- Integrating social determinants of health (SDH) data into EHR systems may help providers address the economic and social risks that negatively affect patient health.
However, a recent Annals of Family Medicine study by Gold et al. identified several barriers inhibiting the integration of SDH data into EHR clinical documentation.
A team of researchers from Kaiser Permanente, OCHIN, Multnomah County Health Department, Cowlitz Family Health Center, and University of California San Francisco implemented a suite of EHR tools designed to collect SDH data at three Pacific Northwest community health centers as part of a pilot study testing the effectiveness of EHR-based SDH documentation.
“The argument for such documentation is compelling: SDH profoundly impact health, so providers should know about social factors that might increase their patients’ health risks, or hinder their ability to follow care recommendations,” stated researchers.
Researchers collected SDH data on 1,130 patients from June 2016 to July 2017 as part of a pilot project to assess the effectiveness and value of the tools.
“We used several implementation strategies to support tool adoption in the pilot CHCs,” explained researchers. “Each clinic identified an SDH champion and staff members were engaged in tool development.”
Providers requested several modifications to the tools during testing and use.
“We held 2 trainings for clinic staff before the tools’ release: 8 staff from the 3 pilot sites were invited, and encouraged to invite other staff to attend; 25 people attended,” the team continued.
All three clinics part of the pilot project altered their clinical workflows to accommodate the EHR tools. Additionally, all participants used mostly paper-based SDH screening questionnaires to gather information from patients.
The use of paper-based questionnaires required that providers complete data entry as part of their workflow, which affected when the information was available in patient EHRs.
Participants made efforts to minimize administrative burden for primary care providers by offloading data entry responsibilities and SDH-related referrals to other members of their care teams.
Between 97 and 99 percent of screened patients indicated a potential SDH-related need, according to researchers. Nineteen percent of patients received an SDH-related referral to address this need.
At one clinic, only 15 percent of patients requested help for an SDH-related need. Another clinic reported that only 21 percent of patients requested help.
Ultimately, providers identified three key barriers limiting adoption and use of the tools.
First, some participants reported that EHR-integrated SDH data created a fragmented view of patient health, with “relevant data in multiple places.”
This fragmentation made it difficult for providers to document a straightforward narrative about patient health.
Additionally, participants had trouble collecting and acting on SDH data available in patient EHRs. Lack of staff familiarity with EHR systems and excessive EHR tool customization partly contributed to these problems.
Finally, adding an additional data entry step into clinical workflows to transfer SDH data from questionnaires into patient EHRs negatively affected clinical efficiency.
“Referral workflows were seen as too time-consuming, especially when no follow-up was planned; and, until questions asking whether patients desired follow-up for SDH needs were added, the high positive screening rate yielded an unmanageable follow-up workload,” noted researchers.
While study results indicated the EHR tools may be inefficient, researchers pointed out that it takes time for users of any new health IT tool to adapt to changes in clinical workflows.
Furthermore, providers are often unable to reduce significant social or economic barriers to patient care, which limits the effectiveness of SDH screening in general.
“Some barriers to SDH screening are likely to occur regardless of the technology used, for example, staff concerns about SDH screening when little intervention is possible,” wrote researchers.
Researchers concluded that integrating SDH data into EHR systems is feasible and potentially useful if clinics consider several factors when implementing new data collection tools.
“When planning for implementation, ensure that new staff are trained in SDH workflows,” wrote researchers. “Consider whether upgrades or other EHR changes may impact SDH tool use and/or necessitate additional training.”
Researchers also advised healthcare organizations to ensure all staff members involved in collecting and entering SDH data into patient EHRs have authorization to access the necessary tools.
“Consider conducting a staged rollout of SDH documentation to help identify needed changes in planned workflows,” wrote researchers. “When designing SDH workflows, try to create workflows where data are entered directly in the computer.”
“If the workflows involve paper-based data collection, specify staff and the timeframe for data entry, and consider that timing of data entry will impact when, how, and by whom the data can be accessed and used,” researchers continued.
Researchers also advised clinicians to keep in mind that completed paper forms do not reveal how a patient scored in specific SDH domains. Scoring is generally easier to interpret after data have been entered into provider EHR systems.
The team also advised that healthcare organizations ensure clinical workflows indicate how to locate SDH summary tools in EHR training.
Researchers also offered recommendations for EHR vendors developing tools to facilitate SDH integration into EHR systems.
“When designing EHR tools for SDH, vendors and programmers should ensure that documentation identifies if patients (with a SDH need) want assistance with addressing the need and what kind of assistance they want,” researchers wrote.
“Consider using text shortcut tools to document provision of community resource materials or referrals provided by SDH topic,” the team added.
Designing documentation tools that seamlessly integrate into existing clinical workflows could also help to boost clinical efficiency for providers.
“Expand approaches to documenting patient-reported data without requiring staff data entry,” researchers suggested.
These and other strategies geared toward streamlining clinical documentation and efficiency may help to boost the effectiveness of EHR tools for SDH collection.