Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health

Rachel Gold; Erika Cottrell; Arwen Bunce; Mary Middendorf; Celine Hollombe; Stuart Cowburn; Peter Mahr; Gerardo Melgar

doi:10.3122/jabfm.2017.04.170046

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Figure 1.
Social determinants of health flowsheet in EPIC.
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Figure 2.
Social determinants of health summary tab.
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Figure 3.
Social determinants of health summary in Synopsis.
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Figure 4.
Social determinants of health preference lists.

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Table 1.

Institute of Medicine Phase 2 Report: Summary of Candidate Domains for Inclusion in All Electronic Health Records

Race/ethnicity^*

Education

Financial resource strain

Stress

Depression^*

Physical activity

Nicotine use/exposure^*

Alcohol use^*

Social connections/social isolation

Exposure to violence: intimate partner violence

Neighborhood characteristics (eg, median income within census tract)

↵* Already routinely captured in electronic health records.

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Table 2.

Options Considered for Addressing Each of the Five Steps Involved in Using Social Determinants of Health Data in Community Health Centers

Step	Options	Description
1. Collecting SDH data	Flowsheet	Groups of related data can be collected in a given EHR “flowsheet.” Flowsheets are commonly used for collecting screening data, such as depression screenings, so users may also be comfortable using them for SDH documentation.
	Patient portal	In the EHR patient portal, patients sign up for an account. This lets them access selected data from their medical record and E-mail their care teams. Questionnaires and surveys can also be sent to be completed and returned by patients through the portal.
	Paper version	Patient-reported data are often collected on hard-copy printouts. These data must subsequently be entered into the EHR by a care team member.
2: Reviewing SDH needs	Reports	Summaries of selected patient data can be created in the EHR in the Synopsis function, or in Patient-Level Reports.
5: Tracking past referrals	Rosters	The EHR's panel management tool lets users sort patient panel data for myriad purposes. Rosters and registries can be built so that updated data sets are easily reproduced; experienced users can create customized searches. Rosters can be used to identify patients with specific diseases or risks for use in tasks such as targeted outreach or for identifying the needs of scheduled patients (ie, chart “scrubbing”). They can be used to track referrals made over a given period in order to support follow-up by the care team.
5: Tracking past referrals	Alerts	Two EHR-based alert/reminder functions are available. Best Practice Advisories identify needed care steps, drug allergies or other safety warnings, and other point-of-care needs. Health Maintenance alerts notify team members when a patient is due for preventive care; at OCHIN, these include recommendations with a US Preventive Services Task Force A/B rating.⁴⁶
3: Identifying referral options	Preference lists	Preset lists of specified kinds of orders can be built to expedite ordering procedures, medications, and referrals. They are maintained by a clinic staff member.
4: Ordering referrals	Look-up tables	These tables could be created with an initial set of local resources.
	Linkages to websites	These linked websites might list community social services (eg, United Way 2-1-1, Purple Binder, Health Leads), in general or for a specific SDH need, within the patient's zip code.
	Lists of search terms	Lists could be created to enable effective Internet searching for local resources (eg Google) in a wiki-style document with vetted search terms and suggestions for how to use Google Maps to locate services.
	A wiki-style document	Lists of local resources familiar to CHC staff could be added to the EHR and updated as needed.

CHC, community health center; EHR, electronic health record; SDH, social determinant of health.

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Table 3.

