Enabling a Healthier Future for Every Community

Social Determinants of Health in the EHR: Moving from Data Collection to Action

By Ned Mossman, Program Manager,  Value-based Care and Social Determinants of Health

OCHIN is a pioneer in the effort to integrate social determinants of health (SDH) data into the EHR. SDH data represent conditions of patients’ social and physical environment such as housing status, race and ethnicity, and material resource strain that impact health risks and outcomes, access to services, and ability to follow recommended care.

SDH data establish context at the point of care that can help inform treatments and interventions, as well as provide a basis to connect patients to community resources. Clinics can also use this data in population health management activities to define subpopulations of interest on a combination of medical and SDH factors. At a planning and strategic level, SDH data can be used in areas of clinic and community policy to illustrate the nature and scope of areas of social need, and provide direction for resource allocation, investment, and advocacy.

Progress and Key Learnings

Through August 1, 2018, OCHIN members entered over 60,000 individual SDH screening questionnaires into the EHR. The current screening tools were initially released in 2016.

To date, key takeaways from our members’ screening efforts have raised common barriers and suggested solutions, provided a better understanding of potential staff roles in the screening effort, and highlighted the value of starting with a small, focused patient population before scaling efforts up.

Current Efforts and Next Steps: Integrating Social Service Resource Locator (SSRL) Services

With the rate of SDH screening continuing to grow among our membership, OCHIN is committed to providing tools to help clinics take action on this data. Through multiple approaches, including partnerships with organizations such as Kaiser Permanente, OCHIN aims to integrate Social Service Resource Locator (SSRL) services into the EHR across its nationwide footprint.

SSRL providers (such as 211info, Aunt Bertha, and NowPow) create and curate lists of resources in the community to help make appropriate referrals for patients with an identified social need. Integrating this information into the EHR will allow OCHIN members unprecedented ability to act on their patients’ SDH, and connect them to services to help address social needs affecting their health and well-being.

For more information on OCHIN’s SDH efforts, contact Ned Mossman at mossmann@ochin.org.