IT Certification program. They have just published the fifth iteration of their Health Data, Technology and Interoperability proposed rules (HTI-5). It will not be officially published until Monday, December 29th, but the documents have been available for a few days from the HHS website. It is a nightmare for anyone that cares about quality medical care, patient safety, patient data protection and privacy.

Here, I am discussing one relatively small change in the HTI rules that affects me personally, but I have identified (so far) at least nine different areas in the proposed rule changes that are very problematic. This small example is indicative of the flagrant disregard for patient engagement, safety, and respect that runs throughout the proposed rule changes.

What’s Being Removed

The proposed HTI-5 rule change removes the requirement that health care information systems include a “Name to Use” field (§170.315(a)(5)(i)(G)). In different systems, this may be called the “chosen name,” “preferred name,” or “name in use.” It may be different from the legal name required for billing or insurance. It is the name that the patient (like me) actually uses in their daily life.

ONC’s rationale for removing this requirement is that “name to use” is an observation, not a demographic, and therefore not essential patient information. There is no acknowledgement of the clinical, patient safety, or engagement implications.

The proposed deletion of this field reveals a fundamental misunderstanding of patient-centered health care. It treats patients as if they were just a billable unit rather than a human being deserving of respect. It emphasizes “technology first, rather than “human-first.”

Who Needs the “Name to Use” Field - It’s Not Just Transgender Patients

It appears that the proposed rules assume the “Name to Use” applies only to transgender people. It is lumped in with other fields like sexual orientation, gender identity, sex, and pronouns. While there is a lot of say about those field removals as well, that is a topic for another article.

Many people use a name different than their legal one, like me. Here are some categories and examples, but it is far from complete.

People Who Use Middle Names (Like Me)

This is extremely common, especially in certain cultures. When I lived in the southern US, I would run into it all the time. You tell James McCartney or William Bradley Pitt that they must be addressed by their first name. Or Christopher Ashton Kutcher and Walter Bruce Willis. Even people who use a shortened form of their first name appreciate being called by their preferred name, like Bill Murray or Al Pacino.

People With Anglicized Names or Eastern Name Order

People with a strong cultural connection to their ancestry (or who were born overseas) often have a legal name that differs from their first name. I mean, you may have never heard of Hosato Takei, but you have heard of George Takei. Choo Kheng Yeoh is unknown to you, but Michelle Yeoh is a famous actress. Her case is even more complex because, at birth, she was named using the standard Eastern name order (surname first, middle), so her original name was Yeoh Choo Kheng. All of these are “real names” that these people have for different purposes (legal versus daily use)

Transgender People

This is the obvious one and the group that appears to have been targeted by this rule change. They may not have legally changed their name yet because it is expensive and requires a court appearance. Or they may have changed it, but it is not updated everywhere. Being called by their wrong name (deadnaming) causes psychological harm and is associated with higher depression, anxiety, and suicide

These are just a few categories of people who may use a name that differs from their legal name. The point is that it affects a substantial percentage of patients, not a small minority.

The Patient Engagement Implications

First Impressions Matter in Healthcare

As I described at the start, being called by my legal name (rather than the “real” name that I use every day) is disrespectful and disconcerting. I feel disrespected and ignored, even if the care is excellent.

The Therapeutic Alliance Research

The “therapeutic alliance” is an idea that originated in psychotherapy but is increasingly accepted in general medicine. Essentially, it states that a strong, trusting, and collaborative relationship between a patient and their healthcare provider is crucial for effective healing. That relationship is built on mutual respect, shared goals, and agreement on treatment tasks, leading to better engagement, adherence, and positive outcomes. That relationship begins by showing the patient enough respect to call them by their preferred name.

The Disclosure Problem

For a patient to disclose sensitive information, they must trust the provider. Would you disclose potentially embarrassing (but vital) information to someone who didn’t bother learn your name?

Patient Satisfaction and Healthcare Consumerism

Patients choose providers that respect them, and that begins with knowing their name. A few bad online reviews that mention “they never even bothered to learn my name” can put a provider out of business.

