A Local Perspective into Electronic Health Record Design, Integration, and Implementation of Screening and Referral for Social Determinants of Health

The SDOH EHR solution has been operationally used over three years by staff to screen 111,486 Medicare and Medicaid beneficiaries, identify 7,878 SDOH, and refer 6,103 high-risk beneficiaries to community resources.Transforming an EHR into a catalyst software to support SDOH screening and referral in a clinical settingis an interdisciplinary process that benefits from various technical, administrative, and clinical experts that provide subject matter knowledge into all phases of the build. Keywords: community referral summary, electronic health records, health information technology, social determinants of health, social needs Introduction Social determinants of health (SDOH)continue to be both undetected and unaddressed despite research demonstrating that social, economic, and physical environment factors have an estimated relative contribution of 55 percent to health outcomes that include measures of mortality and morbidity.1,2Recent healthcare deliverysystem reforms have spurred health policy innovations that have placed increasing emphasis on healthcare systems to respond to SDOH and improve population health through systematic strategies that improve patient access to social resources that may address their unmet social needs. The goal of the AHC Model is to assess whether systematically identifying and addressing SDOH in community-dwelling Medicare and Medicaid beneficiaries through building effective social services, medical care, public health, and community-based partnerships can improve health outcomes and lower healthcare costs and utilization.3 Participating clinical delivery sites use the CMS CMMI's 10-item Health-Related Social Needs (HRSNs)Screening Tool, the AHC screening tool, to identify non-medical needs across five social risk domains: housing instability, food insecurity, transportation problems, utilities, and interpersonal safety.4 Furthermore, there has been a rise in recent research underscoring the importance of incorporating SDOH screening and referral in the electronic health record (EHR).5-7 Few studies, however, have described their design and implementation approach to integrating an EHR with a community resource network management (CRNM) software-as-a-service (SaaS) platform to systematically identify and address SDOH in community-dwelling Medicare and Medicaid beneficiaries across multiple care settings. [...]some of our clinics had an established falls risk screening workflow similar to what we intended to develop for SDOH