The DOI matches its Crossref record; 55 of the 55 references it cites were found in a registry or an index; none of the 25 sources its claims cite is checked for support yet.
Adoption of Social Determinants of Health EHR Tools by Community Health Centers
Open accessAbstract
PURPOSE: This pilot study assessed the feasibility of implementing electronic health record (EHR) tools for collecting, reviewing, and acting on patient-reported social determinants of health (SDH) data in community health centers (CHCs). We believe it is the first such US study. METHODS: We implemented a suite of SDH data tools in 3 Pacific Northwest CHCs in June 2016, and used mixed methods to assess their adoption through July 2017. We modified the tools at clinic request; for example, we added questions that ask if the patient wanted assistance with SDH needs. RESULTS: Social determinants of health data were collected on 1,130 patients during the study period; 97% to 99% of screened patients (n = 1,098) had ≥1 SDH need documented in the EHR, of whom 211 (19%) had an EHR-documented SDH referral. Only 15% to 21% of patients with a documented SDH need indicated wanting help. Examples of lessons learned on adoption of EHR SDH tools indicate that clinics should: consider how to best integrate tools into existing workflow processes; ensure that staff tasked with SDH efforts receive adequate tool training and access; and consider that timing of data entry impacts how and when SDH data can be used. CONCLUSIONS: Our results indicate that adoption of systematic EHR-based SDH documentation may be feasible, but substantial barriers to adoption exist. Lessons from this study may inform primary care providers seeking to implement SDH-related efforts, and related health policies. Far more research is needed to address implementation barriers related to SDH documentation in EHRs.
Overview
AI snapshot
Written from the paper’s full text.
TL;DR
This pilot implemented EHR tools for collecting, reviewing, and acting on patient-reported social determinants of health (SDH) data in 3 Pacific Northwest community health centers. It found systematic EHR-based SDH documentation feasible but identified substantial adoption barriers, with high positive screening rates but low referral and patient-requested-help rates.
Key findings
- SDH data were collected on 1,130 patients, representing 4% to 18% of adult patients with an ambulatory visit at the pilot clinics; 97% to 99% of screened patients had ≥1 SDH need documented, and 211 (19%) had an EHR-documented SDH referral.
- After questions about wanting help were added, 15% of Clinic A patients and 21 of Clinic B patients with a documented SDH need requested help.
- Facilitators included a trusted, EHR-savvy clinic champion, ability to customize EHR views, and reporting requirements; barriers included fragmented patient data, added workflow difficulty, paper-based data entry, time-consuming referrals, and unmanageable follow-up workload before desire-for-help questions were added.
- The clinics successfully documented SDH in the EHR and continued post-study, but referral documentation was especially challenging.
Methods
- Concurrent mixed-methods pilot at 3 OCHIN member community health centers in the Pacific Northwest; Epic-based SDH tools built on PRAPARE were deployed in June 2016 and assessed through July 2017, extended from 12 to 13 months.
- Quantitative EHR data described adult patients with documented SDH data or ≥1 ambulatory visit, including demographics, SDH needs, referrals, and problem list diagnoses.
- Qualitative data included 6 days of workflow observation, 24 interviews with care team members, and observations of clinic decision-maker discussions; analysis used deductive and inductive coding and the constant comparative method.
Limitations
- The paper states it could not calculate SDH screening documentation rates among targeted patients because target populations changed, change dates were unclear, and target criteria were not easily extracted from the EHR; screened vs unscreened differences therefore cannot be interpreted as related to EHR-based SDH screening.
- The paper states screened-patient counts may be low and SDH need prevalence may be higher than in the overall population because some paper surveys were likely not entered into the EHR; referral rates are likely underestimated because referrals were often documented in chart notes rather than discrete fields.
- The paper states it could not assess changes in SDH status, care quality, or biomarkers; could not quantify how often the SDH summary was accessed or by whom; the SDH screening measures have not been validated as predictive of specific outcomes; and the single EHR system limits transferability. Evident from the text: this was a small 3-clinic pilot with clinic-selected pragmatic target groups and no control or comparison group.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Verification
Claims the paper makes
0 of 25 cited sources checked · 0 supported · 0 flagged
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“(2) could add a layer of difficulty to collecting and acting on SDH data; (eg, due to lack of staff EHR expertise, the tools' customized nature, differences in EHR security access by staff role, and the need for new EHR competencies from some staff)”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Only 15% to 21% of patients with a documented SDH need indicated wanting help.”