Social Determinant of Health Domains and Measures Included in the ASSESS Tool and Overlap with Institute of Medicine–Recommended Domains and Measures

SDH Domain	IOM-Recommended Measure/Questions	Same in PRAPARE?	ASSESS Question (If Different from IOM)	Potential Actions
Alcohol use^*^{^†}	AUDIT-C (3Q)	Not included	Already included in OCHIN EHR	Refer to addiction services
	How often do you have a drink containing alcohol? (never/monthly or less/2–4 times a month/2–3 times a week/≥4 times a week)		How many (and what type of) drinks do you have per week? (cans of beer/glasses of wine/shots of liquor/standard drinks or equivalent; all nos.)
	How many standard drinks containing alcohol do you have on a typical day? (1 or 2/3 or 4/5 or 6/7–9/≥10)
	How often do you have ≥4 drinks on one occasion? (never/less than monthly/monthly/weekly/daily or almost daily)
Race/ethnicity^*^{^†}	US Census (2Q)	Which race(s) are you? Check all that apply. (American Indian or Alaskan Native/Asian/black or African American/Native Hawaiian/Pacific Islander/white/other) Are you Hispanic or Latino? (yes/no/unreported or refused)	Already included in OCHIN EHR
Race/ethnicity^*^{^†}	What is this person's race? (white; black, African American, or Negro; American Indian or Alaska Native; Asian Indian/Chinese/Filipino/Japanese/Korean/Vietnamese/Other Asian/Native Hawaiian/Guamanian or Chamorro/Samoan/other Pacific Islander/some other race) Is this person of Hispanic, Latino, or Spanish origin? (no/yes, Mexican, Mexican American, Chicano/yes, Puerto Rican/yes, Cuban/yes, another Hispanic, Latino, or Spanish origin)		Race: Alaskan Native/American Indian/Asian/black/Native Hawaiian/Pacific Islander/patient refused/unknown/white) Ethnicity: Hispanic/non-Hispanic/patient refused/unknown)
Tobacco use and exposure^*^{^†}	NHIS (2Q)	Not included	Already included in OCHIN EHR	Refer to quit services
	Have you smoked at least 100 cigarettes in your entire life? (yes/no/refused/don't know)		Smoking status: current smoker, everyday/current smoker, some days/former smoker/heavy tobacco smoker/light tobacco smoker/never assessed/never smoker/passive smoke exposure, never smoker/smoker, current status unknown/unknown if ever smoked)
	Do you now smoke cigarettes every day, some days, or not at all? (every day/some days/not at all/refused/don't know)
			Smokeless tobacco: current user/former user/never used/unknown)
Depression^*^{^†}	PHQ-2 (2Q)	Not included	Already included in OCHIN EHR; same as IOM	Refer to mental health services
	Over the past 2 weeks, how often have you been bothered by any of the following problems:
	Little interest or pleasure in doing things (not at all/several days/more than half the days/nearly every day)
	Feeling down, depressed, or hopeless (not at all/several days/more than half the days/nearly every day)
Education^*	What is the highest level and years of school completed? (elementary/high school/college/graduate or professional—check years completed) What is the highest degree you earned? (high school diploma/GED/vocational certificate/associate degree [occupational, technical, or vocation program]/associate degree [academic program]/bachelor's degree/master's degree/professional/doctorate)	What is the highest level of school that you have finished? (less than high school/high school diploma or GED/more than high school/I choose not to answer this question)	Adapted IOM wording to be aligned with PRAPARE and more relevant to safety net populations	Identify patients who need more intensive care management, targeted forms of outreach, or for whom teams should consider “teach-back” methods, tailored handouts, etc. Refer to education services (GED/skills training)
Exposure to violence: IPV^*	HARK (4Q)	In the past year, have you been afraid of your partner or ex-partner? (yes/no)	Per the recommendations of our stakeholder group, we included a more general question on violence that is aligned with Kaiser Permanente's YCLS questionnaire	Refer to IPV intervention services
Exposure to violence: IPV^*	HARK (4Q)		Have you ever been physically or emotionally hurt or threatened by a spouse/partner or someone else you know? (yes/no)	Refer to IPV intervention services
	Within the past year, have you been: Humiliated or emotionally abused in other ways by your partner or ex-partner? Afraid of your partner or ex-partner? Insult or talk down to you Raped or forced to have any kind of sexual activity with your partner or ex-partner?	Do you feel physically and emotionally safe where you currently live? (yes/no)	In addition, the CORC opted to include the 4-item validated HITS (Hurt-Insult-Threaten-Scream) domestic violence screening tool^59,60 in the OCHIN EHR. This question will not be part of the SDH flowsheet, but positive responses will be pulled into the SDH summary and synopsis.
	(yes/no) Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner? (yes/no)		How often does your partner: Physically hurt you Threaten you with harm Scream or curse at you
			(never/rarely/sometimes/fairly often/frequently)
Physical activity^*	Exercise Vital Signs (2Q)	Not included	Same as IOM	Refer to local physical activity resources (eg, YMCA, Parks and Recreation services)
	On average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?
