Healthcare’s focus on addressing social determinants of health (SDOH) relies heavily on technology. Patient screening tools, social services referral platforms, EHR integration, and data analytics are essential components. Challenges include a lack of SDOH data standards, data quality issues, and limited integration, hampering population-level SDOH analysis. Interoperability and standardized data formats are crucial for sharing SDOH information among healthcare organizations, government sources, and community entities. As healthcare evolves, the supporting systems are expected to mature and address current gaps in SDOH initiatives.
Most initiatives aimed at addressing social determinants of health within the healthcare system are primarily focused on identifying and fulfilling social needs. However, these endeavors would be incomplete without the essential health information technology (IT) infrastructure to bolster them.
In reality, programs targeting social determinants of health (SDOH) – the environmental factors impacting our health, shaped by our living, working, and recreational environments – are heavily reliant on technology. In the realm of population health management, data reigns supreme, and to capture and make sense of this data, a suite of patient engagement tools becomes indispensable.
According to 2023 data from the American Health Information Management Association (AHIMA), eight out of ten healthcare organizations currently utilize healthcare technology to address SDOH and collect SDOH-related data. These tools play a central role in every aspect of population health programs, starting from screening patients for social needs to referring them to appropriate social services and documenting SDOH data within the Electronic Health Record (EHR).
However, significant challenges persist. The absence of standardized SDOH data and a fragmented SDOH data landscape make it challenging for healthcare organizations to obtain a comprehensive understanding of their patients’ social needs, hindering effective population health management.
Below, PatientEngagementHIT offers an overview of the current state of health IT supporting SDOH and population health initiatives, while also highlighting the existing limitations within the industry.
Screening for Social Determinants of Health (SDOH)
The process of screening for SDOH, along with other types of care screenings, has transitioned from paper to digital tools in line with medicine’s modernization.
SDOH screening tools often work in conjunction with other technologies such as EHRs, data analytics tools, or social services referral tools. They may also be integrated into patient intake technologies.
When considering SDOH screening tools, the focus should not solely be on the technology platform, but also on the content of the surveys themselves. Key considerations for SDOH screenings include assessing patient health literacy levels, offering opt-out options, determining the specific SDOH aspects to focus on, and planning how clinicians and office staff will communicate the screening results with patients.
Healthcare organizations should also prioritize the integration of SDOH screening tools with their broader digital patient engagement suites. Look for screening tools that seamlessly integrate with other technologies, such as EHRs, to ensure that SDOH data becomes an integral part of a patient’s health record. Furthermore, integration with social services referral tools can facilitate the rapid identification of services that address patient needs.
Social Services Referral Tools
Social services and SDOH referral tools aid healthcare providers in locating social services providers and connecting patients to these services.
While this work can be performed without technology, SDOH referral tools streamline the process, reducing the workload for providers and helping organizations stay informed about available social service providers.
Examples of vendors supporting social services referrals include Unite Us, Healthify, NowPow, Cityblock Health, and OpenBeds.
Beyond cost considerations, healthcare organizations should assess how these tools integrate with their EHR systems, as this integration enables a seamless transition between a patient’s medical record and the management of their social complexity. It’s also important for organization leadership to consider how technology usage impacts social services providers and community health partners.
Understanding the type of data that needs to be exchanged between healthcare and social services providers, as well as how this data aligns with the tools used by social services providers, is crucial for ensuring effective communication and coordination.
Electronic Health Records (EHRs)
Effective SDOH initiatives begin with the collection and documentation of SDOH data within the EHR.
Currently, a majority of healthcare organizations engage in SDOH data collection through their EHR systems, with 83 percent reporting such usage in an ONC study. EHR vendors like Epic Systems, Cerner, athenahealth, and Allscripts enable the specific capture of SDOH data, although this list is not exhaustive.
However, healthcare providers face challenges in this regard. One prominent challenge is the absence of standardized SDOH data. Approximately three-quarters of hospitals employ health IT solutions to standardize SDOH data, allowing it to be more easily integrated into various technology systems beyond the EHR. About 29 percent use diagnosis codes for this purpose.
Providers have also cited a lack of education in capturing and coding SDOH data as a barrier to collection. Until data standards catch up with the needs of organizations regarding SDOH, providers will continue to encounter difficulties in integrating SDOH considerations into their population health interventions.
In addition to data integration, data quality and integrity pose significant challenges. SDOH factors can change rapidly, necessitating regular patient surveys and updates to medical records. Smaller or resource-strapped organizations may find it particularly challenging to keep up with these SDOH data demands.
Data Analytics and Population Health Tools
In addition to documenting SDOH data, healthcare organizations must analyze and interpret this data. This is where population health tools play a crucial role.
These systems review SDOH screening data and identify patients who may require access to social services, similar to risk stratification for social complexity. Vendors in this space include IBM Watson Health and Socially Determined, although many EHR vendors offer population health add-ons that serve a similar purpose.
These tools are invaluable not only for patient-level interventions but also for assisting organizations in designing comprehensive population health strategies.
As previously mentioned, there are significant limitations to using SDOH data in its current state. The lack of data standards and the challenges associated with data collection within the EHR hinder healthcare organizations from drawing population-level conclusions about SDOH burden.
A crucial aspect of SDOH data collection is its interoperability and exchange. This is driven by two key factors: SDOH data can originate from various sources beyond patient surveys, including government agencies and community entities, and other stakeholders, such as community health partners and social services providers, also require access to standardized EHR data to assess social risk factors.
To address these challenges, standardized data formats are essential. The Office of the National Coordinator for Health Information Technology (ONC) has initiated various programs aimed at addressing SDOH data standards, including the United States Core Data for Interoperability (USCDI), ONC Interoperability Standards Advisory, ONC Standards Bulletin, ONC Health IT Certification Program, and Standards Version Advancement Process.
Healthcare organizations are increasingly leveraging interoperability and data exchange platforms to obtain a comprehensive view of a patient’s SDOH. According to the ONC report cited above, 60 percent of hospitals acquire SDOH data from electronic sources, and 46 percent obtain it from health information exchanges (HIEs).
While SDOH has long been recognized as a crucial determinant of patient health and well-being, it has gained heightened attention in recent years as the healthcare industry shifted toward value-based payment models. As healthcare experts continue their efforts to support SDOH initiatives, the systems that underpin them – including medical records, data integration and exchange, and social services connections – are expected to evolve and address current gaps and challenges.