Physician awareness of social determinants of health documentation capability in the electronic health record
Open accessAbstract
Healthcare organizations are increasing social determinants of health (SDH) screening and documentation in the electronic health record (EHR). Physicians may use SDH data for medical decision-making and to provide referrals to social care resources. Physicians must be aware of these data to use them, however, and little is known about physicians' awareness of EHR-based SDH documentation or documentation capabilities. We therefore leveraged national physician survey data to measure level of awareness and variation by physician, practice, and EHR characteristics to inform practice- and policy-based efforts to drive medical-social care integration. We identify higher levels of social needs documentation awareness among physicians practicing in community health centers, those participating in payment models with social care initiatives, and those aware of other advanced EHR functionalities. Findings indicate that there are opportunities to improve physician education and training around new EHR-based SDH functionalities.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Those who care for vulnerable populations or routinely use social care services are more likely to engage with EHR determinants data.
“those who care for vulnerable populations or routinely use social care services are more likely to engage with EHR determinants data [34].”
From The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation (2024) · cites this paper as [34]
The Results report greater awareness of EHR social-determinants documentation capability among physicians at community health centers, and the Discussion says physicians frequently involved in screening and social care may be more aware. The paper measures awareness, however, not whether these physicians are more likely to engage with or use EHR determinants data; it also presents the link to frequent social care work as a possibility. (LLM, conf=0.88)
Experimental — accuracy not yet measuredClinicians may not be aware of structured SDH documentation tools, and prior work has shown that free-text notes were more commonly used for SDH documentation.
“Alternatively, clinicians may not be aware of structured SDH documentation tools, 18 and prior work has shown that free-text notes were more commonly used for SDH documentation. 5”
From Structured and unstructured social risk factor documentation in the electronic health record underestimates patients’ self-reported risks (2024) · cites this paper as [18]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid
Alley, D. E., Asomugha, C. N., Conway, P. H., & Sanghavi, D. M. (2016) · New England Journal of Medicine · doi:10.1056/nejmp1512532 · Cited by 606 · see citing works
Electronic health record adoption in US hospitals: the emergence of a digital “advanced use” divide
Adler-Milstein, J., Holmgren, A. J., Kralovec, P., Worzala, C., Searcy, T., & Patel, V. (2017) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocx080 · Cited by 392 · see citing works
Self-citationPatients in context--EHR capture of social and behavioral determinants of health
Adler, N. E., & Stead, W. W. (2015) · New England Journal of Medicine · doi:10.1056/nejmp1413945 · Cited by 317 · see citing works
Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2
Domains, B. (2015) · Cited by 299 · see citing works
Adoption of Social Determinants of Health EHR Tools by Community Health Centers
Gold, R., Bunce, A., Cowburn, S., Dambrun, K., Dearing, M., Middendorf, M., Mossman, N., Hollombe, C., Mahr, P., Melgar, G., et al. (2018) · The Annals of Family Medicine · doi:10.1370/afm.2275 · Cited by 252 · see citing works
Self-citationSchickedanz, A. B., Hamity, C., Rogers, A., Sharp, A. L., & Jackson, A. H. (2019) · Medical Care · doi:10.1097/mlr.0000000000001051 · Cited by 225 · see citing works
Influence of Patients' Socioeconomic Status on Clinical Management Decisions: A Qualitative Study
Bernheim, S. M., Ross, J. S., Krumholz, H. M., & Bradley, E. H. (2008) · The Annals of Family Medicine · doi:10.1370/afm.749 · Cited by 212 · see citing works