	On average, how many minutes do you engage in exercise at this level?
Social connections and social isolation^*	NHANES III	How often do you see or talk to people that you care about and feel close to? (for example, talking to friends on the phone, visiting friends or family, going to church or club meetings) (less than once a week/1 or 2 times a week/3–5 times a week/>5 times a week/I choose not to answer this question)	Same as IOM; plus, per the recommendation of our stakeholders, we added an additional response to the NHANES question on weekly social contacts to encompass alternative forms of communication	Refer to community resources/support groups/group activities/volunteer services
	Are you married or living together with someone in a partnership? (married or domestic partner/living with partner in committed relationship/in a serious or committed relationship, but not living together/single/separated/divorced/widowed)			Provide more intensive case management
				Develop an emergency action plan
	In a typical week, how often do you: Talk with family, friends, or neighbors by phone? Get together with family, friends, or neighbors? (never/once a week/2 days a week/3–5 days a week/nearly every day)		In a typical week, how often do you: Use email, text messaging, or Internet to communicate with family, friends, or neighbors?
	How often do you: Attend church or religious services Attend meetings of the clubs or organizations you belong to? (never/once a year/2–3 times a year/≥4 times a year/at least once a week)		Our stakeholders also recommended including 2 more general questions on social isolation that are part of the Kaiser Permanente YCLS questionnaire
			How often do you feel lonely or isolated from those around you? (never/rarely/sometimes/often/always)
			Do you have someone you could call if you needed help?^{^‡} (yes/no)
Stress^*	Stress means a situation in which a person feels tense, restless, nervous, or unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days? (not at all/a little bit/somewhat/quite a bit/very much)	Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you? (not at all/a little bit/somewhat/quite a bit/very much/I choose not to answer this question)	We used the PRAPARE version of the question because of difficulties obtaining copyright	Refer to stress management programs
Stress^*				Advise closer monitoring of blood pressure, cholesterol
Financial resource strain^*	How hard is it for you to pay for the very basics like food, housing, heating, medical care, and medications? (not hard at all/somewhat hard/very hard)	In the past year, have your or any family members you live with been unable to get any of the following when it was really needed? Check all that apply. (food/transportation/clothing/child care/utilities/medicine or medical care/rent or mortgage/phone/health insurance/other/I choose not to answer this question)	Same as IOM, plus an additional follow-up question if they answered somewhat hard or very hard that is used in the Kaiser Permanente YCLS	Assess food/housing insecurity
Financial resource strain^*			What is hard to pay for? (food/utilities food, utilities, transportation, medicine or medical care, health insurance, clothing, rent/mortgage, child care, phone)	Refer to relevant social and legal services
Housing	Not included in the final list of IOM-recommended domains	What is your housing situation today? (I have housing/I do not have housing [staying with others, in a hotel, on the street, in a shelter])/I choose not to answer this question)	In the past month, have you slept outside, in a shelter, or in a place not meant for sleeping? (yes/no)
			In the past month, have you had concerns about the conditions and quality of your housing? (yes/no)
			In the past 12 months, how many times have you moved from one home to another?
Food	Not included in the final list of IOM-recommended domains	Not included	USDA Household Food Security Survey Module
			Which of the following describes the amount of food your household has to eat? (enough of the kinds of food we want to eat/enough but not always the kinds of food we want/sometimes not enough to eat/often not enough to eat/don't know or refused)
			Please tell me whether the statement was often true, sometimes true, or never true for (you/your household) in the last 12 months:
			(I/We) worried whether (my/our) food would run out before (I/we) got money to buy more.
			The food that (I/we) bought just didn't last, and (I/we) didn't have money to get more.
			(I/we) couldn't afford to eat balanced meals.
Sexual orientation and gender identity	Not included in the final list of IOM-recommended domains	Not included	This is a required UDS data element beginning in 2016^64,65 and is slated for inclusion in MU-3 requirements
Sexual orientation and gender identity	Not included in the final list of IOM-recommended domains	Sexual orientation (lesbian or gay/straight [not lesbian or gay]/bisexual/something else/I don't know/choose not to disclose/other sexual orientation [comment for other])
		Gender identity (female/male/transgender female [male to female]/transgender male [female to male]/other/choose not to disclose/other identity [comment for other])
		Preferred pronoun (he/him, she/her, they/them, ze/zim, decline to answer, unknown)

