By Janet Campbell (Epic), Chair, EHR Association Social Determinants of Health & Health Equity Task Force

A patient’s risk within social determinant of health (SDOH) domains is typically assessed by social care or healthcare professionals through either conversation or use of standard screening questionnaires or validated testing instruments. The challenge, however, is a lack of consensus on which specific domains should be assessed for patients, and how they should be assessed.

• Healthy People 2030 lists five broad domains of risk.
• The Future of Nursing 2020-2030 lists 11 domains of risk.
• The Gravity Project lists 20 Social Risk Terminology Value Sets.
• CMS’s Quality ID #487: Screening for Social Drivers of Health, requires screening of five domains.

Inconsistency Inhibits Interoperability

This lack of uniformity reflects the absence of a consistent, universally agreed-upon, and prioritized list of domains for assessment. The result is overlapping domains, complicating the exchange and interpretation of this data. 

This absence of clear guidelines for risk assessment and standardized representation of risks in EHRs also hinders effective data exchange to inform interactions at the point of care. The receiving EHR may not be able to interpret data in a way that is helpful to the user. Nor is there a path to aggregate data across multiple systems to gain insights into social risks at a broader geographical or environmental scale.

This complexity is exacerbated by regulatory agencies that aren’t operating in sync. Meanwhile, the growing proliferation of terminology only adds to the confusion.

To effectively respond to evolving policymaking, the industry must align on a standardized approach for representing risk and agree on which risks are prioritized for collection and analysis.

To effectively respond to evolving policymaking, the industry must align on a standardized approach for representing risk and agree on which risks are prioritized for collection and analysis. At the same time, we should allow for individual or site-by-site variability as to how those risks are assessed, to reflect the broad range of approaches based on local resources, knowledge, staff, and familiarity.

Identifying an Effective Solution

To address this growing problem and enable EHR developers, providers, and other stakeholders to effectively respond to evolving policymaking, the EHR Association’s Social Determinant of Health and Health Equity Task Force has published Recommendations for Determinant Capture. 

In the paper, the SDOH Task Force identified several recommendations that would provide a reasonable path forward for EHR developers and the healthcare industry. The effectiveness of those recommendations was then assessed against four criteria: feasibility across EHR systems; adaptability to diverse healthcare settings; interoperability for social risk data; and support for research and data utilization. 

In the paper, the SDOH Task Force identified several recommendations that would provide a reasonable path forward for EHR developers and the healthcare industry. 

That assessment resulted in four recommendations:

• EHRs should standardize how they represent domain risk. At a minimum, an EHR should be able to indicate whether a patient was assessed for a domain risk, whether that risk is present, and the method of assessment if a standardized instrument or questionnaire was used.
• The standards industry should determine how domain risk is represented in data exchange. A structured representation simplifies the process for EHRs transmitting data to other systems by focusing on the essential elements of a risk assessment. EHRs receiving this data can easily determine and represent whether social risk exists across assessed domains. 
• The healthcare community should list and prioritize which domains should be assessed. In line with the 2023 IPPS rule, which recommends the assessment of food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety, we urge that EHRs be equipped to support the documentation of the corresponding Gravity Project domains: food insecurity, housing instability, transportation insecurity, inadequate housing, and intimate partner violence.
• Risk assessment methods should remain flexible for now. Although standardized instruments for assessing risk can offer more reliability, mandating their exclusive use in EHRs is not advisable. Such a requirement could inadvertently limit the flexibility required by users’ diverse needs and capabilities. Therefore, it is critical to avoid regulation that prescribes the use of specific screeners and assessments at this time. 

The suggested approach is designed to accommodate a gradual transition toward more widespread adoption of standardized screeners that is in sync with the industry’s evolution and readiness to adopt these tools.

Recommendations for Determinants Capture is a detailed discussion by the SDOH and Health Equity Task Force of the need to standardize determinant domains and their capture, requirements for effective standards, and the recommendations themselves. It can be accessed here.