- Also stated in: § SDH Screening Documentation and Referrals · plain
“15% of Clinic A patients and 21% of Clinic B patients with a documented need requested help.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Abstract
Strength:plain· not yet calibratedn = 182Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes- Also stated in: § SDH Screening Documentation and Referrals · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“97% to 99% of screened patients (n = 1,098) had ≥1 SDH need documented in the EHR”
- Also stated in: § SDH Screening Documentation and Referrals · hedged
“Most screened patients (97% to 99%) indicated a potential SDH need in ≥1 SDH domain”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Abstract
Strength:plain· not yet calibratedn = 1,098Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes- Also stated in: § SDH Screening Documentation and Referrals · hedged
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Referral documentation proved especially challenging.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesThe paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“(3) sought to minimize the primary care provider's role in SDH documentation, and in making SDH-related referrals.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“All 3 clinics: (1) adapted their workflows as needed”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“(3) necessitated a data entry step if SDH information were collected on paper.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesThe paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Making it known that SDH data might address reporting requirements increased staff motivation.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Strength:hedged· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“until questions asking whether patients desired follow-up for SDH needs were added, the high positive screening rate yielded an unmanageable follow-up workload”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Referral workflows varied by clinic, differentially impacting our ability to determine SDH domains associated with referrals.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- It may state two separate claims as one. 26
- Probably not a substantial claim. 23
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Like most CHCs, the study clinics' patient populations are primarily publicly insured or uninsured and aged <65 years; 10% to 31% are non-white and 10% to 30% are of Hispanic ethnicity (Table 2).”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Setting
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Despite the many identified challenges to adopting all of the SDH data tools, the study clinics did successfully document SDH in the EHR, and continued to do so post-study.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Clinics B and C routed most SDH referrals to community health workers or similar staff; these internal referrals generally lacked the information required to match them to a specific SDH need.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“B 379 367 (96.8) 26 (6.8)”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedn = 379Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“A 602 583 (96.8) 141 (23.4)”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedn = 602Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“C 149 148 (99.3) 44 (29.5)”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedn = 149Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Facilitators to using EHR tools to document SDH included a clinic champion who was trusted, EHR-savvy, able to customize EHR views to support workflows, and willing to use adoption data to iterate workflows.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Clinic A first tested their workflows with a few randomly chosen patients per day, then added all new patients plus those completing annual insurance reauthorizations, and eventually added patients receiving care coordination, HIV services, and behavioral health services.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Clinic B began with patients in their diabetes and Hepatitis C case management programs, then added patients aged 65 years and older.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Key barriers included perceptions that EHR-based SDH data tools: (1) created a fragmented view of the patient, with relevant data in multiple places, and did not readily support documenting a narrative about a given patient”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > SDH Screening Documentation and Referrals
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Consider that the completed paper form does not reveal how a patient scored on the SDH domains; this scoring is not easily identifiable until the data are in the EHR.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Social determinants of health data were collected on 1,130 patients during the study period”
- Also stated in: § SDH Screening Documentation and Referrals · plain
“Social determinants of health data were collected on 1,130 patients, representing 4% to 18% of adult patients with an ambulatory visit at the pilot clinics during the study period (Table 2 and Table 3).”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Abstract
Strength:plain· not yet calibratedn = 1,130Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
- Also stated in: § SDH Screening Documentation and Referrals · plain
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Consider using text shortcut tools to document provision of community resource materials or referrals provided by SDH topic (this does not provide agency details, but is a fast and easy way to document SDH referrals).”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:hedged· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“(2) principally used the paper-based SDH screening questionnaire, necessitating a data entry workflow step that impacted when the data were available in the EHR”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Each clinic first screened a limited population of patients, then scaled up.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Implementation
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“This pilot study is the first to formally test adoption of EHR-based SDH data documentation, review, and action in CHCs, and is one of the first in any clinical setting.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > CONCLUSION
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✗ Based: failsProbably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
None of the sources cited for this claim could be matched to a paper in Crossref, so there is nothing to check it against.
In the paper
“While some aspects of the tools were not widely adopted, this is common to such efforts [58][59][60][61] ; adoption of new EHR tools can take time.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
What the sources say
- Not matchedcites [58]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Not matchedcites [59]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Not matchedcites [60]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“however, for the benefits of systematic EHR-based SDH documentation to be realized, barriers to adoption of EHR tools must be addressed.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > CONCLUSION
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence.
In the paper
“SDH documentation, review, and referral-making in EHRs can be feasible and useful, but is challenging to adopt.63”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
What the sources say
- Not matchedcites [63]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Some barriers to SDH screening are likely to occur regardless of the technology used, for example, staff concerns about SDH screening when little intervention is possible.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Analysis followed the constant comparative method 46 ; new data were compared with previously collected/coded data to detect commonalities/differences, and to develop nuanced understandings of clinic experiences.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
What the sources say
- Not matchedcites [46]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
- Not matched
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“For example, some clinic counts of patients screened did not match our quantitative data from the EHR; further, we observed that data entry workflows were not always standardized.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Limitations
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Regular study team meetings and discussions with stakeholders informed each step of analysis and results interpretation.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Social determinants of health documentation in EHRs could enable care plan adjustments/referrals to social services, and tracking such referrals' results.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“This study was approved by the Kaiser Permanente Northwest Institutional Review Board.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“We could not calculate rates of SDH screening documentation among targeted patients because the study clinics' target populations changed during the study period, the dates of these changes were unclear, and target criteria were not easily extracted from the EHR.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Limitations
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Quantitative and qualitative data were collected simultaneously.Preliminary results from each informed subsequent data collection (eg, discrepancies between interview descriptions of clinic workflows and corresponding quantitative data were further explored in site visits).”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
Strength:plain· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The systematic EHR documentation and management of SDH needs could impact CHC patients' health, but optimizing such EHR tools and integrating them smoothly into clinic workflows will require addressing substantial knowledge gaps.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > CONCLUSION
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
None of the sources cited for this claim could be matched to a paper in Crossref, so there is nothing to check it against.