↵* IOM-recommended domain.
↵† Already routinely collected in electronic health record (EHR).
↵‡ Modified from item in PROMIS Item Bank version 1.0: Emotional distress, anger, Short Form 1, and AARP overall loneliness item from AARP survey about loneliness in older adults. The original PROMIS item was written in first person. Loneliness was added to reduce literacy level.
AUDIT-C, Alcohol Use Disorders Identification Test; GED, General Equivalency Diploma; HARK, Humiliation, Afraid, Rape, Kick; IOM, Institute of Medicine; IPV, intimate partner violence; MU-3, meaningful use level 3; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; PRAPARE, Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences; PHQ-2, 2-item Patient Health Questionnaire; SDH, social determinant of health; Q, questions; UDS, Uniform Data System; YCLS, Your Current Life Situation.

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Table 4.

Algorithm for Identifying Positive Social Determinant of Health Screens

Questions^*	Response Options (from Hard-Copy Version or Flowsheet)	Responses That Flags a Positive Screen
1. How do you learn best?	Reading Listening Looking at pictures	None
2. What is the highest level of school that you have finished?	Less than a high school diploma High school diploma/GED More than high school	None
3. How hard is it for you to pay for the very basics like food, housing, heating, medical care, and medications?	Not hard at all Somewhat hard Very hard	Somewhat hard or very hard
	If you answered “Somewhat hard” or “Very hard,” what is it hard to pay for?	Yes to any of these
	Food, utilities, transportation, medicine or medical care, health insurance, clothing, rent/mortgage, child care, phone
4a. In the past month, have you slept outside, in a shelter, or in a place not meant for sleeping?	Yes No	Yes
4b. In the past month, have you had concerns about the conditions and quality of your housing?	Yes No	Yes
5. In the past 12 months, how many times have you moved from one home to another?	(Patient to indicate number of times)	≥2 moves flagged for follow-up
6a. In the past 12 months, (I/we) worried whether (my/our) food would run out before (I/we) got money to buy more.	Often true Sometimes true Never true	Often true or sometimes true
6b. In the past 12 months, the food that (I/we) bought just didn't last, and (I/we) didn't have money to get more.	Often true Sometimes true Never true	Often true or sometimes true
6c. In the past 12 months, (I/we) couldn't afford to eat balanced meals.	Often true Sometimes true Never true	Often true or sometimes true
7. In the past 12 months, have you ever been physically or emotionally hurt or threatened by a spouse/partner or someone else you know?	Yes No	Yes
8a. On average, how many: Days per week do you engage in moderate to strenuous exercise (like walking fast, running, jogging, dancing, swimming, biking, or other activities that cause a light or heavy sweat)?	(Patient to choose a number between 0 and 7)	Multiply days per week (8a) by number of minutes (8b); <150 flagged for follow-up
8b. On average, how many minutes do you exercise at this level?	(Patient to indicate number of minutes)
9. Are you married or living together with someone in a partnership?	Married or domestic partner Living with partner in committed relationship In a serious or committed relationship, but not living together Single Separated Divorced Widowed	Questions 9–11: Composite score based on the Berkman-Syme Social Network Index
		Question 9: 1 point for “married or domestic partner,” “living with partner in committed relations,” or “in a serious or committed relationship, but not living together”
10a. In a typical week, how often do you: Talk with family, friends, or neighbors by phone or video chat (e.g. Skype, Facetime)?	Never Once a week 2 Days a week 3–5 Days a week Nearly every day	Question 10a-c: 1 point if they have a total of ≥3 contacts per week.
10b. In a typical week, how often do you get together with family, friends, or neighbors?	Never Once a week 2 Days a week 3–5 Days a week Nearly every day
10c. In a typical week, how often do you use email, text messaging, or internet (eg, Facebook) to communicate with family, friends, or neighbors?	Never Once a week 2 Days a week 3–5 Days a week Nearly every day
11a. How often do you attend church or religious services?	Never Once a year 2–3 Times a year ≥4 Times a year At least once a month At least once a week	Question 11a: 1 point for attending church or attending church or religious services “≥4 times a year,” “at least once a month,” or “at least once a week”
11b. Attend meetings of the clubs or organizations you belong to?	Never Once a year 2–3 Times a year ≥4 Times a year At least once a month At least once a week	Question 11b: 1 point if attends meetings “2–3 times a year,” “≥4 times a year,” “at least once a month,” or “at least once a week”)
		Maximum points = 4
		High risk (flagged for follow-up) = 0–2
12. How often do you feel lonely or isolated from those around you?	Never Rarely Sometimes Often Always	Often or always
13. Do you have someone you could call if you needed help?	Yes No	No
14. During the past month, how much stress would you say you experienced?	A lot of stress A moderate amount of stress Relatively little stress Almost no stress at all	A lot of stress or a moderate amount of stress

