Getty Images/iStockphoto

Top Technologies Supporting Social Determinants of Health Work

Social determinants of health screening and referral are booming, but healthcare still lacks the data standards needed to meaningfully use this information.

While most health system social determinants of health initiatives are fundamentally about uncovering and fulfilling social needs, those efforts would not be complete without the health IT necessary to support them.

Indeed, programs that address social determinants of health—the circumstances in which we live, work, and play which affect our health outcomes—almost entirely hinge on technology. In the population health work, data is king, and in order to capture that data and make sense of it, a suite of patient engagement tools will be necessary.

Currently, eight in 10 healthcare organizations use healthcare technology to approach their SDOH—and SDOH data collection—efforts, according to 2023 data from the American Health Information Management Association (AHIMA). Starting from screening patients for social needs, to referring to social services, all the way to documenting SDOH into the EHR, these tools are central to the whole of population health programs.

But there is still much work to be done. With lacking data standards and a fragmented SDOH data landscape, it can be difficult for healthcare organizations to gain a fuller picture of their patients’ social needs, stymying approaches to population health management.

Below, PatientEngagementHIT outlines the current state of the health IT that supports SDOH and population health work while underscoring the limitations that still haunt the industry.

Social determinants of health screenings

While social determinants of health screenings—and other types of care screenings—can be done on paper, medicine’s increasing modernization has also brought these to digital tools.

Social determinants of health screening tools are not always individual technologies themselves; instead, they often come part in parcel with other tools like the EHR, data analytics tools, or social services referral tools. Screenings may also be embedded in patient intake technologies.

Many of the key considerations for SDOH screening tools have less to do with the technology platform and more to do with the content of the surveys themselves. SDOH screening considerations may include

  • Patient health literacy levels
  • Providing opt-out options
  • The SDOH to be focused upon in the screenings
  • How clinicians and other office staff will discuss screenings with patients

However, it is also good for healthcare organizations to also consider how an SDOH screening technology will fit into their larger digital patient engagement suites. Organizations should look for screening tools that can integrate with other technologies, like the EHR, so that SDOH data can become a part of the patient’s health record.

Moreover, integration with social services referral tools could make it easier for providers to quickly draw up a list of services that can help meet patient needs.

Social services referral tools

Social services and SDOH referral tools are the technologies that help healthcare providers find social services providers and connect patients to care.

To be clear, this work can be done without technology. Consider a care coordinator or social worker opening her Rolodex to find a food pantry for a food-insecure patient. SDOH referral tools streamline that task, easing provider workloads and helping organizations stay on top of social service providers that are still open.

Examples of vendors supporting social services referrals include but are not limited to, Unite Us, Healthify, NowPow, Cityblock Health, and OpenBeds.

In addition to cost, healthcare organizations need to consider how these tools integrate with the EHR, according to a 2020 KLAS report on SDOH referral tools. EHR integration allows healthcare providers to seamlessly pass between a patient’s medical record and manage patients’ social complexity.

Additionally, organization leadership should consider how use of the technology will affect the social services providers and community health partners with which the provider works.

What kind of data will need to be exchanged between the healthcare and social services providers? How will this data integrate with any tools the social services provider uses? Answering these questions will help providers ensure that their technology is a useful conduit between themselves and social services.


SDOH work must start with SDOH data, and that data needs to be documented in the EHR.

Currently, most healthcare organizations are engaging in SDOH data collection within the EHR, with 83 percent reporting as much in an ONC study. EHR vendors that enable specific SDOH data capture include Epic Systems, Cerner, athenahealth, and Allscripts, although that list is not exhaustive.

But challenges abound, providers have said. For one thing, there’s a lack of SDOH data standards. Around three-quarters of hospitals told ONC they use some sort of health IT to standardize SDOH data, making it more usable on disparate technology systems that are not part of the EHR. Around one in three (29 percent) use diagnosis codes to standardize SDOH data.

Respondents to the above-mentioned 2023 report from AHIMA said that lack of data standards plus limited provider education in capture and coding of SDOH also get in the way of collection. Until data standards can catch up to organizations’ SDOH needs, providers will be hamstrung in their efforts to integrate SDOH considerations into their population health interventions.

But it’s not just data integration that beleaguers healthcare providers; it is also data quality and integrity. Social determinants of health needs change quickly, so it is instrumental for organizations to regularly survey patients and update medical records.

Keeping on top of these SDOH data challenges can be more difficult for smaller or rural organizations that are resource-strapped.

Data analytics, population health tools

In addition to documenting SDOH data, healthcare organizations need to make sense of that data. That’s where population health tools come in.

These systems skim SDOH screening data and flag patients who might need access to social services, akin to risk stratification for social complexity. Vendors in this space include but are not limited to IBM Watson Health and Socially Determined, although many EHR vendors have population health add-ons that can do similar work.

Notably, these tools help organizations assess SDOH burden on a population level, not just the patient level. These technologies are not only useful for patient-level interventions but also for helping organizations design system-wide population health strategies.

As noted above, there are some serious limits to using SDOH data right now. Lack of data standards and data collection with the EHR limit healthcare organizations from using the analytics tools to draw population-level conclusions about SDOH burden.

Interoperability platforms

Part in parcel with SDOH data collection is SDOH data interoperability and exchange. The reasons for this are twofold: first, healthcare organizations do not always rely solely on the SDOH screenings their patients fill out. Rather, SDOH data can come from numerous places, including government sources, community entities, and other social services.

Second, healthcare organizations are not the only stakeholders concerned with social determinants of health. Indeed, community health partners and other social services providers want to assess patients’ social risk factors, but do not have access to standardized EHR data.

To reconcile both issues, data standards are necessary. ONC has a few programs in place for addressing SDOH data standards, including

  • United States Core Data for Interoperability (USCDI)
  • ONC Interoperability Standards Advisory
  • ONC Standards Bulletin
  • ONC Health IT Certification Program
  • Standards Version Advancement Process

Healthcare organizations are also working with different interoperability and data exchange platforms to get a bigger picture of a patient’s SDOH. Per the ONC report cited at the top of this article, healthcare organizations heavily leverage interoperability systems to get SDOH data. For example, 60 percent of hospitals get SDOH data from electronic sources; 46 percent get it from a health information exchange (HIE).

Although long a pillar of patient health and well-being, SDOH has only gotten focused attention from the healthcare industry in recent years. SDOH is a key part of successful population health management programs, which rose to prominence as the industry embraced value-based payment models.

As healthcare experts continue working at supporting SDOH efforts, the systems that support them—medical records, data integration and exchange, and social services connections—will ideally mature to fill in current gaps or pitfalls.

Next Steps

Dig Deeper on Patient data access

xtelligent Health IT and EHR