Fall 2024 Issue

Industry Perspectives: A Path Forward
By Janet Campbell
For The Record
Vol. 36 No. 4 P. 28

Recommendations for Standardizing Social Determinants Capture

When it comes to evaluating a patient’s risk within social drivers of health (SDOH) domains, the health care industry continues to struggle with a lack of uniformity in its prioritization and definition. It’s a barrier that inhibits interoperability and often leads to overlapping domains, hampering the full and effective use of this critical data.

To address this growing problem, the EHR Association SDOH and Health Equity Task Force recently released Recommendations for Determinant Capture as a path forward for EHR developers and the health care industry to maximize this data’s impact.1 In particular, the recommendations should enable EHR developers, providers, and other stakeholders to respond more effectively to evolving policies governing SDOH reporting and use.

An Interoperability-Inhibiting Landscape
Health and Human Services defines SDOH as environmental conditions influencing a person’s health, functioning, and quality of life.2 These situational determinants are categorized into risk areas or domains such as nutrition insecurity, food insecurity, or housing insecurity.

To determine a patient’s domain-level risk, social care or health care professionals conduct assessments either conversationally or with standard screening questionnaires or validated testing instruments. However, while it’s generally accepted that addressing domain risks must start with that assessment, there’s no real consensus on which specific domains should be assessed; even the manner of assessment varies based on setting and user.

Consider the following:

• Healthy People 2030 lists five broad domains of risk.
• The Future of Nursing 2020–2030 lists 11 domains of risk.3
• The Gravity Project lists 20 Social Risk Terminology Value Sets.4
• CMS’s Quality ID #487: Screening for Social Drivers of Health, requires screening of five domains.5

This lack of uniformity reflects the absence of a consistent, universally agreed-upon, and prioritized list of domains for assessment. The result is often overlapping domains that complicate the exchange and interpretation of this data.

Effective data exchange to inform interactions at the point of care is inhibited by the absence of clear guidelines for risk assessment and standardized representation of risks in EHRs. When data is transferred from one EHR to another, the receiving system may not be able to interpret it in a way that is helpful to the user. Without a clear, standardized way to represent risk, there is no path to aggregate data across multiple systems to gain insights into social risks at a broader geographical or environmental scale.

This complexity is exacerbated by regulatory agencies that are not operating in sync and by the growing proliferation of terminology. Thus, to effectively respond to evolving policymaking, the industry must do the following:

• align on a standardized approach for representing risk; and
• agree on which risks to prioritize for collection and analysis.

An Effective Approach for Standardization
To address this growing issue, the EHR Association Task Force developed four recommendations for standardizing determinant capture:

1. EHRs should standardize how they represent domain risk. EHR developers, in deep collaboration with users, are best positioned to determine how risk should be captured in users’ workflows to meet specific user and patient needs. As such, the task force does not prescribe a uniform workflow for member companies, nor does it endorse specific screeners. However, at a minimum, an EHR should be able to indicate whether a patient was assessed for a domain risk, whether that risk is present, and the method of assessment used.

For example, a user might evaluate risk through informal methods such as a conversation or a paper form, subsequently coding the identified risk using Z codes. Similarly, a patient’s existing problem or visit diagnosis may indicate an elevated domain-level risk. For example, if the patient’s problem list includes a code related to depression, a screener question for depression is not necessary.

The EHR can indicate if housing insecurity was evaluated, if the patient is at risk of housing insecurity, and if standard tools like PRAPARE or the Housing Vital Sign are utilized. While an EHR developer has the option to incorporate multiple approaches to offer a broader range of workflow choices to its users, doing so is not mandatory.

2. The standards industry should determine how domain risk is represented in data exchange. With a unified approach to risk representation, the standards industry is tasked with establishing how these elements are communicated. The representation of a social risk domain might contain the following:

• the domain: represented by a standard code (eg, housing insecurity);

• risk presence or absence: clearly indicating whether a risk was identified; and

• optional screener identifier: corresponding to the instrument or question used for risk assessment.

This structured representation simplifies the process for EHRs transmitting data to other systems by focusing on the essential elements of a risk assessment. Receiving EHRs can easily determine and represent whether social risk exists across assessed domains. Furthermore, if additional rigor in risk assessment is required, receiving organizations can opt to disregard assessments not conducted with standardized instruments.

While a more detailed representation of risk factors would be valuable, simply knowing that the patient has challenges in obtaining a stable housing situation is sufficient for clinicians and social workers to provide more informed care. An indication of the presence or absence of risk, as determined by the last caregiver, would represent a significant advancement over current practices in information exchange.