The Patient Safety Implications

The Joint Commission identifies patient identification as a critical safety issue. You may think this will not occur, but I can assure you that it does. As I mentioned earlier, I had the same name and birth date as my father. When I was young, I had a serious illness, and the doctors ordered many tests to figure out the cause. My care and treatment were seriously delayed by my test results ending up in my father’s medical record. Would that have been prevented by having a “preferred name” on the records? I don’t know, but every small move to avoid a medical error is a good move.

The Trauma-Informed Care Dimension

Trauma-informed care is a standard of practice. Patients deserve for their health care providers to recognize the prevalence of trauma and avoid re-traumatization. Survivors of abuse, whether it be childhood abuse, domestic violence, sexual trauma, or LGBTQI+ people who escaped negative family situations, hearing their legal name (especially their full legal name) can be exceptionally traumatizing. A medical office should be a safe place where a person is acknowledged and respected.

The Implementation Reality – This Is Not Difficult

Most electronic health record systems already have this capability. They may have added it to meet HTI-1 through HTI-4 standards, but I prefer to believe they have it because it is so fundamental to patient-centered care. It is a one-time data-entry requirement with ongoing benefits at no additional cost. The patient feels more valued and supported. There is no downside to keeping the “Name to Use” field.

The Broader Signal This Sends

However, removing the “Name to Use” field requirement sends a message to vendors that this isn’t important and can be removed. For health systems, it says patient preferences are optional and focuses on billing rather than the patient experience. Of course, as has been said many times, it tells the patient that they don’t matter.

The “Just Update Your Legal Name” Fallacy”

Some people might argue: “Just legally change your name if you want to be called something else.” Here are a few reasons:

1. It’s expensive ($200-$500 just for the name change - not including costs of all the other documents)

2. It’s time-consuming - court appearance, months of processing

3. Massive bureaucratic burden - need to update dozens of documents, from driver’s license to passports, bank accounts, credit cards, etc.

4. It is not always the desired choice. People may wish to keep their legal name as it is for family or cultural reasons.

In short, why should the patient be punished for the inflexibility of the computer system? Why should the person who should be the center of the system have to make an expensive and time-consuming change to match a computer system? That is an absurd burden to place on a person when the problem can be solved by adding a simple data field. The real solution is simple: the electronic record has two different name fields for two distinct purposes (one for patient interaction and one for administrative needs like billing)

Comparison to Other Industries

I fly a lot because my law school is in a different state from my home. My airline tickets have a legal name (and match all of my official documentation). My airline records (frequent flyer program) have my preferred name. I can log in to Alaska Airlines (shout-out to Alaska Airlines) and be identified as John. But when I go into my trip records to check in, add baggage, etc, everything there shows my legal name. This is as it should be. Airlines can do it. American Express (which I sometimes use to buy my plane tickets) calls me John, but still accurately lists my legal name on the ticket. How is this different than my doctor’s office knowing to call me John when I’m in the office, but also learning to use Earl when they bill my insurance company? It’s not different. That’s the point.

The Interoperability Excuse

Last potential ONC argument - “different names confuse data exchange”. That is blatantly false.

The current standard for data exchange in healthcare (and the one mandated by the Centers for Medicare and Medicaid Services, among others) is known as HL7 FHIR (Health Level 7 Fast Healthcare Interoperability Resources). HL7 FHIR already supports multiple names (although it calls them “Official Name” and “Usual Name”). It also has additional fields for “nickname” and “maiden name”.

The potential “workarounds” are worse than simply keeping the existing field. You could have staff write the preferred name on patient notes, but that is not standardized and does not transfer to other systems. They could put an “AKA” online in the patient notes. Again, not transferable, not searchable, and easy to either miss or lose. The standardized fields are logically and clearly the better solution.

There is no rational reason to remove the “Name to Use” field from the HHS certification requirements.

Conclusion

Using a patient’s correct name is foundational to respectful, safe, professional healthcare. It affects patient engagement and clinical outcomes. It is not a significant change (in fact, it already exists in most health information systems), but it positively affects a large number of patients. Rather than removing the requirement and seeing health information systems slowly “obsolete” the field, HHS should signal that patient preferences matter. Healthcare should be patient-first (for all patients, not just those who fit into a predefined bubble). I ask everyone to please comment on the ONC after the official notice of the rule change is published in the Federal Register.