The US Centers for Disease Control and Prevention recently adopted new International Classification of Diseases (ICD) codes for human trafficking.¹ These codes help improve the health, safety, and well-being of individual patients by ensuring future healthcare providers are aware of the patient’s history, needs, and concerns. At the aggregate level, these ICD codes will also help track suspected and confirmed cases of human trafficking. Hospitals and health systems can use these data to better understand victim needs and improve the health of their communities.² The data can also be used for research into human trafficking risk factors, comorbid illnesses and injuries, and potential prevention strategies.Reference Macias-Konstantopoulos³

Documenting any sensitive information in a patient’s electronic health record (EHR), including human trafficking ICD codes, carries risks. For example, one concern is that a trafficker or other abuser could possibly access a patient’s information (for example, through a patient portal) and could harm the patient based on the information observed. Patients may also be subject to bias (conscious or unconscious) or discrimination by healthcare providers.Reference Stoklosa, MacGibbon and Stoklosa⁴ Patients may feel shame knowing the information is available in the EHR, or this sensitive information may be used against the patient (for example in a legal proceeding).

In an article in this issue of Journal of Law, Medicine & Ethics,Reference Greenbaum⁵ Greenbaum helps mitigate the risks of using ICD codes for human trafficking by describing principles for safe implementation, based on an interdisciplinary, expert convening, co-hosted by Health Education Advocacy and Linkage (HEAL) Trafficking, the Health & Human Services (HHS) Office on Trafficking in Persons (OTIP), and the International Centre for Missing & Exploited Children (ICMEC).⁶ This important contribution provides practical guidance for healthcare providers to plan for and implement these codes. In this commentary, we build on these principles and provide additional suggestions to help accelerate the safe use of human trafficking ICD codes.

Importantly, documentation of ICD codes and other sensitive information is only one aspect of the comprehensive care needed to support patients who have been impacted by trafficking or other forms of violence. Healthcare providers must be educated and equipped to recognize and appropriately respond to affected patients or families. This includes identifying patients who may be impacted by any type of violence including human trafficking, protecting vulnerable patients while under the facility’s care and service, assisting patients or families with access to community agencies (e.g., law enforcement agencies, county welfare agencies, and non-governmental organizations that provide victim/survivor support and services), documenting ICD codes and sensitive information as appropriate in the EHR, and reporting concerns of abuse, neglect, or violence as defined and required by law or regulation.

It is also important to highlight that two groups need to be actively involved in the planning and implementation for human trafficking ICD codes at hospitals and health systems: 1) Health care providers; and 2) Health system leaders. Health care providers need to be trained to recognize human trafficking and best practices on documentation, including ICD codes. Further, some providers who are subject matter experts in clinical workflow or human trafficking should be included in planning. Health system leaders are critical to developing policy, understanding the privacy implications, and configuring the EHR for these sensitive data. Support and engagement from both groups is critical to successful implementation.

Greenbaum also identifies training of healthcare providers as a key strategy for implementation.⁷ The analysis encourages education on human trafficking and other forms of violence in general, as well as best practices and policies on using ICD codes for human trafficking. There are often many competing priorities for training in healthcare organizations. We suggest a multi-pronged training approach, including general human trafficking training for all health care providers and more detailed training for targeted groups that are most likely to care for patients that have experienced violence or human trafficking. Offering continuing medical education and nursing continuing education credit may help incentivize training completion. Given that many providers may not have regular contact with patients who have been impacted by violence, traditional one-time training materials should be supplemented with just-in-time resources available for healthcare staff to consult when needed, such as tip sheets and videos.

Technology also has the ability to help identify and guide management of patients who have experienced violence or human trafficking. For example, at certain hospital check-in locations across CommonSpirit Health, the EHR is configured for violence screening. If a provider sets this flag, they receive clinical decision support consistent with the health system’s policies for caring for patients that have experienced violence, including human trafficking. Manual screening workflow requires clinicians to recognize and take additional steps for those patients impacted by violence, which can be difficult especially in busy clinical settings. Health information technology also has the ability to detect events and automatically trigger decision support.Reference Landman⁸ ICD codes may not be available to activate decision support during a patient’s initial visit since these codes are typically entered at the end of the patient encounter or after the patient has been discharged. Evidence-based rules or machine learning algorithms may eventually be developed that can review EHR data including free text notes in real-time during the visit, and provide alerts for patients at risk for violence and human trafficking. More frequent and accurate use of ICD codes for human trafficking will provide larger and more complete data sets to build and refine these models.

Health systems should monitor their human trafficking ICD code implementations closely, continuously improving the program to improve coding frequency and accuracy. A formal quality assurance program should be established to regularly review use of human trafficking ICD codes and also identify missed cases, where ICD codes were not used. As health systems gain experience in implementing human trafficking ICD codes, they should also be encouraged to share lessons learned, including sample policies and training materials. Formal evaluations or process improvement projects should be published. Presentations at national conferences should be encouraged and a follow-up national convening should be considered.

In conclusion, this article is an important start. Greenbaum⁹ has provided core guiding principles to help health care system leaders and health care provider champions implement ICD code use for human trafficking. ICD coding is one important element of a comprehensive plan for caring for patients impacted by trafficking. We must find novel ways to engage and train our providers in the appropriate use of these codes and then monitor usage over time and continuously improve the processes. Sharing lessons learned and continuing to publish manuscripts like this one will help ensure all health care providers use these best practices to provide the highest quality care to patients who have experienced human trafficking, including documenting ICD codes, when appropriate.