Social determinants of health (SDOH) encompass environmental and socioeconomic factors, such as housing, education, employment, and access to food. SDOH have a major impact on access to quality care and are critical to the health and well-being of patients. While medical care accounts for approximately 20 percent of healthcare, physical environment, socioeconomic factors, and health-related behaviors, all elements of SDOH account for about 80 percent of outcomes.
Incorporating SDOH data into electronic health records (EHRs) “could dramatically increase the scope, quality, and timeliness of data available for planning interventions targeted at SDOH factors.” With essential SDOH information such as housing, transportation, and diet captured in real time, clinicians can leverage that data to make more informed, targeted medical decisions that deliver higher quality care.
This article details information required for integration into EHRs to build personalized treatment plans and develop successful SDOH programs that provide resources and support for patients in need. In addition, successful SDOH programs implemented by Kaiser Permanente and Boston Medical Center showcase how supporting clinicians with real-time SDOH data can lead to patient-centric care.
Create a 360-Degree Patient View Through Technology
The Office of the National Coordinator for Health Information Technology (ONC) indicates that the “collection, documentation, reporting, access, and use of SDOH data … can be used to help identify and eliminate health disparities and to improve health outcomes at an individual and population level.” These four areas include standards and data (advance standards); infrastructure (HIEs, state, local); policy (emerging policy challenges and opportunities); and implementation (integration, innovation, and health IT tools).
Capturing this fundamental SDOH data, such as social-cultural, physical, and economic/educational factors, provides a holistic view of the patient. Screening tools, such as Tool for Health & Resilience In Vulnerable Environments (THRIVE), provide clinicians with the following patient information:
- Where do you live? Do you have shelter?
- Do you have access to food?
- Can you afford paying for your medications?
- Do you have trouble getting transportation to medical appointments?
- Are you a caretaker responsible for a child, family member, or friend?
- Are you unemployed or looking for a job?
Through these important questionnaires, clinicians can identify patients who are noncompliant with their medical regimen due to SDOH circumstances that are out of their control.
For example, a diabetic patient experiencing financial hardships may be taking only a half dose of their insulin to make the medication last longer. That same patient may also lack the means to afford healthful, fresh foods and is limited to canned goods. While canned foods may be less expensive, many come with a high concentration of preservatives, high fructose corn syrup, and salt content, leading to uncontrolled diabetes and other comorbidities such as hypertension and cardiovascular disease.
Integrate SDOH Data into the EHR: Community Case Studies
Healthcare facilities now have the capability to funnel the SDOH data captured from screening tools and incorporate this information into the EHR to guide overall patient care. For example, Kaiser Permanente launched an initiative, Thrive Local, to assess a patient’s physical, mental, and social conditions, and then match related needs to appropriate services available in the community. Based on data collected, Kaiser determined that “63 percent of Northern California members had at least one unmet social need,” 29 percent of its members reported food insecurity as the largest medical challenge, and 23 percent reported instability with housing. Kaiser’s program has helped spearhead a number of programs, such as the creation of 5,000 affordable housing units and services to help with access to food and support with healthy relationships.
Similarly, Boston Medical Center’s (BMC) “WE CARE” program was launched to identify unmet needs and offer interventions to address critical gaps. Screenings and surveys are integrated into Boston Medical Center’s EHR, providing the clinician a complete view on the patient to ensure personalized treatment plans and recommendations based on unique challenges. Through the WE CARE program, a person’s access to food pantries and employment services increased from 8 percent to 70 percent, and enrollment in community programs such as public housing and Head Start increased from 24 percent to 39 percent.
For both programs outlined above, SDOH data integrated into the EHR enables care providers to intervene and offer solutions, such as housing, Meals on Wheels, food vouchers, and other resources and support to meet the patient’s care and wellness needs.
Inform Preventative Care for Specific Patient Populations
In addition to spawning community programs, the integration of SDOH data into the EHR helps clinicians identify micro and macro trends across their patient populations. For example, risk stratification based on age, sex, gender, and socioeconomic factors can help clinicians proactively address cohorts of patients who would benefit from a specific preventative intervention to manage chronic conditions such as diabetes, asthma, mental health issues, and opioid addiction.
Early detection of such chronic conditions is essential. With roughly 8.5 million people living with undiagnosed diabetes, early intervention is critical to help lower the risk of serious complications. According to the Centers for Disease Control and Prevention (CDC), understanding socioeconomic status of populations is crucial for diabetes diagnosis. For diagnosed diabetes among adults, 13.4 percent had less than a high school education, 9.2 percent had a high school education, and 7.1 percent had more than a high school education. Financial status is also a factor. The CDC reports “adults with family income below the federal poverty level had the highest prevalence [of Diabetes] for both men (13.7 percent) and women (14.4 percent)”
Eliminate Mistrust in Healthcare: One Social Factor at a Time
Finally, SDOH data can be used to understand cultural and social factors resulting in patients’ mistrust of the healthcare industry. Specifically, Black Americans are less willing to get the COVID-19 vaccine due to mistrust of the healthcare system. According to the Pew Research Center, only 43 percent of Black Americans are open to receiving the COVID-19 vaccination.
To combat COVID-19 vaccination resistance, healthcare providers such as retail pharmacy chain, Kroger Health, launched $1 million giveaways and groceries for a year to increase vaccination rates. In 2022, Kroger Health won the American Pharmacists Association Immunization Champion Award, in recognition of high COVID-19 vaccine rates across their communities.
Understanding the impact of SDOH, including socioeconomic barriers to accessing healthcare, is an important step in building trust among populations that are skeptical of the healthcare system. Government-driven support, such as the CDC’s $3 billion funding program to improve equity and access to healthcare among underserved populations, is vitally important for increasing COVID-19 vaccination rates.
Positive Care Outcomes
There is no doubt that incorporating SDOH data into EHRs is increasingly important to personalize care and improve care outcomes. There is a systematic shift in recognizing that physical environment, socioeconomic factors, and health-related behaviors account for many health outcomes.
For clinicians, the ability to capitalize on SDOH data requires access to information on housing, education, employment, and access to food—factors that must become an integral part of each patient’s EHR to support personalized care decisions. Finally, to identify rising risk patients where we can intervene and make a difference, placing these meaningful tools in the hands of physicians and care management teams can promote positive health outcomes.
About Ankit Rohatgi is the chief clinical officer at AssureCare. He received his medical degree from Grant Medical College (Mumbai, India) followed by residency in internal medicine from Unity Hospital (Rochester, NY). He received his MBA with a concentration in Health Sector Management (HSM) from Duke University. He is a fellow with American College of Physicians (ACP) and is board certified by American Board of Internal Medicine.
Read the AHIMA white paper, “Social Determinants of Health: Improving Capture and Use by Applying Data Governance Strategies.”
By Ankit Rohatgi, MD, MBA, CPE, FACS
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