How Do Family Physicians Document Patients’ Social Needs in Electronic Health Records?

• Electronic Health Records
• Family Physicians
• Social Determinants of Health
• Surveys and Questionnaires

Unmet social needs have long been associated with worse health outcomes.¹ Documentation of social needs in electronic health records (EHRs) can help identify patients at high risk of adverse health outcomes, promote follow-up across organizations, and track quality metrics.² In 2014, the National Academy of Medicine (then the Institute of Medicine) published standards for which social and behavioral needs clinicians should document in EHRs, such as financial strains, social isolation, and neighborhood deprivation.³ However, there is still a lack of standardization around how social needs are documented in EHRs.⁴ The few studies on this topic have found that most clinicians almost never capture social needs with diagnosis codes or structured data inputs (eg, drop-down menus) but may capture them in free-text notes.^5,6

To better understand how family physicians document social needs, we used data from the American Board of Family Medicine (ABFM) 2022 Continuous Certification Questionnaire (CCQ). Family physicians are especially important for social needs screening since they are more likely than other primary care providers to practice in rural and other underserved locations and because they provide more than 20% of all outpatient visits in the US— more than any other specialty.⁷ As the survey is required for all family physicians seeking to continue their ABFM certification, it has a 100% response rate. The survey randomized respondents to different sets of questions, 1 of which focused on the different ways that physicians use EHRs.

Among the 5998 respondents to the 2022 CCQ, 2050 were randomized to questions that included documentation of social needs. Most worked in either hospital-/managed care-owned clinics (44%) or independent clinics (30%). A majority (74%) across practice sites reported that they sometimes or often document social needs using any method (Figure 1). Over 80% in academic and federal settings reported often or sometimes documenting social needs, but other settings had lower rates. The most common form of documentation was in a note, with 63% of all respondents saying that they often or sometimes document social needs this way. Documentation practices significantly differed across practice types (P < .005); physicians in academic and federal clinics documented at similar rates, but physicians at federal clinics tended to document more often using drop-down menus and other structured data inputs.

• Download figure
• Open in new tab

Figure 1.

Respondents (n = 2050 overall) by their self-reported frequency and method of documenting social needs in electronic health records. Abbreviation: HMO = health maintenance organization, which also includes managed care.

Our research suggests that family physicians self-report documenting social needs at far higher rates than previous observational studies have suggested. This discrepancy raises the possibility of social desirability bias in self-reporting, which would not be expected in retrospective data. Physicians’ preferences for using unstructured formats limits the value of EHRs for connecting patients across organizations or for allocating resources based on needs. Further work should investigate how physicians can be incentivized to more often use standardized data formats such as diagnosis codes. Social needs screening adds to physicians’ growing documentation burden, often without leading to resources to address identified needs. Research is needed to understand how reducing documentation burden, perhaps through documentation by support staff, and enhancing resources to respond to social needs may improve capture of patients’ social needs.

• Received for publication August 31, 2022.
• Revision received October 7, 2022.
• Accepted for publication October 11, 2022.