By Elizabeth M. Dries, J.D.
The Office of the Assistant Secretary for Planning and Evaluation of Health Policy (ASPE) issued a report investigating the development of software products that allow health care providers to identify and address patient’s social determinants of health (SDH) in health care settings. The study titled "Incorporating Social Determinants of Health in Electronic Health Records: A Qualitative Study of Perspectives on Current Practices among Top Vendors" revealed that while vendors are actively developing products to facilitate the collection and use of SDH data for clients, there is currently a lack of policy standard and guidelines surrounding SDH data (ASPE Report, October 15, 2018).
SDH factors and EHRs. SDH factors, such as income, education, race, ethnicity, employment, community resources, and social support are all associated with health outcomes. Health Care reform initiatives have focused on the adoption and development of electronic health records (EHRs). The integration of SDH into EHRs would enable health providers to address health inequities and support research into how social and environmental factors influence health. However, a lack of standardization for incorporating data from various screening tools has limited the usefulness of the data in EHR systems.
The study and findings. The study selected the top ten vendors by market share in both inpatient and ambulatory settings and interviewed them in sixty minute long audio recorded sessions. Several key themes were discussed with the vendors including (1) why vendors are developing SDH products; (2) what kinds of products they are developing and for what uses; (3) how standardized SDH data are used, and how easily can they be shared among and across different types of providers; (4) lessons learned from developing and implementing SDH products; and (5) policy-related requests to further the development and use of SDH products.
Vendors cited value-based care programs as one of the biggest motivators of SDH product development within their EHRs. The types of SDH products vary greatly based on client needs, input, and strategic planning. In general, vendors have or are in the process of incorporating SDH data in screening tools, population health management tools, tools to improve referral management and analytic tools. Screening tools themselves were found to be the most common type of SDH product. In addition, population health management is commonly used for SDH data. For the vendors with products capable of making referrals for community services their use is still in early development. Vendors reported a lack of consistency in how referrals are documented or managed across EHR systems. Finally, vendors also varied in their ability to provide data analytics and reporting.
While screening tools are the most common way of capturing SDH data, they are also dispersed throughout the EHR. Vendors are able to collect SDH data at different parts of the clinical encounter and by different people. Vendors reported that the most appropriate manner to collect specific types of SDH data are: (1) for behavioral health questions and assessments, it may be better for behavioral health workers or providers to facilitate those screening tools; (2) in community health centers with limited resources, clinical health workers are appropriate person for entering SDH data; (3) for sensitive domains or questions such as domestic violence, homelessness, and child abuse patients may feel more comfortable and be more truthful answering through a kiosk or patient portal. Finally, data standards are codes for the capture and exchange of electronic health data. Due to lack of standardization, vendors describe challenges with coding SDH measures.
Recommendations. Currently, there is a lack of policy standards around SDH data, and product specific decision may end up being de-facto policies given the market shares of particular vendors. In order to advance the collection and use of SDH data in health care settings through EHRs, the findings from this study suggest taking three steps: (1) identify core SDH elements where standard development is still needed; (2) provide guidance on preferred terminology standards for some SDH measures; and (3) identify if there are a subset of SDH measures that all EHRs can collect.
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