Identifying and Addressing Social Determinants of Health with an Electronic Health Record

Phase 1 (2020 to 2021)

In the first phase, an SDoH questionnaire was generated by selecting predesigned questions from an EPIC Healthy Planet–a population health management module from the EPIC system–guided by our health needs assessment. The 2019 St. Luke’s University Health Network Community Health Needs Assessment (CHNA) was used to determine the most prescient social needs to be screened.¹⁰ Ten screening questions were ultimately chosen, focusing on key aspects of health including food access, financial insecurity, transportation, alcohol use, smoking, and social history. These questions were integrated with various parts of the screening and rooming protocol found in EPIC and required documentation during patient interviews.

In the course of administering the survey, it became apparent that many patients did not fully disclose their needs, especially those related to financial, housing, or transportation access, possibly due to perceived stigmas. For example, a patient would state they have no financial need when initially questioned and only later do they divulge that information during their interaction with the clinician. In an effort to address the possibility that staff behavior might have contributed to this barrier, an effort was made to educate the medical team to address these stigmas in patient care. The training incorporated information and demonstration from the FindHelp website. FindHelp is a national database of assistance programs for patients with social needs. The FindHelp.org website serves as an endpoint in the referral pipeline, where users can be connected to local resources such as food, housing, and financial assistance. The online training was a combination of explanation of the process, sensitivity when asking questions, and FindHelp education. In addition to the online training, there were 12 in-person training sessions for medical assistants, clerical staff, and medical personnel on SDoH and how to approach these questions with patients. All these resources were then integrated into the onboarding training for new staff members joining the team.

Phase 2 (Mid-2021 to Dec 2022)

There was a significant time constraint with asking the 10-point questionnaire, and patients felt overwhelmed during the initial phase. The Community Needs Assessment tool was used to streamline the screening process by selecting the top 3 needs most represented among the patient population: food insecurity, financial constraints, and transportation access (Figure 1). To further simplify the process, these questions–previously scattered in the EHR–were consolidated into an EPIC rooming tab and integrated into the rooming procedure. The EHR has a rooming section built for all rooming tasks. Medical assistants (MAs), licensed practical nurses (LPNs), and registered nurses (RNs) asked patients the questions and entered responses into the EHR. In addition, the questions were available on article and could be completed in the waiting room, then entered into the EHR by the rooming staff. The questions were also accessible in the patient electronic health portal to be answered before a visit. Some practices adopted a hybrid approach, using an iPad for patients to answer the questions, with the rooming staff later entering the responses into the EHR. If a patient responded positively to one or more of these domains, a Best Practice Advisory (BPA) pop-up screen was triggered. The BPA in this phase automated a social work referral, and the result was entered into a database specific to the patient's SDoH needs. As part of this process, patients were also connected to the FindHelp.org resource website, linking them to resources in their ZIP code that addressed their specific needs. The team from FindHelp.org worked closely with our leadership and care management teams to assist with creating and streamlining a process for patients who provided positive responses to SDoH surveys. During this process, we also established community partnerships to address the needs identified through the referrals. A training module was also integrated into the employee learning platform, a mandatory online education resource for all health center employees.

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Figure 1.

The EPIC Toolbox Questionnaire is available to staff during the rooming process. The process is simplified through a click-box selection function.

Phase 3 (Jan 2023 to 2024)

Once the workflow and EPIC integration were established, a comprehensive discussion shared between operational and clinical leadership took place, focusing on the roles and responsibilities of clinicians in light of these changes. The automated workflow referring patients with positive screens to social work was revised due to the overwhelming burden on care managers. When a positive answer triggered a BPA, rather than automating the referral, the patient was first asked if they would like a social work consult. If the patient agreed, a referral was sent and signed by the clinicians during the encounter. Furthermore, 2 separate FindHelp.org links into EPIC were integrated, making them easily accessible to both staff in the EHR and to patients on their MyChart platform–a secure online portal that allows patients to access their personal health information and communicate with their health care clinicians. The network’s case management and community outreach manager continued to work on engaging the community to be able to track how many referrals resulted in resource allocation. In addition, staff were trained to navigate the FindHelp.org resource page and monitor patients who use the community services. Staff began to collect data to measure impact/outcome.