In the paper
“Before benefits can be fully realized, the unique challenges of EHR-based SDH documentation and referral-making must be understood and addressed.1,39,48”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
What the sources say
- Not matchedcites [1]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Not matchedcites [39]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Not matchedcites [48]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence.
- Not matched
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Data collection and analysis were iterative and inductive; emergent understanding and questions from preliminary findings were explored.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Therefore, to meet the growing national emphasis on EHR-based SDH documentation and referral, numerous factors must be considered.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Strength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
In the paper
“Our findings are consistent with those of a prior case study on EHR-based SDH documentation.62”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
What the sources say
- Not matchedcites [62]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Final results were compared to validate and confirm analytic interpretations.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Data Collection and Analyses
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our results raise important questions about the feasibility of EHR-based SDH documentation per national recommendations.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > DISCUSSION
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Results may be informative to CHCs and other primary care providers seeking to implement SDH-related efforts, especially if SDH documentation becomes required or associated with financial incentives.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > CONCLUSION
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“It is possible that our count of screened patients may be low, and prevalence of SDH needs among screened patients may be higher than in the clinics' overall population, as some data from paper surveys were likely not entered into EHRs, especially if no SDH needs were identified.”
§ Adoption of Social Determinants of Health EHR Tools by Community Health Centers > Limitations
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The authors state this as an assumption.
The study is the first US study on the collection of SDH data using EHR-based tools in community health centers.
“We believe it is the first such US study.”
“We believe this is the first US study on the collection of SDH data using EHR-based tools in CHCs.”
The paper relies on this without support.
Most health care systems document and track most patient information in EHRs.
“Since most health care systems document and track most patient information in EHRs, SDH data should also be in EHRs.”
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?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“They also do not include measures that reflect whether SDOH data are reviewed after being documented.”
From Documentation and review of social determinants of health data in the EHR: measures and associated insights (2021) · cites this paper as [13]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“These studies reveal the value of measuring different approaches to SDOH documentation in the EHR but do not offer a generalizable set of measures that can be used to compare different EHR-based SDOH documentation options.”
From Documentation and review of social determinants of health data in the EHR: measures and associated insights (2021) · cites this paper as [13]
The cited source says what the claim attributes to it.
In the citing paper
“This suggests that simply adding dedicated SDOH fields and tools to EHRs is insufficient to drive increased documentation of social needs, a conclusion consistent with other publications.13,21”
From Documentation and review of social determinants of health data in the EHR: measures and associated insights (2021) · cites this paper as [13]
Citations
Cites
Using thematic analysis in psychology
Braun, V., & Clarke, V. (2006) · Qualitative Research in Psychology · doi:10.1191/1478088706qp063oa · Cited by 194,414
Designing and Conducting Mixed Methods Research
Robinson, P. M. (2007) · Australian and New Zealand Journal of Public Health · doi:10.1111/j.1753-6405.2007.00096.x · Cited by 23,362
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. E. (2015) · Implementation Science · doi:10.1186/s13012-015-0209-1 · Cited by 4,963
The Constant Comparative Method of Qualitative Analysis
Glaser, B. G. (1965) · Social Problems · doi:10.2307/798843 · Cited by 4,937
A Framework for Public Health Action: The Health Impact Pyramid
Frieden, T. R. (2010) · American Journal of Public Health · doi:10.2105/ajph.2009.185652 · Cited by 1,535
(2003) · doi:10.1093/acprof:oso/9780195138382.001.0001 · Cited by 1,149
Patient reported outcome measures in practice
Nelson, E. C., Eftimovska, E., Lind, C., Hager, A., Wasson, J. H., & Lindblad, S. (2015) · BMJ · doi:10.1136/bmj.g7818 · Cited by 758
Boyce, M., Browne, J. P., & Greenhalgh, J. (2014) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-002524 · Cited by 528
A Systematic Review of Interventions on Patients’ Social and Economic Needs
Gottlieb, L. M., Wing, H., & Adler, N. E. (2017) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2017.05.011 · Cited by 455 · cited 3×
“Key barriers included perceptions that EHR-based SDH data tools: (1) created a fragmented view of the patient, with relevant data in multiple places, and did not readily support documenting a narrative about a given patient; (2) could add a layer of difficulty to collecting and acting on SDH data; (eg, due to lack of…”
BackgroundMethodSelf-citationGottlieb, L. M., Hessler, D., Long, D., Laves, E., Burns, A. R., Amaya, A., Sweeney, P., Schudel, C., & Adler, N. E. (2016) · JAMA Pediatrics · doi:10.1001/jamapediatrics.2016.2521 · Cited by 419
Self-citation
Flagged first, then by citations
Research works printed but not linked: 1
- U. S. Department of Health & Human Services (DHHS). Healthy People 2010, 2nd Edition. Washington, DC: US Government Printing Office; 2000.
