by Allison VanLeu
We are in the golden age of data. Electronic Health Records (EHRs) are helping health systems collect a massive amount of health data, but additional focus needs to be on collecting – and putting to use –non-health data. Non-health factors, such as environment and behaviors, contribute up to 80% of what makes a population healthy. The factors are commonly referred to as Social Determinants of Health (SDOH). The CDC defines SDOH as “the conditions in the places where people live, learn, work, and play”. SDOH data includes employment status, income level, education level, transportation needs, smoking status, alcohol usage, household/living situation, social connections, stress, depression, access to food, and more.
The ability to record and track SDOHs has been available in EHRs for years, yet the tools remain underutilized. As an example, Epic released SDOH functionality which gave its users the ability to capture SDOH data points and view the associated risk factors in a visually appealing, colorful wheel. Once the data is collected, the information can be factored into patient risk scores which can enable the tracking of high-risk patients, trigger referrals to the appropriate social services, or enhance real-time clinical decision making.
Although the impact of fully utilizing SDOH data seems abundantly clear, roadblocks prevent health systems from capturing it. As with most data capture, the burden falls to the care providers, who already are required to capture significant amounts of administrative data for billing purposes. It is increasingly frustrating to ask clinicians to capture data that already exists with agencies outside traditional healthcare venues such as food banks, addiction services, domestic violence groups, and other services that address environmental risks. However, with the current lack of interoperability standards, there is not an easy way to integrate data from social and community services into the patient health record.
While integrating the relevant data from these external systems is an ideal long-term approach, there are still short-term actions you can take to adopt SDOH data collection and use the data to improve patient outcomes. Let’s look at some basic considerations:
What data should we collect? There are hundreds, maybe thousands, of data points that can be considered SDOH. Until we have a national standard for SDOH data exchange, where should you focus your efforts? A good place to start would be this list of 26 leading health indicators (LHIs) for 2020, put together by the Healthy People program in order to communicate high-priority health issues. Keep an eye out as planning is already underway for the updated 2030 goals. Lastly, be sure not to reinvent the wheel. Reach out to your EHR vendor as well as your peers to see what is already in place.
Who should collect the data? Everyone! The toughest barrier here is the best way to collect SDOH is to include data collection within and, more importantly, outside the health systems. However, due to the lack of interoperability standards, it is nearly impossible for health systems to get non-health data from public health sectors and social services. Within your health system, the answer is still everyone. Most importantly, the burden should not fall entirely on physicians. Patients are often the best equipped to answer these questions themselves. Use online questionnaires to assess smoking status, stress levels, living situation, and education level. Once at the hospital or clinic, the data starts with administrative staff – during patient registration, ensure they are collecting items such as race, ethnicity, and employment status. When providers are collecting this data, do not silo to the primary care providers, collect this data throughout the entire continuum of care including non-physician roles such as nurses, outreach coordinators, and therapists.
Where should we display this data? Before getting into the complexities of calculating patient risk scores or executing patient outreach services, you can simply display this information prominently in the EHR as you would vitals or diagnoses. If you get SDOH information in front of clinicians during patient interactions, it gives them an additional tool to make better real-time decisions. Imagine a physician has the patient’s financial insecurities available while determining a care path. Upon seeing the patient has recently lost their job or their insurance, the physician can determine an expensive procedure or medication may not be the most suitable treatment and instead they can offer a more affordable but appropriate care path.
What should we do with the data? Start by understanding what your highest risk populations are and which social factors are strongly correlated with those populations. Maybe you have high admission rates among your more rural populations. That could be because their access to primary and preventative care is limited. Use this information as leverage to advocate for telehealth services in rural populations or more at-home care tools. The overall goal of collecting SDOH information should be to get the data you need to help close gaps in patient care and create healthier patient populations.
Taking this action in the short-term can improve patient care and outcomes, and over time, start to reduce organizational costs as outcomes improve. At the same time, continue to advocate for large infrastructure changes that are desperately needed. We need stronger partnerships between healthcare providers, payors, and the outside agencies which address social and environmental risks. We need national standards for SDOH data collection and technology innovation which allow for sharing this data between health and non-health services. While the U.S. healthcare system is slowly making its way towards improving some of these systemic issues, do what is within your power now to reduce care inequalities in your communities.