Moving Electronic Medical Records Upstream
Gottlieb, L. M., Tirozzi, K. J., Manchanda, R., Burns, A. R., & Sandel, M. T. (2015) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2014.07.009 · Cited by 178 · see citing works
Self-citationAdler‐Milstein, J., DesRoches, C. M., Furukawa, M. F., Worzala, C., Charles, D., Kralovec, P. D., Stalley, S., & Jha, A. K. (2014) · Health Affairs · doi:10.1377/hlthaff.2014.0453 · Cited by 173 · see citing works
Self-citationGottlieb, L. M., Fichtenberg, C., Alderwick, H., & Adler, N. E. (2019) · Journal of Healthcare Management · doi:10.1097/jhm-d-18-00160 · Cited by 156 · see citing works
Self-citationSocial Determinants of Health in Managed Care Payment Formulas
Ash, A. S., Mick, E. O., Ellis, R. P., Kiefe, C. I., Allison, J. J., & Clark, M. A. (2017) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2017.3317 · Cited by 137 · see citing works
Meddings, J. A., Reichert, H., Smith, S. N., Iwashyna, T. J., Langa, K. M., Hofer, T. P., & McMahon, L. F. (2016) · Journal of General Internal Medicine · doi:10.1007/s11606-016-3869-x · Cited by 136 · see citing works
Electronic health records in small physician practices: availability, use, and perceived benefits
Rao, S. R., DesRoches, C. M., Donelan, K., Campbell, E. G., Miralles, P. D., & Jha, A. K. (2011) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2010-000010 · Cited by 133 · see citing works
Capturing Social and Behavioral Domains in Electronic Health Records: Phase 1
Domains, B. (2014) · Cited by 128 · see citing works
Cottrell, E. K., Dambrun, K., Cowburn, S., Mossman, N., Bunce, A. E., Marino, M., Krancari, M., & Gold, R. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.014 · Cited by 111 · see citing works
EHRs in primary care practices: benefits, challenges, and successful strategies.
Goldberg, D. G., Kuzel, A. J., Feng, L. B., DeShazo, J. P., & Love, L. E. (2012) · PubMed · Cited by 110 · see citing works
Addressing the Social Determinants of Health Within the Patient-Centered Medical Home
Garg, A., Jack, B. W., & ZUCKERMAN, B. S. (2013) · JAMA · doi:10.1001/jama.2013.1471 · Cited by 102 · see citing works
Improving Social Needs Intervention Research: Key Questions for Advancing the Field
Fichtenberg, C., Alley, D. E., & Mistry, K. B. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.018 · Cited by 98 · see citing works
University of California, S. F., Adler, N. E., Cutler, D. M., Harvard University, Fielding, J. E., University of California, L. A., Galea, S., Boston University, Glymour, M. M., University of California, S. F., et al. (2016) · NAM Perspectives · doi:10.31478/201609t · Cited by 96 · see citing works
Association of Social Determinants With Children’s Hospitals’ Preventable Readmissions Performance
Sills, M. R., Hall, M., Colvin, J. D., Macy, M. L., Cutler, G. J., Bettenhausen, J. L., Morse, R. B., Auger, K. A., Raphael, J. L., Gottlieb, L. M., et al. (2016) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/jamapediatrics.2015.4440 · Cited by 93 · see citing works
Self-citationCartier, Y., Fichtenberg, C., & Gottlieb, L. M. (2020) · Health Affairs · doi:10.1377/hlthaff.2019.01588 · Cited by 89 · see citing works
Self-citationAddressing Social Determinants of Health: Challenges and Opportunities in a Value-Based Model
Garg, A., Homer, C., & Dworkin, P. H. (2019) · Pediatrics · doi:10.1542/peds.2018-2355 · Cited by 75 · see citing works
Gruß, I., Bunce, A., Davis, J. V., Dambrun, K., Cottrell, E., & Gold, R. B. (2020) · Population Health Management · doi:10.1089/pop.2019.0205 · Cited by 71 · see citing works
Differing faculty and housestaff acceptance of an electronic health record
Hier, D. B., Rothschild, A. S., LeMaistre, A., & Keeler, J. (2005) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2005.03.006 · Cited by 67 · see citing works
Khullar, D., Schpero, W. L., Bond, A. M., Qian, Y., & Casalino, L. P. (2020) · JAMA · doi:10.1001/jama.2020.13129 · Cited by 66 · see citing works
Rahal, R. M., Mercer, J. G., Kuziemsky, C. E., & Yaya, S. (2021) · BMC Medical Informatics and Decision Making · doi:10.1186/s12911-021-01434-9 · Cited by 61 · see citing works
Adopting electronic medical records: are they just electronic paper records?