Cited by
Sorted by citations
Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association
Ndumele, C. E., Rangaswami, J., Chow, S. L., Neeland, I. J., Tuttle, K. R., Khan, S. S., Coresh, J., Mathew, R. O., Baker-Smith, C. M., Carnethon, M. R., et al. (2023) · Circulation · doi:10.1161/cir.0000000000001184 · Cited by 2,208
Meanings and misunderstandings: a social determinants of health Lexicon for health care systems
ALDERWICK, H., & GOTTLIEB, L. M. (2019) · The Milbank Quarterly · doi:10.1111/1468-0009.12390 · Cited by 528
Self-citationAlcaraz, K. I., Wiedt, T. L., Daniels, E. C., Yabroff, K. R., Guerra, C. E., & Wender, R. C. (2020) · CA: A Cancer Journal for Clinicians · doi:10.3322/caac.21586 · Cited by 530
Part II: a qualitative study of social risk screening acceptability in patients and caregivers
Byhoff, E., De Marchis, E. H., Hessler, D., Fichtenberg, C., Adler, N., Cohen, A. J., Doran, K. M., Ettinger de Cuba, S., Fleegler, E. W., Gavin, N., et al. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.016 · Cited by 255
Self-citationPart I: a quantitative study of social risk screening acceptability in patients and caregivers
De Marchis, E. H., Hessler, D., Fichtenberg, C., Adler, N., Byhoff, E., Cohen, A. J., Doran, K. M., Ettinger de Cuba, S., Fleegler, E. W., Lewis, C. C., et al. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.07.010 · Cited by 194
“25 Successful screening implementation in select settings may suggest that patients do not object to screening, 26–37 though some clinicians have expressed concerns about time constraints 38 and the potential for increasing patient stigma.”
Self-citationQuantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19
Horwitz, L. I., Chang, C., Arcilla, H. N., & Knickman, J. R. (2020) · Health Affairs · doi:10.1377/hlthaff.2019.01246 · Cited by 205
Screening and Interventions for Social Risk Factors
Eder, M. L., Henninger, M. L., Durbin, S., Iacocca, M. O., Martin, A., Gottlieb, L. M., & Lin, J. S. (2021) · JAMA · doi:10.1001/jama.2021.12825 · Cited by 191
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
“This could include clinical decision support tools that guide medication selection or other referral and treatment choices (Gold et al., 2018), staff education and training (e.”
BackgroundSelf-citationSocial and Environmental Factors Influencing Obesity
Lee, A. M., Cardel, M. I., & Donahoo, W. T. (2019) · Europe PMC (PubMed Central) · Cited by 133
Cottrell, E. K., Hendricks, M., Dambrun, K., Cowburn, S., Pantell, M., Gold, R., & Gottlieb, L. M. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.16852 · Cited by 126
Self-citationReimagining Public Health in the Aftermath of a Pandemic
Brownson, R. C., Burke, T. A., Colditz, G. A., & Samet, J. M. (2020) · American Journal of Public Health · doi:10.2105/ajph.2020.305861 · Cited by 124
Do Patients Want Help Addressing Social Risks?
Marchis, E. H. D., Alderwick, H., & Gottlieb, L. M. (2020) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2020.02.190309 · Cited by 109
“In a recent community health center study, for instance, over 90% of patients screened positive for at least one social risk factor, but only about 20% wanted assistance from health center staff.(7) In other studies, differences are less dramatic, but the theme has surfaced across multiple settings.”
BackgroundSelf-citationScreening for Social Determinants of Health: The Known and Unknown
Davidson, K. W., & McGinn, T. (2019) · JAMA · doi:10.1001/jama.2019.10915 · Cited by 106
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 101
Addressing Transportation Insecurity Among Patients With Cancer
Graboyes, E. M., Chaiyachati, K. H., Gall, J. S., Johnson, W., Krishnan, J. A., McManus, S. S., Thompson, L., Shulman, L. N., & Yabroff, K. R. (2022) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/djac134 · Cited by 102
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
Self-citationWang, M., Pantell, M. S., Gottlieb, L. M., & Adler-Milstein, J. (2021) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocab194 · Cited by 107
Self-citationDrake, C., Batchelder, H. R., Lian, T., Cannady, M., Weinberger, M., Eisenson, H., Esmaili, E., Lewinski, A. A., Zullig, L. L., Haley, A. S., et al. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06991-3 · Cited by 115
Pantell, M. S., Hessler, D., Long, D., Alqassari, M., Schudel, C., Laves, E., Velazquez, D. E., Amaya, A., Sweeney, P., Burns, A., et al. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.6445 · Cited by 90
Self-citationHatef, E., Ma, X., Rouhizadeh, M., Singh, G., Weiner, J. P., & Kharrazi, H. (2021) · Population Health Management · doi:10.1089/pop.2020.0043 · Cited by 88
“For instance, many sources of data on social needs can be found in a typical EHR (eg, notes, diagnoses, assessments) and some EHR vendors have started adding specific data fields for collecting information on social needs.(32,33) However, no universally accepted or standardized format exists for documenting social nee…”
BackgroundMethodMarchis, E. H. D., Hessler, D., Fichtenberg, C., Fleegler, E. W., Huebschmann, A. G., Clark, C. R., Cohen, A. J., Byhoff, E., Ommerborn, M. J., Adler, N. E., et al. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.21201 · Cited by 85
Self-citationGruß, 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
“Interview questions were developed based on previously collected qualitative data.(18) The interviews were designed to explore facilitators to use of the screening tools and included questions about motivation to adopt EHR-based SDH documentation, as well as the implementation process.”
