While documentation of social determinants of health (SDOH) factors is a critical step for primary care organizations to address care disparities, ensuring the information is accessible through EHR integration is key to connecting patients with the resources they need.
According to the National Academy of Medicine, 80 to 90 percent of contributors to healthy outcomes for a population are social determinants of health (SDOH), such as food insecurity.
However, for making up such a large portion of health, SDOH factors are not always available in the EHR at the point of care. While case managers or social workers may screen for SDOH factors, they often document information in their own templates, so the data is unavailable within the PCP's EHR workflow.
Recognizing this, Memorial Primary Care in South Florida looked to an SDOH EHR integration to ensure primary care providers had access to SDOH data at their fingertips.
"We're one of the largest public healthcare systems in the country, and our mission is to support the community that we serve, and the community that we serve is hurting in many ways," Jennifer Goldman, DO, MBA, FAAFP, chief of Memorial Primary Care, told EHRIntelligence in an interview. "We have different health outcomes based on the zip code that our patients live in."
"Our ultimate goal was to build a system that would help to break down barriers for communities that were traditionally marginalized," she said.
The healthcare organization began by implementing a tool within its Epic EHR called the Social Determinants of Health Wheel to streamline SDOH screening and documentation.
From there, Memorial Primary Care decided which care team member should conduct patient SDOH screening.
As a patient-centered medical home, the organization has resources to help improve care outcomes for at-risk populations, such as health coaches, which are non-clinical workers that help motivate and track the progress of patients working on lifestyle changes.
"We started with our health coaches doing the screening," Goldman explained. "However, we've now developed a workflow where all our medical assistants are being trained to do the screening of social determinants of health for every patient that comes into Memorial Primary Care and ultimately to our healthcare system."
To identify the workload involved in screening and addressing SDOH barriers for patients, Memorial Primary Care focused on collecting information from patients with multiple comorbidities and who had gone to the emergency room multiple times.
"From there, we were able to develop a cleaner workflow with our informatics team to integrate those questions into the workflow for medical assistants throughout the system," Goldman explained.
Next, the organization focused on displaying SDOH data in a way that allowed clinicians to integrate it for clinical documentation easily.
In a recent survey, 92 percent of physicians reported one or more issues that make them feel burned out regularly, including excessive documentation. Recognizing this, Goldman said that her primary concern was ensuring the EHR integration did not add an administrative burden on PCPs.
"We took the data that our medical assistants would collect in the screening questions, and then we mapped that data with ICD-10 codes, otherwise known as Z codes for social determinants of health," she explained.
"Then we linked those in a best practice advisory to the clinician so that all the clinician had to do was click accept, and all of the social determinants of health that the patient is being screened for would go on to be coded for automatically," Goldman said.
Having SDOH data in the patient EHR problem list ensures that barriers are viewable by every clinician that encounters the patient.
Take, for instance, medication adherence. Goldman explained that clinicians often designate patients who struggle with medication adherence as non-compliant in the EHR.
"It doesn't help us to achieve a better state of health for our patients if we're dismissing the non-adherent behavior as non-compliant," Goldman said. "If somebody doesn't have transportation or housing, it's very difficult for them to focus on a lot of the complex medical regimens that they're being put on."
"You can have more awareness among clinical teams of the risk factors and the other factors that the patients are dealing with every day," Goldman said.
"For example, if you know that somebody's facing these challenges, maybe a three times a day dosing schedule just doesn't work for them, and you would get better adherence to medicine if you changed to extended-release medicine that was once a day," she pointed out.
To help ensure care team members connect patients with SDOH resources, Memorial set up an in-basket workflow that automatically alerts care team members when a patient is positive for an SDOH factor.
"The most important reason we're doing this is to address SDOH, so every time somebody is positive for one of these social determinants of health, the care team knows about it right away," Goldman said.
After that, a care team member reaches out to the patient and works with them to understand what help they need.
"They're able to personally connect a patient with an organization that's providing housing or work with the patient to fill out transportation forms," Goldman said. "Resources are available and searchable via the patient's zip code within the EHR, so it's relatively easy to find what organizations in the community are helping to provide affordable food or transportation support."
"As a healthcare system, we need to take it further than giving a patient a piece of paper and telling them to contact these resources, because many times people know where the resources are, but there may be stigma barriers to getting there," she continued.
For instance, if a patient does not have a car, accessing food from a food bank and carrying it home may be their biggest barrier.
"This involves the personal touch, and this is a continuous evolution in our healthcare system," Goldman said.
Since creating this automated workflow, Memorial Primary Care has tripled the number of SDOH factors documented in the EHR, and Goldman said that number continues to rise.
"What we've known all along in working in our community is one size cannot fit all, it shouldn't fit all, and that the addressing of the social determinants of health becomes this collaborative effort between the healthcare system and our community," she emphasized.
"There's a lot more to be done, but starting with documenting social determinants of health and then looking at data to see where patients are coming from can really help to inform collaborative efforts between organizations," Goldman said.