Table 2.

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

1. Collecting SDH dataFlowsheetGroups 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 portalIn 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 versionPatient-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 needsReportsSummaries of selected patient data can be created in the EHR in the Synopsis function, or in Patient-Level Reports.
5: Tracking past referralsRostersThe 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.
AlertsTwo 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 optionsPreference listsPreset 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 referralsLook-up tablesThese tables could be created with an initial set of local resources.
Linkages to websitesThese 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 termsLists 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 documentLists 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.