↵* Question sources: (1) Developed by OCHIN's Clinical Operations Review Committee. (2) Adapted from standard education questions to align with patient population of OCHIN membership. (3) Slight modification of Institute of Medicine–recommended financial hardship item (medications added to list of examples), Puterman et al,⁶¹ and Hall et al.⁶² The follow-up question, “What is hard to pay for?” was added to get more granularity and enable the care team to identify needed interventions; the question was adapted from a Kaiser Permanente social determinants of health (SDH) questionnaire, with permission. (4) and (5) Housing questions were from the Health Begins Upstream Risk Screening Tool (http://www.healthbegins.org/).⁶³ (6) US Department of Agriculture 18-item Household Food Security Survey. (7) Adapted from a Kaiser Permanente SDH questionnaire, with permission. (8) Exercise Vital Sign, questions 1 and 2 and Sallis RE. Developing health care systems to support exercise: exercise as the fifth vital sign. Br J Sports Med 2011;45:473–4. Epic already has copyright permission. (9–11) Third National Health and Nutrition Examination Survey. Epic already has permission to use this question. Scoring is based on the Berkman-Syme Social Network Index (SNI); Pantell et al. Social isolation: a predictor of mortality comparable to traditional clinical risk factors. Am J Public Health 2013;103:2056–62. Item 10c was created as a parallel to items 10a and 10b to capture social connection via newer electronic modes that were not available when the Berkman-Syme SNI was created. Frequency categories for questions 10 and 11 were slightly modified from original. Kaiser is also using this approach in their screening tool. Epic already has permission to use this question. (12) Modified from item in PROMIS Item Bank version 1.0, Emotional Distress - Anger - Short Form 1 - and AARP overall loneliness item from AARP survey about loneliness in older adults. The original PROMIS item was written in first person. Loneliness was added to reduce literacy level. (13) Your Current Life Situation Questionnaire from Kaiser Permanente. (14) 1998 Adult Prevention Module of the National Health Interview Survey.