Self-citationPantell, M. S., Prather, A. A., Downing, J. M., Gordon, N. P., & Adler, N. E. (2019) · JAMA Network Open · doi:10.1001/jamanetworkopen.2019.3933 · Cited by 70
Veldheer, S., Scartozzi, C., Knehans, A. C., Oser, T. K., Sood, N., George, D. R., Smith, A., Cohen, A. J., & Winkels, R. M. (2020) · Journal of Nutrition · doi:10.1093/jn/nxaa209 · Cited by 69
Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act
Magnan, S. J. (2021) · NAM Perspectives · doi:10.31478/202106c · Cited by 72
“One study in community health centers reported that only 20% of the 90% who screened positive wanted assistance [45].”
BackgroundSocial determinants of health in mental health care and research: a case for greater inclusion
Deferio, J. J., Breitinger, S. A., Khullar, D., Sheth, A., & Pathak, J. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz049 · Cited by 74
“Domains were prioritized for screenings in community health centers, yet the tool has been adapted for use by other institutions in several US regions.(26,27) The availability of PRAPARE and other similar tools, such as HealthBegins and WellRx, are necessary first steps, but they have yet to be implemented broadly acr…”
MethodFiori, K. P., Rehm, C. D., Sanderson, D., Braganza, S. F., Parsons, A. S., Chodon, T., Whiskey, R., Bernard, P., & Rinke, M. L. (2020) · Clinical Pediatrics · doi:10.1177/0009922820908589 · Cited by 64
“Households requesting CHW assistance 287 Outreach attempts between CHW and household, total (median, range) 856 (3, 1-13) Initial encounter method In-person (warm hand-off) 18 (6) Phone 269 (94) Follow-up timeb in days, median (25th-75th IQR) 46 (25-67) SDH needs reported by household Total number of social needs cate…”
BackgroundIf social determinants of health are so important, shouldn’t we ask patients about them?
Moscrop, A., Ziébland, S., Bloch, G. C., & Iraola, J. R. (2020) · BMJ · doi:10.1136/bmj.m4150 · Cited by 63
Ndumele, C. E., Rodríguez, F., Dixon, D. L., Khan, S. S., Mukherjee, D., Bajaj, M. S., Bangalore, S., Bozkurt, B., Breathett, K. K., Clarke, S. L., et al. (2026) · Circulation · doi:10.1161/cir.0000000000001453 · Cited by 101
ICD-10 Z-Code Health-Related Social Needs and Increased Healthcare Utilization
Bensken, W. P., Alberti, P. M., Stange, K. C., Sajatovic, M., & Koroukian, S. M. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.10.004 · Cited by 58
Clark, C. R., Wilkins, C. H., Rodriguez, J. A., Preininger, A. M., Harris, J. W., DesAutels, S. J., Karunakaram, H., Rhee, K. B. L., Bates, D. W., & Dankwa‐Mullan, I. (2021) · Journal of General Internal Medicine · doi:10.1007/s11606-021-06846-x · Cited by 57
“Barriers to collecting SDOH data in primary care include the need to develop workflows to collect data, a lack of experience using patient-centered tools developed to collect SDOH data, and the need for standardized processes and resources to respond to needs identified through data collection.(22) Barriers to better…”
MethodStrengthening methods for tracking adaptations and modifications to implementation strategies
Haley, A. D., Powell, B. J., Walsh‐Bailey, C., Krancari, M., Gruß, I., Shea, C. M., Bunce, A., Marino, M., Frerichs, L., Lich, K. H., et al. (2021) · BMC Medical Research Methodology · doi:10.1186/s12874-021-01326-6 · Cited by 58
“The Implementation Support Team guides the clinics through a multi-step process called the ‘Clinic Action Plan,’ developed based on lessons learned from a pilot study [23] and refined from wedge to wedge.”
MethodSelf-citationTrochez, R. J., Sharma, S., Stolldorf, D. P., Mixon, A. S., Novak, L. L., Rajmane, A. B., Dankwa‐Mullan, I., & Kripalani, S. B. (2023) · Population Health Management · doi:10.1089/pop.2022.0279 · Cited by 58
Ndumele, C. E., Rodriguez, F., Dixon, D. L., Khan, S. S., Mukherjee, D., Bajaj, M., Bangalore, S., Bozkurt, B., Breathett, K., Clarke, S. L., et al. (2026) · JACC · doi:10.1016/j.jacc.2026.03.056 · Cited by 90
Parent Perspectives on Screening for Social Needs During Pediatric Hospitalizations
Leary, J. C., Rijhwani, L., Bettez, N. M., Harrington, Y., LeClair, A. M., Garg, A., & Freund, K. M. (2022) · Hospital Pediatrics · doi:10.1542/hpeds.2021-006411 · Cited by 52
Kardashian, A. A., Wilder, J. M., Terrault, N. A., et al. (2020) · Hepatology · doi:10.1002/hep.31605 · Cited by 52
“Many validated social determinant screening tools, such as the PRAPARE toolkit (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences),(50) have been implemented into primary care settings and integrated into the electronic health record,(51) but have yet to be applied to our specialty clin…”
MethodSocial Risks Among Primary Care Patients in a Large Urban Health System
Heller, C. G., Parsons, A. S., Chambers, E. C., Fiori, K. P., & Rehm, C. D. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.11.011 · Cited by 52
Nonresponse to Health-Related Social Needs Screening Questions
Ray, K. N., Gitz, K. M., Hu, A., Davis, A. A., & Miller, E. P. (2020) · PEDIATRICS · doi:10.1542/peds.2020-0174 · Cited by 49
“004* ,1 mo ago 47 (57) 22 (55) 4 (24) — 2–5 mo ago 26 (32) 13 (33) 5 (29) — $6 mo ago 9 (11) 5 (13) 8 (47) — Immunization status, n (%) Up to date per parent report (n = 144) 80 (95) 34 (81) 15 (83) .”
