Variation in Electronic Health Record Documentation of Social Determinants of Health Across a National Network of Community Health Centers

Abstract

Introduction: This paper describes the adoption of an electronic health record-based social determinants of health screening tool in a national network of more than 100 community health centers. Methods: In 2016, a screening tool with questions on 7 social determinants of health domains was developed and deployed in the electronic health record, with technical instructions on how to use the tool and suggested clinical workflows. To understand adoption patterns, the study team extracted electronic health record data for any patient with a community health center visit between June 2016 and May 2018. Patients were considered "screened" if a response to at least 1 social determinants of health domain was documented in the electronic health record tool. Results: A total of 31,549 patients (2% of those with a visit in the study period) had a documented social determinants of health screening. The number of screenings increased over time, time; 71 community health centers (67%) conducted at least one screening, but almost 50% took place in only 4 community health centers. Over half (55%) of screenings only included responses for only 1 domain. Screening was most likely to occur during an office visit with an established patient and documented in the electronic health record by a medical assistant. Conclusions: Screening documentation patterns varied widely across the network of community health centers. Despite the growing national emphasis on the importance of screening for social determinants of health, these findings suggest that simply activating electronic health record tools for social determinants of health screening does not lead to widespread adoption. Potential barriers to screening adoption and implementation should be explored further.

Comparison of Community-Level and Patient-Level Social Risk Data in a Network of Community Health Centers

“…There was significant variation among OCHIN CHCs in the number of screenings conducted, the types of patients selected for screening, and the social risk questions that were asked. 18 Because of the limitations of these EHR data, we cannot determine if differing response rates across SDH domains can be attributed to patient refusal to answer or clinics’ decisions not to ask them. Bias resulting from missing, inaccurate, or inadequate address data are also unknown.…”

“…As reported elsewhere, CHCs use a variety of different criteria in selecting patients for social risk screening, and there are significant differences between patients who are screened and not screened. 5 , 18 Patients were excluded if they did not have a residential address in the same state as where the screening occurred (to enable meaningful comparison of screening responses and census-tract level information) or if they lacked an address of adequate quality to enable geocoding. Patients who recently moved and/or those who traveled across state lines to receive care may have had a higher likelihood of being excluded.…”

“…To date, food insecurity, housing insecurity, and financial resource strain are among the most frequently documented social risk domains in OCHIN CHCs, in part because they are actionable (eg, through referrals to local resources). 18 Second, relative to other patient-level measures that focus on psychosocial domains (eg, relationship safety, social connection/isolation, stress), these domains are most aligned with the socioeconomic factors integrated into the SDI. Third, despite the limited consensus on standardized SDH screening recommendations, there is emerging consensus around standardized questions to assess food insecurity, housing insecurity, and financial resource strain.…”

Healthcare Sector Activities to Identify and Intervene on Social Risk: An Introduction to the American Journal of Preventive Medicine Supplement

“…This finding points to potential benefits of screening even if effective social risk−targeted interventions are not available. A final paper on screening by Cottrell and colleagues 24 provides descriptive work on the adoption of screening practices in more than 400 community health centers that launched an electronic health record social risk module. Perhaps not surprisingly, the authors find that merely making electronic health record social screening tools available is insufficient for achieving measurable and impactful practice changes.…”

Complexities in Integrating Social Risk Assessment into Health Care Delivery

“…Furthermore, electronic health records are not configured to systematically collect social risk data. 20 De Marchis et al 18 present a relevant perspective to inform the scientific discussion on social risks.…”