Price, M., Singer, A. G., & Kim, J. (2013) · Europe PMC (PubMed Central) · Cited by 60 · see citing works
Linking Performance With Payment
VanLare, J. M., Blum, J. D., & Conway, P. H. (2012) · JAMA · doi:10.1001/jama.2012.14834 · Cited by 56 · see citing works
Browne, J., McCurley, J. L., Fung, V., Levy, D. E., Clark, C. R., & Thorndike, A. N. (2021) · Journal of Primary Care & Community Health · doi:10.1177/2150132721993651 · Cited by 41 · see citing works
Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes
Moffett, M. L., Kaufman, A., & Bazemore, A. (2017) · Journal of Community Health · doi:10.1007/s10900-017-0403-y · Cited by 36 · see citing works
Menachemi, N., Powers, T. L., & Brooks, R. G. (2011) · Journal of Healthcare Management · doi:10.1097/00115514-201105000-00007 · Cited by 34 · see citing works
Pantell, M. S., Adler‐Milstein, J., Wang, M. D., Prather, A. A., Adler, N. E., & Gottlieb, L. M. (2020) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaa175 · Cited by 33 · see citing works
Self-citationInformatics to support the IOM social and behavioral domains and measures
Hripcsak, G. M., Forrest, C. B., Brennan, P. F., & Stead, W. W. (2015) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocv035 · Cited by 32 · see citing works
Ceiling effect in EMR system assimilation: a multiple case study in primary care family practices
Trudel, M.-C., Marsan, J., Paré, G., Raymond, L., de Guinea, A. O., Maillet, É., & Micheneau, T. (2017) · BMC Medical Informatics and Decision Making · doi:10.1186/s12911-017-0445-1 · Cited by 31 · see citing works
Byrd, J. N., & Chung, K. C. (2021) · JAMA Surgery · doi:10.1001/jamasurg.2021.3746 · Cited by 28 · see citing works
Martin, R. (2004) · Primary Health Care Research & Development · doi:10.1191/1463423604pc222oa · Cited by 21 · see citing works
Otto, P., & Nevo, D. (2013) · Journal of Enterprise Information Management · doi:10.1108/17410391311289613 · Cited by 18 · see citing works
Randhawa, G. K., Shachak, A., Courtney, K. L., & Kushniruk, A. W. (2019) · BMJ Health & Care Informatics · doi:10.1136/bmjhci-2019-100086 · Cited by 14 · see citing works
Assessing and Addressing Social Needs in Primary Care
Drake, C., & Eisenson, H. (2019) · NEJM Catalyst · Cited by 12 · see citing works
Hong, Y., Turner, K. L., Nguyen, O. T., Tabriz, A. A., & Revere, L. (2021) · Population Health Management · doi:10.1089/pop.2021.0212 · Cited by 7 · see citing works
Plescia, M., & Dulin, M. (2017) · North Carolina Medical Journal · doi:10.18043/ncm.78.4.238 · Cited by 4 · see citing works
Yorkery, B. (2017) · North Carolina Medical Journal · doi:10.18043/ncm.78.4.242 · Cited by 3 · see citing works
Fields, R. (2017) · North Carolina Medical Journal · doi:10.18043/ncm.78.4.245 · Cited by 3 · see citing works
Flagged first, then by citations
Research works printed but not linked: 5
- [1]1. Muhlestein D, Saunders RS, Richards R, et al. Recent progress in the value journey: growth of ACOs and value-based payment models in 2018 j Health affairs. Heatlh Aff Blog 2018. https://www.healthaffairs.org/do/ 10.1377/hblog20180810.481968/full/. Accessed November 28, 2021. · DOI
- [13]13. National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health . Washington, DC: The National Academies Press; 2020.
