Linking Electronic Health Records and In-Depth Interviews to Inform Efforts to Integrate Social Determinants of Health Into Health Care Delivery: Protocol for a Qualitative Research Study (Preprint)

Abstract

BACKGROUND Health systems are attempting to capture social determinants of health (SDoH) in electronic health records (EHR) and use these data to adjust care plans. To date, however, methods for identifying social needs, which are the SDoH prioritized by patients, have been underexplored, and there is little guidance as to how clinicians should act on SDoH data when caring for patients. Moreover, the unintended consequences of collecting and responding to SDoH are poorly understood. OBJECTIVE The objective of this study is to use two data sources, EHR data and patient interviews, to describe divergences between the EHR and patient experiences that could help identify gaps in documentation of SDoH in the EHR; highlight potential missed opportunities for addressing social needs; and identify unintended consequences of efforts to integrate SDoH into clinical care. METHODS We are conducting a qualitative study that merges discrete and free-text data from EHRs with in-depth interviews with women residing in rural, socio-economically deprived communities in the Mid-Atlantic region of the United States. Participants had to confirm that they had at least one visit with the large health system that serves the region. Interviews with the women included questions regarding health, interaction with the health system, and social needs. Next, with consent, for each participant we extracted discrete data (e.g., diagnoses; medication orders) and free-text clinician notes from this health system’s EHRs between 1996 and the year of the interview. We used a standardized protocol to create an EHR narrative, a free-text summary of the EHR data. We used NVivo to identify themes in the interviews and the EHR narratives. RESULTS To date, we have interviewed 88 women, including 51 White women, 19 Black women, 14 Latina women, 2 mixed Black and Latina women, and 2 Asian Pacific women. We have completed the EHR narratives on 66 women. The women range in age from 18 to 90. We found corresponding EHR data on all but 4 of the interview participants. Participants had contact with a wide range of clinical departments (e.g., psychiatry, neurology, infectious disease) and received care in various clinical settings (e.g., primary care clinics, emergency departments, inpatient hospitalizations). A preliminary review of the EHR narratives revealed that the clinician notes were a source of data on a range of SDoH, but did not always reflect the social needs that participants described in the interviews. CONCLUSIONS This study will provide unique insight into the demands and consequences of integrating SDoH into clinical care. This work comes at a pivotal point in time, as health systems, payors, and policy makers accelerate attempts to deliver care within the context of social needs.