Social determinants of health, outlined by the U.S. Department of Health and Human Services, refer to environmental conditions impacting health and quality of life, including where individuals are born, live, learn, work, play, worship, and age. These factors differ from physical, biological, or demographic elements. Not all disparities are social determinants; for instance, being assigned female at birth or being Black are not considered social determinants, despite impacting health outcomes. Examples of social determinants include lack of transportation access and low literacy, leading to poorer health outcomes and longer hospital stays. These determinants are categorised into risk domains like nutrition insecurity or housing insecurity. Evaluation typically involves collaboration with healthcare or social care professionals and may use informal conversations, standardised screeners, or validated testing instruments.
The Fragmented Landscape of Social Determinant Domains
There's widespread acknowledgement of the importance of assessing risks in various social determinant domains, but there's no consensus on which specific domains should be evaluated for patients. Healthy People 2030 identifies five broad risk domains, but there's confusion about classifying more specific risks within these categories. The Future of Nursing 2020-2030 lists 11 risk domains, including structural and intermediary determinants. The Gravity Project has categorised a broad list into 20 Social Risk Terminology Value Sets. Meanwhile, CMS's 2023 IPPS Rule mandates screening for five domains, starting in 2024.
The lack of consensus among stakeholders in prioritising and defining social risk domains results in the absence of a consistent and universally agreed-upon list of domains for assessment by providers. This inconsistency leads to overlapping domains, complicating data exchange and interpretation. The absence of clear guidelines for risk assessment and standardised representation in Electronic Health Records (EHRs) hampers effective data exchange and aggregation. Without a standardised approach, data cannot be aggregated across systems to understand social risks at a broader scale. Regulatory agencies' lack of synchronisation and the proliferation of terminology further add to the confusion. To address evolving policy-making, the industry must align on a standardised approach to represent and prioritise social risks for collection and analysis.
EHRA’s Key Criteria for Effective Recommendations
The EHR Association has established key criteria for effective recommendations:
- Feasibility Across EHR Systems: Solutions should be implementable by the majority of member EHRs, regardless of size or speciality, to avoid high costs or burdens that could hinder adoption.
- Adaptability to Diverse Healthcare Settings: Solutions must be scalable to accommodate various healthcare delivery organisations, including those in rural and urban settings with different economic models, considering the challenges posed by the COVID-19 pandemic.
- Interoperability for Social Risk Data: Effective approaches should facilitate seamless sharing and exchange of social risk data between systems, enhancing value at the point of care.
- Support for Research and Data Utilisation: Robust solutions should enable the use of social determinant risk data for research purposes, allowing data from multiple systems to be aggregated for higher-level analysis to aid researchers, social scientists, and public health professionals in understanding social risks within communities.
Recommendations to Advance Standardisation and Collaboration
The EHR Association’s Social Determinant of Health and Health Equity Task Force emphasises several recommendations to enhance social determinant risk assessment and data exchange in healthcare:
The Task Force advocates for standardisation in how EHRs represent domain risk, urging EHRs to indicate whether a patient was assessed for a domain risk, whether the risk is present, and the method of assessment used. This standardisation promotes interoperability and ensures accurate communication of social risk factors between healthcare systems.
The Task Force suggests that the standards industry take the lead in determining how domain risk is represented in data exchange. A structured representation could include elements such as the domain itself, indication of risk presence or absence, and optional coded values corresponding to the assessment method. This standardised approach simplifies data transmission between EHR systems, enabling effective utilisation of social risk data in patient care.
Acknowledging the complexity of social determinants, the Task Force recommends listing and prioritising domains for assessment within healthcare organisations. It endorses the comprehensive list of standardised domains provided by the HL7 Gravity Project and advises collaboration with the Gravity Project for inclusion of new domains. The Task Force suggests limiting mandatory assessment domains to prevent excessive burdens on clinicians and reduce regulatory burdens on healthcare organisations.
In line with the 2023 IPPS rule's recommendations, the Task Force urges EHRs to support documentation of corresponding Gravity Project domains, including food insecurity, housing instability, transportation insecurity, inadequate housing, and intimate partner violence. This ensures that EHR systems facilitate standardised assessment and documentation of social determinants of health across healthcare settings.
Overall, these recommendations aim to promote consistency, interoperability, and effectiveness in addressing social determinants of health within the healthcare industry.
Risk Assessment Flexibility is Key
The current landscape of social risk assessment lacks a universal approach, requiring flexibility to accommodate varying organisational preferences and EHR systems. Some organisations prefer standardised instruments, while others favour shorter screeners or informal methods. While standardised instruments offer reliability, mandating their exclusive use in EHRs is cautioned against, as it may restrict flexibility needed to meet diverse user needs. Therefore, regulations prescribing specific screeners and assessments are advised against at this time. The suggested approach allows for a gradual transition towards standardised screeners, aligned with the industry's readiness and evolution to adopt such tools.
The current recommendations offer a reasonable path forward for EHR developers and the healthcare industry, considering feasibility, adaptability, interoperability, and support for research. The proposed flexibility in risk assessment methods imposes a low technical burden on EHR developers, allowing scalability across diverse healthcare settings. EHR developers have the freedom to design solutions that meet the needs of their target users, regardless of sophistication. These recommendations support the exchange of social risk data and facilitate aggregation at the population level for better understanding of at-risk populations. Moving forward, CMS is advised to postpone the requirement for patient screenings on social determinants in 2024 to allow time for insights and learning from industry practices. As the industry evolves, careful consideration of new domains or prescriptive guidance around screeners is encouraged, ensuring effective implementation without increasing clinician burden.
Source: EHRA
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