3. The health care community should list and prioritize which domains should be assessed. The EHR Association recognizes the work of the HL7 Gravity Project in establishing a comprehensive list of standardized domains.4 It endorses this list as a foundational guide for health care organizations and regulatory agencies in determining essential domains for regular assessment. If the industry determines new domains should be assessed, it urges collaboration with the Gravity Project for inclusion in its master list.

While the importance of thorough screening across various domains is recognized, the association also advises restraint. Mandating extensive screening for every organization could place an excessive burden on clinicians, particularly in settings where resources like case workers and social workers are limited. Organizations must also have the flexibility to assess the domains most relevant to their patient population and treatment capabilities. Therefore, we strongly recommend that regulators limit the number of mandatory assessment domains. We further recommend that health care delivery organizations support this parsimonious approach to reduce the regulatory burden on their users.

Finally, in keeping with the 2023 inpatient prospective payment system rule recommending the assessment of food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety, EHRs should be equipped to support the documentation of the corresponding Gravity Project domains.

4. Risk assessment methods should remain flexible for now. Because there’s no one-size-fits-all approach to assessing social risk, a flexible approach is needed. Different organizations and their EHR systems vary in their preferred risk assessment methods. Although standardized instruments for assessing risk can offer more reliability, mandating their exclusive use in EHRs is not advisable as it could inadvertently limit the flexibility necessary to meet users’ diverse needs and capabilities.

Therefore, it’s critical for now to avoid regulation that prescribes the use of specific screeners and assessments. Flexibility accommodates a gradual transition toward more widespread adoption of standardized screeners, in sync with the industry’s evolution and readiness to adopt these tools.

Assessing the Validity of Recommendations
To help ensure the validity of its recommendations, the EHR Association task force developed four criteria against which to assess their effectiveness:

1. Feasibility across EHR systems: Proposed solutions must be feasible for implementation by all EHR users, regardless of size or system type. Solutions that impose excessive costs or burdens are less likely to be adopted and would therefore not be effective.

2. Adaptability to diverse health care settings: The spectrum of health care delivery organizations is broad, with organizations operating in both rural and urban environments using varying economic models. Most also are struggling to regain their economic footing after the COVID-19 pandemic. Technology must be scalable to suit the diverse needs, capacities, and time constraints of their users.

3. Interoperability for social risk data: An effective approach must facilitate the sharing and exchange of social risk data. Information captured in one system should be seamlessly exchangeable with another, enhancing value at the point of care.

4. Support for research and data utilization: A robust solution should enable the use of social determinant risk data for research purposes. It’s essential that data gathered across multiple systems can be combined and aggregated for higher-level analysis to aid researchers, social scientists, and public health professionals in understanding the broader scope of social risk within communities.

These criteria enabled the EHR Association to determine that its recommendations provide a reasonable and effective path forward for EHR developers and the health care industry. For example, the proposed flexibility in risk assessment methods is feasible across EHR systems because it imposes the lowest technical implementation burden for all EHR developers.

The adaptability criterion is met because EHR developers are free to design solutions that can scale to meet their target users, regardless of their sophistication and familiarity with assessing social risk. Regarding interoperability, the recommendations, coupled with the development of accompanying standards, support the exchange of usable information on broad areas of social risk. Care settings that require a more rigorous assessment of risk can understand how risk was assessed at the originating organization and accept or reevaluate it accordingly.

Finally, while not as reliable as more granular risk assessment data, the recommendations support aggregation at the population level to better identify and understand at-risk populations. Thus, they support research and data utilization.

Moving Forward
As the industry matures, new domains or more prescriptive guidance around screeners should be carefully considered. Any such expansion must be backed by a comprehensive understanding of how to implement these changes effectively, without increasing clinician burden.

— Janet Campbell is chair of the Social Determinants of Health and Health Equity Task Force of the EHR Association (EHRA.org).

 

References
1. EHR Association. Recommendations for Determinants Capture. https://www.ehra.org/sites/ehra.org/files/EHR%20Association%20Recommendations%20for%20Determinant%20Capture%20April%202024_0.pdf. Published April 2024.

2. Social determinants of health. U.S. Department of Health and Human Services website. https://health.gov/healthypeople/priority-areas/social-determinants-health

3. Social Determinants of Health and Health Equity. In: National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al, eds. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, D.C.: National Academies Press (US); May 11, 2021. https://www.ncbi.nlm.nih.gov/books/NBK573923/

4. Gravity Project. Social risk terminology value sets. HL7 Confluence website. https://confluence.hl7.org/display/GRAV/Social+Risk+Terminology+Value+Sets. Published July 18, 2024.

5. Centers for Medicare and Medicaid Services. 2023 MIPS Clinical Quality Measures. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2023_Measure_487_MIPSCQM.pdf. Published November 2022.