- [38]38. MIPS and the Social Determinants of Health. 2020. https://www.healthaffairs.org/do/10.1377/he20201013.694857/full/Practice\_of\_Medicine\_ 2020\_slides.pdf. Accessed January 16, 2022. · DOI
- [54]54. Olson D, Oldfield B, Morales Navarro S. Standardizing social determinants of health assessments j Health affairs blog. Health Aff Blog . https:// www-healthaffairs-org.proxy.lib.umich.edu/do/10.1377/hblog20190311. 823116/full/. Accessed April 27, 2021. · DOI
- [60]60. Callegaro M. Social desirability. In: Lavrakas P, ed. Encyclopedia of Survey Research Methods . Thousand Oaks, CA: Sage Publications, Inc.; 2008.
Cited by
Sorted by citations
Insights into the Social Determinants of Health in Older Adults
Perez, F. P., Perez, C. A., & Chumbiauca, M. N. (2022) · Journal of Biomedical Science and Engineering · doi:10.4236/jbise.2022.1511023 · Cited by 84 · see citing works
“These records will allow providers to use the collected data for the integrated health care plan to make medical decision and referrals to social care services [40].”
BackgroundDesRoches, C. M., Wachenheim, D., Garcia, A., Harcourt, K., Henry, J. L., Shah, R., & Patel, V. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.44376 · Cited by 19 · see citing works
Iott, B. E., Rivas, S., Gottlieb, L. M., Adler-Milstein, J., & Pantell, M. S. (2024) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocad261 · Cited by 17 · see citing works
Self-citationYelton, B., Rumthao, J. R., Sakhuja, M., Macauda, M. M., Donelle, L., Arent, M. A., Yang, X., Li, X., Noblet, S. B., & Friedman, D. B. (2023) · JMIR Formative Research · doi:10.2196/47461 · Cited by 16 · see citing works
Hartzler, A. L., Xie, S. J., Wedgeworth, P., Spice, C., Lybarger, K., Wood, B. R., Duber, H. C., Hsieh, G., Singh, A., SDoH Community Champion Advisory Board, et al. (2023) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocad043 · Cited by 15 · see citing works
Iott, B. E., Adler-Milstein, J., Gottlieb, L. M., & Pantell, M. S. (2023) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocac251 · Cited by 13 · see citing works
Self-citationPhysician Documentation of Social Determinants of Health: Results from Two National Surveys
Iott, B. E., Patel, V., & Richwine, C. (2024) · Journal of General Internal Medicine · doi:10.1007/s11606-024-09184-w · Cited by 9 · see citing works
Self-citationManaging childhood asthma with an eye toward environmental, social, and behavioral features
Skeen, E. H., Hamlington, K. L., Keyser, H. H. D., Liu, A. H., & Szefler, S. J. (2025) · Annals of Allergy Asthma & Immunology · doi:10.1016/j.anai.2025.02.013 · Cited by 8 · see citing works
Sood, N., Stetter, C., Kunselman, A., & Jasani, S. (2024) · PLOS Digital Health · doi:10.1371/journal.pdig.0000428 · Cited by 6 · see citing works
Bias due to re-used databases: Coding in hospital for extremely vulnerable patients
Milcent, C. (2024) · Health Policy and Technology · doi:10.1016/j.hlpt.2024.100851 · Cited by 5 · see citing works
Linfield, G. H., Patel, S., Ko, H., Lacar, B., Gottlieb, L. M., Adler-Milstein, J., Singh, N. V., Pantell, M. S., & Marchis, E. D. D. (2023) · Health Informatics Journal · doi:10.1177/14604582231200300 · Cited by 4 · see citing works
Self-citationClinician Awareness of Patient-Reported Health-Related Social Needs: There’s Room for Improvement
Nederveld, A., Bertin, K. B., Dickinson, L. M., Beall, S., Nelson, J., Glasgow, R. E., & Huebschmann, A. G. (2024) · Journal of Primary Care & Community Health · doi:10.1177/21501319241290887 · Cited by 3 · see citing works
“Understanding whether clinicians are aware of patient-reported needs might help indicate areas for improvement in HRSN screening and referral workflows or clinician-focused interventions around adjusting care based on HRSNs.”
