August 2019

Coding Corner: How Rethinking SDOH Codes Can Eliminate the Alligators
By Lori Petersen
For The Record
Vol. 31 No. 7 P. 8

The impact of social determinants of health (SDOH) on an individual’s overall well-being may best be summed in the axiom, “When you’re up to your neck in alligators, it’s difficult to remember that your initial objective was to drain the swamp.”

People who are hungry, or are uncertain of where they’re going to sleep that night when the storm hits, or are facing any of the other challenges in the first two levels of Maslow’s hierarchy of needs are going to be far more focused on solving those issues than on abstract concepts such as the long-term impact of not taking their medications as prescribed or missing a follow-up appointment with their physician.

The health care industry has been a little late to the party in understanding how much SDOH shape patient health, but it has been making up for lost time in the last few years. Judging by all the articles in industry publications—and the discussions at industry events such as HIMSS—SDOH have become a top-of-mind concern.

An upgrade to ICD-10 in 2015 that created a subset of SDOH-related Z codes enabled providers to document more detail about patients’ social conditions. Now, when a provider identifies a social barrier such as food insecurity or housing instability, that issue can be documented in the patient’s EHR, ideally enabling follow-up actions to either alleviate the social barrier or adjust care accordingly.

Challenges in Applying SDOH Codes
Unfortunately, that concept works better in theory than in practice. For example, clinicians aren’t using the SDOH-related Z codes nearly as much as they could. In fact, a 2017 study in the journal Medical Care found that SDOH codes (other than those related to mental health and alcohol/substance abuse) are used infrequently for discharges in inpatient settings. Nor are they regularly using codes in LOINC, SNOMED, or CPT that relate to SDOH topics.

Whether it’s lack of awareness about the existing codes; inadequacy of the existing codes to reflect clinical activities related to SDOH; lack of time or incentives to explore these issues; reluctance on the part of clinicians to ask such tough, personal questions; or some other cause, medical documentation of SDOH-related activities is underwhelming at best.

Even if the existing codes are used, the reality is that they are inadequate to accurately reflect SDOH-related clinical activities. Some codes are too general, grouping distantly related areas under a single description that makes it difficult to understand what actions should be taken to alleviate them; others are too specific, addressing some SDOH issues while leaving others out.

Take the example of a patient with food insecurity (ie, unreliable access to a sufficient quantity of affordable, nutritious food) presenting for clinical care at a physician’s office or other medical facility. First, there is a high likelihood that the food insecurity issue would be missed entirely by the clinical staff, who will be focused on the patient’s clinical rather than SDOH needs.

Even if the food insecurity issue is uncovered, it might be assigned Z code 59.4, which is defined as “lack of adequate food and safe drinking water.” That is a very broad assessment, however, as adequate food and safe drinking water are very different issues requiring different assessment and treatment responses.

Of even greater concern, few codes exist that enable documentation of actions taken in response to a particular social barrier diagnosis. In this instance, there is currently no way to use medical standards to indicate that a patient was referred for long-term government food assistance vs emergency food programs. Additionally, regardless of where the patient is referred, there is no way of reporting the outcome of that social intervention back into the EHR. As a result, these actions exist in isolation rather than being aggregated to help the quality and effectiveness of future interventions.

Enter the SIREN Gravity Project
Some of these issues are being addressed by the Social Interventions Research & Evaluation Network (SIREN) Gravity Project (of which I am a committed volunteer). Operating out of the University of California, San Francisco and funded by the Robert Wood Johnson Foundation in partnership with EMI Advisors, the Gravity Project is focused on identifying and expanding medical codes across multiple standards systems to improve providers’ capacity to document SDOH screening, diagnoses, and related interventions.

This is the first time multiple stakeholder groups—including clinical, community-based providers; technology vendors; and standards development organizations (including SNOMED International)—have convened with a focus on improving the way interoperable SDOH codes are used in conjunction with EHRs. The interest has been remarkable. More than 330 people joined the initiative’s kick-off meeting, and the expectation is that many more will participate as the effort moves forward.

All of the members of the Gravity Project are volunteers; they represent diverse stakeholders in health care practice, research, and policy. The goal is to develop consensus on data definitions for SDOH concepts documented across four clinical areas, identify coding gaps, and eventually develop codes that can be incorporated into a single, consolidated health record.

This consensus-based approach is critical to future adoption and utilization. The data definitions are intended to establish a foundation for developing a standardized code system that properly addresses the social barriers underlying many health issues and/or the barriers that prevent health issues from being resolved, and to ensure that those new codes are used consistently across all health care systems.

The Gravity Project is currently concentrating on three SDOH domains: food insecurity, housing instability and quality, and transportation. These are the most commonly assessed (and addressed) areas in clinical settings. They are also the social issues for which there are a host of new payment/finance mechanisms—such as programs from Medicaid and Medicare Advantage—that may incentivize clinicians to become more active in these areas.

In the future, the Gravity Project may build on this foundation by expanding its work to standardize codes in other SDOH domains as well.

One of the most important realizations has been the recognition of the many steps needed to make SDOH-related codes effective. The Gravity Project will begin by helping to ensure codes are available to document clinical activities around SDOH and standardize their use in ways that maximize interoperability. Once more comprehensive codes are available, stakeholders can turn to designing incentives and creating educational programs to ensure they are put into practice.

Standardizing the Identification of Social Risks
While initial efforts to address the impact of SDOH on health outcomes are already delivering positive results, the existing coding system does not do enough to enable more comprehensive initiatives that target the social health of underserved populations.

A data definition approach to standardize the identification of social risks is imperative to do the following:

• ensure that an individual’s specific circumstances are understood by care providers;

• facilitate effective communication between medical and social care providers; and

• track and share outcomes of interventions across systems.

As the last decade of experience with EHRs has shown, it isn’t meaningful to simply capture data. The data need to be easily understood and shareable if they are to have value.

Developing social data definitions can establish the bridge between traditional clinical systems and social care provider organizations. With standardization, we can ensure that all organizations involved in addressing an individual’s medical and social needs speak the same language in order to efficiently connect services.

Establishing Greater Collaboration
The Alliance for Better Health uses data to bridge the gaps that exist between traditional clinical systems and the networks of social care providers to facilitate better care among individuals with social barriers in the Capital Region of New York. Today, our work is based on building these collaborative networks from the ground up.

With the output from the Gravity Project, the alliance will be better positioned to create measurable value from the data it collects through these interactions.

Medical providers will be able to enter these codes into EHRs in the context of their normal clinical workflows and easily send them to the appropriate social care providers in a familiar, readable format. At the same time, social care providers will be able to report back on the social services provided, closing the loop on the original referral.

Standardized, interoperable data will provide a foundation for comparing services delivered and enable the use of analytics to improve care management. As more data are gathered, the analytics will help medical providers do a better job of pointing patients to the specific social care providers that can best address their issues, helping drive better health outcomes.

No More Alligators
The axiom is correct: It really is difficult to drain the swamp when your most pressing problem is fending off the alligators. By improving the standardization, specificity, interoperability, and measurability of SDOH-related codes, however, the Gravity Project will help clear the way to deliver a better, more effective health care experience for all.

— Lori Petersen is a senior IT business analyst for Alliance for Better Health, which engages medical and social service providers in developing innovative solutions to promote the health of people and communities, with a goal of transforming the care delivery system into one that incentivizes health and prevention. The alliance partners with more than 2,000 providers and organizations across a six-county area in New York’s Tech Valley and Capital Region. She can be reached at Lori.Petersen@abhealth.us.