Screening for Social Risk at Federally Qualified Health Centers: A National Study
Cole, M. B., Nguyen, K. H., Byhoff, E., et al. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.11.008 · Cited by 49
“, number of fulltime equivalents, FQHC-related capabilities, management or leadership) could drive the adoption of social risk screening.(17)”
BackgroundAn Infrastructure Framework for Remote Patient Monitoring Interventions and Research
Claggett, J. L., Petter, S., Joshi, A. M., Ponzio, T. A., & Kirkendall, E. S. (2024) · Journal of Medical Internet Research · doi:10.2196/51234 · Cited by 68
“The final RPM infrastructure component is to present information obtained from the analysis to support clinicians’decision-making processes [11,12].”
BackgroundSocial determinants of health impacting adherence to diabetic retinopathy examinations
Cai, C. X., Li, Y., Zeger, S. L., & McCarthy, M. L. (2021) · BMJ Open Diabetes Research & Care · doi:10.1136/bmjdrc-2021-002374 · Cited by 49
Samuels‐Kalow, M. E., Ciccolo, G. E., Lin, M., Schoenfeld, E. M., & Camargo, C. A. (2020) · Journal of the American College of Emergency Physicians Open · doi:10.1002/emp2.12191 · Cited by 45
Garg, A., Brochier, A., Messmer, E., & Fiori, K. P. (2021) · Academic Pediatrics · doi:10.1016/j.acap.2021.02.007 · Cited by 46
Li, C., Mowery, D. L., Ma, X., Yang, R., Vurgun, U., Hwang, S., Donnelly, H. K., Bandhey, H., Senathirajah, Y., Visweswaran, S., et al. (2024) · Journal of Clinical and Translational Science · doi:10.1017/cts.2024.571 · Cited by 58
“Studies have shown that SDoH factors are commonly discussed in clinical encounters but rarely documented in structured fields, consistent with gaps in systematic SDoH data capture in EHRs [27].”
InfluentialGold, R. B., Bunce, A., Cottrell, E., Marino, M., Middendorf, M., Cowburn, S., Wright, D. A., Mossman, N., Dambrun, K., Powell, B. J., et al. (2019) · Implementation Science · doi:10.1186/s13012-019-0855-9 · Cited by 41
Self-citationBensken, W. P., McGrath, R., Gold, R. B., & Cottrell, E. (2023) · Journal of Clinical and Translational Science · doi:10.1017/cts.2023.680 · Cited by 41
“A study strength is our use of data from a nationwide network of community-based healthcare organizations that have been innovators in social risk screening since 2016 [22,46,47].”
BackgroundSelf-citationScreening Discordance and Characteristics of Patients With Housing-Related Social Risks
Marchis, E. H. D., de Cuba, S. E., Chang, L., Sheward, R. S., Doran, K. M., Gottlieb, L. M., Cohen, A. J., Fleegler, E. W., & Sandel, M. T. (2021) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2021.01.027 · Cited by 36
Self-citationChan, N. W., Moya‐Mendez, M. E., Henson, J. B., et al. (2022) · American Journal of Transplantation · doi:10.1111/ajt.17096 · Cited by 35
Livet, M., Levitt, J. M., Lee, A., & Easter, J. C. (2021) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2021.100032 · Cited by 36
Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers
Gold, R. B., Kaufmann, J., Cottrell, E., Bunce, A., Sheppler, C. R., Hoopes, M. J., Krancari, M., Gottlieb, L. M., Bowen, M., Bava, J., et al. (2023) · NEJM Catalyst · doi:10.1056/cat.23.0034 · Cited by 39
Self-citationThe global cardiovascular–liver–metabolic syndemic: epidemiology, trends and challenges
Chew, N., Mehta, A., Goh, R. J. L., Koh, J., Chen, Y., Chong, B., Chan, M. Y., Khan, M. S., Muthiah, M. D., Butler, J., et al. (2025) · Nature Reviews Cardiology · doi:10.1038/s41569-025-01220-4 · Cited by 35
Psychosocial information use for clinical decisions in diabetes care
Senteio, C. R., Adler‐Milstein, J., Richardson, C. R., & Veinot, T. C. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz053 · Cited by 35
“One major initiative involved the introduction of a screening tool in an EHR platform used by community health centers (CHCs).(17) The Center for Medicare and Medicaid Services has also made the Accountable Health Communities Health-Related Social Needs Screening Tool a standard for CHCs.”
MethodPrevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO)
Schiavoni, K. H., Helscel, K., Vogeli, C., Thorndike, A. N., Cash, R. E., Camargo, C. A., & Samuels‐Kalow, M. E. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-08721-9 · Cited by 33
“Increasingly, health systems are screening patients for HRSN during routine care and integrating responses into the electronic medical record (EMR), with the goal to refer or provide resources to address identified needs [8, 9].”
BackgroundSandhu, S., Xu, J., Eisenson, H., & Bettger, J. P. (2021) · Journal of Primary Care & Community Health · doi:10.1177/21501327211021021 · Cited by 32
He, Z., Pfaff, E., Guo, S. J., Guo, Y. M., Wu, Y., Tao, C., Štiglic, G., & Bian, J. (2023) · Yearbook of Medical Informatics · doi:10.1055/s-0043-1768732 · Cited by 32
Goldman, R. H., Zajac, L., Geller, R. J., & Miller, M. D. (2021) · BMC Medical Education · doi:10.1186/s12909-021-02921-3 · Cited by 33
“electronic medical record (EMR) [70, 71], efforts could be made to include relevant EH history questions and anticipatory guidance.”
BackgroundSensitivity and Specificity of Real-World Social Factor Screening Approaches
Vest, J. R., Wu, W., & Mendonça, E. A. (2021) · Journal of Medical Systems · doi:10.1007/s10916-021-01788-7 · Cited by 31
“Research and demonstration projects have successfully implemented screening questions in practice [3, 9, 15], but overall uptake remains low and inconsistent [20].”
BackgroundComparing the performance of two social risk screening tools in a vulnerable subpopulation
Lewis, C. C., Wellman, R., Jones, S. W., Walsh‐Bailey, C., Thompson, E., Derus, A. J., Paolino, A. R., Steiner, J. F., Marchis, E. H. D., Gottlieb, L. M., et al. (2020) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_650_20 · Cited by 33
Self-citationSandhu, S., Xu, J., Blanchard, L., Eisenson, H., Crowder, C., Munoz, V. S., Drake, C., & Bettger, J. P. (2021) · International Journal of Integrated Care · doi:10.5334/ijic.5501 · Cited by 30
“Previous studies have explored the feasibility of screening for unmet social needs in the community health center setting [19, 27, 54], but have lacked discussion as to how community providers might build this capacity to conduct screening and follow-up.”
BackgroundEvaluation of the core 5 social determinants of health screening tool
Bechtel, N., Jones, A., Kue, J., et al. (2021) · Public Health Nursing · doi:10.1111/phn.12983 · Cited by 30
Sezgın, E., Kocaballi, A. B., Dolcé, M., Skeens, M. A., Militello, L. K., Huang, Y., Stevens, J. H., & Kemper, A. R. (2024) · JMIR Human Factors · doi:10.2196/57114 · Cited by 32
“Therefore, EHR integration and adoption require detailed investigation to reduce barriers and inequality in medical documentation [57,58].”
Gold, R. B., Sheppler, C. R., Hessler, D., Bunce, A., Cottrell, E., Yosuf, N., Pisciotta, M., Gunn, R., Leo, M. C., & Gottlieb, L. M. (2021) · JMIR Research Protocols · doi:10.2196/31733 · Cited by 31
Self-citationAssociation of Patient and System-Level Factors With Social Determinants of Health Screening
Savitz, S. T., Nyman, M., Kaduk, A., Loftus, C. G., Phelan, S. M., & Barry, B. A. (2022) · Medical Care · doi:10.1097/mlr.0000000000001754 · Cited by 28
Fiori, K. P., Heller, C. G., Flattau, A., Hollingsworth, N., Parsons, A. S., Rinke, M. L., Chambers, E. C., Hodgson, S., Chodon, T., & Racine, A. D. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-053633 · Cited by 30
Clinical Stakeholder Perspectives on Pediatric Inpatient Screening for Social Needs
Leary, J. C., Rijhwani, L., Bettez, N. M., LeClair, A. M., Murillo, A., Berrios, M. R., Garg, A., & Freund, K. M. (2021) · Academic Pediatrics · doi:10.1016/j.acap.2021.09.015 · Cited by 28
Rouillard, C. J., Nasser, M. A., Hu, H., & Roblin, D. W. (2022) · Medical Care · doi:10.1097/mlr.0000000000001683 · Cited by 27
“19 20 – 23 ICD-10-CM Z codes, however, are underused, 24,25 and lack the granularity and breadth necessary to guide design of social interventions.”
BackgroundThe Impact of Social and Clinical Complexity on Diabetes Control Measures
Cottrell, E., O'Malley, J. P., Dambrun, K., Park, B., Hendricks, M. A., Xu, H., Charlson, M. E., Bazemore, A., Shenkman, E. A., Sears, A., et al. (2020) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2020.04.190367 · Cited by 26
“16,17 23 However, there are numerous barriers to integrating SDH screening into clinical settings and ensuring standardized documentation in EHRs.”