BackgroundInfluentialGomez, M. L., Clayton, E. W., Walsh, C. G., & Unertl, K. M. (2025) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaf220 · Cited by 1 · see citing works
“72 Documenting SDOH data carries significant risk, particularly for trafficked individuals or abused patients.”
Henry, S. B. (2025) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaf020 · Cited by 1 · see citing works
Social Determinants of Health Data for Health Analytics
Boland, M. R. (2024) · Springer eBooks · doi:10.1007/978-3-031-74383-2_13
Bunce, A., Morrissey, S. E., Gold, R. B., Donovan, J., Pisciotta, M., Gill, I. J., Watkins, S. L., McGrath, R., & Gottlieb, L. M. (2025) · SSM - Qualitative Research in Health · doi:10.1016/j.ssmqr.2025.100544 · Cited by 1 · see citing works
Self-citationRetos de la Documentación en Salud desde la Perspectiva Bibliotecológica
Chávez-Martínez, O. (2025) · Biblioteca Universitaria · doi:10.22201/dgbsdi.0187750xp.2025.1.1582
The Intersection of Social Determinants of Health and Informatics
Galloway, A., Schenker, M. L., Wu, D., & Adhyaru, B. B. (2025) · Medical Clinics of North America · doi:10.1016/j.mcna.2025.07.008
Khan, S. A., Khan, M. A., Lynch, I., Khan, N., Khan, S. E., Zafar, F., Ventura-Gabarró, C., Westwood, E., Kalbarczyk, A., Morgan, R., et al. (2026) · Health Policy and Planning · doi:10.1093/heapol/czag029
Klee, E. (2026) · International Journal of Health Sciences · doi:10.53730/ijhs.v10n1.15914
Social Drivers of Health in the Electronic Health Record
Iott, B. E., Pantell, M. S., & Adler‐Milstein, J. (2026) · Annual Review of Biomedical Data Science · doi:10.1146/annurev-biodatasci-092724-023921
Self-citationUnder‐documentation of social determinants of health in kidney stone patients in high‐risk region
Mihalo, J. R., Walters, M., Walters, T., Alrayyes, N., Mitchell, K., Morley, C., McClelland, D., Washington, S. L., Bayne, D., & Semins, M. J. (2026) · UroPrecision · doi:10.1002/uro2.70082
- Authors
- Iott, B. E., Pantell, M. S., Adler-Milstein, J., & Gottlieb, L. M.
- Affiliations
- University of California, San Francisco (US)
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF) , San Francisco, California, USA
- Corresponding author
- Iott, Bradley E
- Venue
- Journal of the American Medical Informatics Association
- Publisher
- Oxford University Press (OUP)
- Published
- 2022-09-07
- Volume
- 29
- Issue
- 12
- Pages
- 2110-2116
- ISSN
- 1067-5027 (ISSN-L)
- 1527-974X
- PMC
- PMC9667172
- OpenAlex
- W4294916236
- Cited by
- 22
- References
- 44
- Citations by year
- 2026: 4 · 2025: 6 · 2024: 7 · 2023: 3 · 2022: 2
- FWCI
- 3.37
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- Journal of the American Medical Informatics Association (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Keywords
- social determinants of health, electronic health records, physician awareness, social care integration, community health centers, payment models, physician training
- MeSH terms
- Community Health Centers, Documentation, Humans, Physicians, Electronic Health Records, Social Determinants of Health
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
