“Community vital signs” : incorporating geocoded social determinants into electronic records to promote patient and population health

Abstract

Social determinants of health significantly impact morbidity and mortality; however, physicians lack ready access to this information in patient care and population management. Just as traditional vital signs give providers a biometric assessment of any patient, "community vital signs" (Community VS) can provide an aggregated overview of the social and environmental factors impacting patient health. Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes. This information could also help care teams target disease prevention initiatives and other health improvement efforts for clinic panels and populations. Given the proliferation of big data, geospatial technologies, and democratization of data, the time has come to integrate Community VS into the electronic health record (EHR). Here, the authors describe (i) historical precedent for this concept, (ii) opportunities to expand upon these historical foundations, and (iii) a novel approach to EHR integration.

Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice

“…17 The recognition that social determinants influence health fueled the creation of community-oriented primary care concepts in the 1940s, [18][19][20] the development of family medicine as a medical specialty in the late 1960s, 21,22 the passage of legislation to create the neighborhood Health Center Program in 1964 (predecessor to federally qualified health centers), 23 and the Alma-Ata declaration in 1978, which stated that "primary health care…is the first level of contact of indi-viduals, the family, and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first elements of a continuing health care process." 24 Primary care has a tradition of partnering with patients, communities, and public health professionals to attempt to address SDH, [25][26][27] yet the ability to act on SDH in medical care settings in a meaningful, systematic way has been constrained by a fee-for-service payment structure, a medical culture focused on treating disease rather than promoting health, and limited technologies, among other barriers. 28 Recent changes in health care policy, however, including the passage of the Patient Protection and Affordable Care Act, paired with rapid advances in data and technology, have presented opportunities for a paradigm shift in primary care delivery.…”

“…[42][43][44] Community-level SDH (or community vital signs) are readily available in national data sets, and it is technically possible to integrate these community-level SDH into a patient's medical record using current geocoding technologies; however, community vital signs have not yet been widely imported into primary care data systems. 25 Once we make progress toward routine collection of SDH data, the second step is making the data available and useful in ways that enhance care (the right data, at the right time, in the right place). By systematizing the integration of SDH data into EHRs, these data become more readily and reliably available to the health care team, providing important contextual information and facilitating more relevant screenings, referrals to resources, and better tracking of processes and outcomes.…”

Assessing Statewide All-Cause Future One-Year Mortality: Prospective Study With Implications for Quality of Life, Resource Utilization, and Medical Futility (Preprint)

“…Last but not least, this study also featured with SDH at the community level (ZIP code level), which was recently recognized as increasingly influential on morbidity and mortality 18,[36][37][38] . Among several social determinant inputs, the Social Vulnerability Index (SVI) and Respiratory Hazard Index (RHI) were highly weighted.…”

“…Barriers to a widely applicable and accurate model include insufficient predictors 16 , incomplete data available in administrative datasets 17 , and lack of generalizability of study patients. Knowledge gaps also exist with regard to the new challenges of social determinants of health (SDH) in terminally ill patients, in terms of the accessibility of healthcare resources, exposure to hazards, as well as knowledge of healthy behaviors [18][19][20] . Considering SDH in healthcare decision-making could help care teams better target context-informed care, which fills a huge gap between hospital and hospice.…”

Integrating Community-Level Data Resources for Precision Medicine Research

“…The Accelerating Data Value Across a National Community Health Center Network (ADVANCE) pilot study has begun conducting electronic assessments of the built environment, environmental exposures, and neighborhood economic conditions to synthesize a "community vital sign" (Bazemore et al 2016). This work is similar to other assessments, like the SocioEconomic Status Index (Roblin 2013) and the Neighborhood Deprivation Index (Messer et al 2006).…”