Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.
Physicians routinely track details about a patient’s diabetes or high blood pressure in electronic health records (EHRs). But what about other factors that may compromise the patient’s health, such as inconsistent access to food or on-the-job exposure to air pollution? A paper published in the Annals of Internal Medicine in 2014 found that “residence within a disadvantaged U.S. neighborhood” is a factor in hospital readmissions at about the same rate as chronic pulmonary disease.
Nearly 80 percent of office-based physicians use EHRs today, but most of these systems are not designed to collect data on social determinants. Given the growing body of evidence about the health effects of social factors, however, there has been a push to bridge that information gap. If EHRs screened for social determinants of health, physicians could triangulate that information with clinical data to map a more comprehensive path to patient care. Such data also could help care providers achieve their population health management goals and inform health equity research.
In 2014, the Institute of Medicine (IOM) issued two reports based on the premise that health care providers and health systems can more effectively influence patient and population health if they have information on social and behavioral determinants. Specifically, IOM suggested EHRs capture sociodemographic, psychological, and behavioral factors, as well as individual-level social relationships and community-level data.
“So many of the health care problems that physicians may see in primary care or in hospitals are not necessarily a function of poor health practices, but may be lack of resources like food, shelter, or a safe park to walk in,” said Arthur E. Blank, PhD, associate professor and codirector of the Division of Research in the Department of Family and Social Medicine at the Albert Einstein College of Medicine. A physician can urge a patient to change eating habits, but that’s a problem when the person’s community has limited access to healthy food, he pointed out.
“So many of the health care problems that physicians may see in primary care or in hospitals are not necessarily a function of poor health practices, but may be lack of resources like food, shelter, or a safe park to walk in.”
Arthur E. Blank, PhD, Albert Einstein College of Medicine.
Blank cowrote a paper on combining clinical and population-level data to better understand neighborhood health. Published in the March 2015 issue of the American Journal of Public Health, the study identified differences in demographics, health behaviors, and overall health among patients at four health centers in the Bronx by including dietary intake and other behavioral information in the health centers’ EHRs. The authors concluded that recording patient intake of sugar-sweetened beverages—in addition to other factors such as physical activity—could help clinicians better identify patients who could benefit from counseling on dietary and other lifestyle changes.
In June 2015, the AAMC’s(ROCChe) convened to discuss how academic medical centers can begin to follow the IOM recommendations.
“My vision is to capture some of those upstream factors in the electronic health record so we can address those issues in addition to the clinical issues,” said initiative participant Desiree de la Torre, director of community health improvement, health care transformation, and strategic planning at Johns Hopkins Medicine. “Education, social environments, and everything that is upstream needs to be considered in the overall health of the patient.”
How social determinants data are used
A study in the American Journal of Preventive Medicine presented several examples of how institutions have used social determinants data to improve patient care. Pediatricians at Johns Hopkins Children’s Center entered a basic family social history into the notes section of their EHR, which helped refer families in need to a community group that provides social services. At Boston Medical Center (BMC), a medical-legal partnership integrated a letter into the EHR to help low-income patients with chronic conditions retain heat and electricity services.
Laura Gottlieb, MD, MPH, a coauthor of the study, said the BMC experience was impressive because it documented significant results, including a 300 percent increase in the number of completed utility-protection letters. “We need more evidence that doing this work at the intersection of social determinants and medical care actually makes a financial impact on health systems,” said Gottlieb, a member of the University of California, San Francisco, Department of Family and Community Medicine.
Research documented by Kaiser Permanente Colorado (KPCO) underscores some of the fundamental challenges in linking social determinants data with clinical information. In 2011, KPCO began screening for hunger during patients’ clinical visits, referring food-insecure members to a nonprofit that provides food and nutrition resources. The process is not seamless, however. Kaiser’s EHR populates a record with a letter that approves outreach on a patient’s behalf. Physicians refer the cases to community specialists on Kaiser’s staff, who then fax the letter to the nonprofit.
Apart from complying with patient privacy regulations and keeping data secure, the smooth sharing of information can be stymied by technical challenges when computer systems cannot communicate. The cost of connecting those dots can also be an impediment.
Pediatrician Sandra Hoyt Stenmark, MD, who helped lead KPCO’s efforts to collect food-insecurity data, maintains that social determinants of health need to be part of the basic medical school curriculum. “I once sat through an hour lecture on why children fail to thrive, and every possible differential diagnosis was discussed except the possibility that maybe they didn’t have enough food,” Stenmark said. “I think medical schools would really benefit from having some emphasis on the medical role in meeting patients’ social and nonmedical needs.”
This article originally appeared in print in the May 2015 issue of the AAMC Reporter.