BackgroundSelf-citationHolt, J. M., Cusatis, R. N., Asan, O., Williams, J. S., Nukuna, S., Flynn, K. E., Moore, J. E., & Crotty, B. H. (2019) · Healthcare · doi:10.1016/j.hjdsi.2019.100369 · Cited by 25
Keloth, V. K., Selek, S., Chen, Q., Gilman, C., Fu, S., Dang, Y., Chen, X., Hu, X., Zhou, Y., He, H., et al. (2025) · npj Digital Medicine · doi:10.1038/s41746-025-01645-8 · Cited by 24
Stipelman, C. H., Kukhareva, P., Trepman, E., Nguyen, Q., Valdez, L., Kenost, C., Hightower, M., & Kawamoto, K. (2022) · Yearbook of Medical Informatics · doi:10.1055/s-0042-1742518 · Cited by 26
“An additional study (one article) and eight non-redundant additional articles about remaining studies that were not identified by the PubMed search were added, resulting in 28 studies (36 articles) included in the review [30-65].”
BackgroundTorres, C. H., Gold, R. B., Kaufmann, J., Marino, M., Hoopes, M. J., Totman, M. S., Aceves, B., & Gottlieb, L. M. (2023) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2023.02.018 · Cited by 24
Self-citationPredmore, Z., Hatef, E., & Weiner, J. P. (2019) · Population Health Management · doi:10.1089/pop.2018.0151 · Cited by 24
Xi, W., Banerjee, S., Olfson, M., Alexopoulos, G. S., Xiao, Y., & Pathak, J. (2023) · Scientific Reports · doi:10.1038/s41598-023-31387-0 · Cited by 23
Palakshappa, D., Benefield, A. J., Furgurson, K. F., Harley, M. G., Bundy, R. A., Moses, A., Taxter, A. J., Bensinger, A., Cao, X., Denizard-Thompson, N. M., et al. (2020) · Population Health Management · doi:10.1089/pop.2020.0059 · Cited by 23
“14 The team used the data capture functionality that is already available in the electronic patient portal with the digital health system, so the screening results were directly captured in the EHR.”
Parry, J. E., Vanstone, M. G., Grignon, M., & Dunn, J. R. (2021) · International Journal for Equity in Health · doi:10.1186/s12939-021-01546-8 · Cited by 26
Tuzzio, L., Wellman, R., Marchis, E. H. D., Gottlieb, L. M., Walsh‐Bailey, C., Jones, S. M. W., Nau, C., Steiner, J. F., Banegas, M. P., Sharp, A. L., et al. (2022) · The Annals of Family Medicine · doi:10.1370/afm.2774 · Cited by 24
“To measure trust in provider, we used the Consumer Assessment of Healthcare Providers and Systems on a scale of 1 (not at all) to 10 (completely) that was collapsed into 3 categories based roughly on equal-sized tertiles: completely (10), high (8-9), and medium-to-low (1-7) trust.”
MethodSelf-citationPatient Interest in Receiving Assistance with Self-Reported Social Risks
Gruß, I., Varga, A. M., Brooks, N. B., Gold, R. B., & Banegas, M. P. (2021) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2021.05.210069 · Cited by 22
“18,20 The only other study on requests for help by risk domain, set in an urban health clinic for young adults, 19 found that patients most commonly requested help with income security (83% of those reporting a risk requested help), education (56%), and nutrition and fi tness (50%).”
BackgroundSelf-citationImplementing Social Determinants of Health Screening in US Emergency Departments
Loo, S. S., Molina, M. F., Ahmad, N. J., Swanton, M. F., Chen, O., Boggs, K. M., Camargo, C. A., & Samuels‐Kalow, M. E. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.0137 · Cited by 22
Berg, K., Doktorchik, C. T. A., Quan, H., & Saini, V. (2022) · Health Systems · doi:10.1080/20476965.2022.2075796 · Cited by 22
“Individual and population-level data reveal predictable, independent, and intersectional associations between SDOH variables and health outcomes (Conway et al., 2019; Gold et al., 2018; Gottlieb et al., 2015; Lofters et al., 2017; Marmot et al., 2008).”
BackgroundIott, B. E., Pantell, M. S., Adler-Milstein, J., & Gottlieb, L. M. (2022) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocac154 · Cited by 22
Self-citationReceipt of Social Needs Assistance and Health Center Patient Experience of Care
Nguyen, K. H., Trivedi, A. N., & Cole, M. B. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2020.08.030 · Cited by 23
A Systematic Review of Electronic Community Resource Referral Systems
Drewry, M., Yanguela, J., Khanna, A., O’Brien, S., Phillips, E., Bevel, M., McKinley, M. W., Corbie, G., & Dave, G. (2023) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2023.06.001 · Cited by 21
April-Sanders, A. (2024) · Journal of the American Heart Association · doi:10.1161/jaha.124.036518 · Cited by 23
Taccheri, C., Jordan, J. A., Tran, D., Wang, J., Han, D., Varadaraj, V., Crews, D. C., & Cai, C. X. (2023) · Ophthalmology · doi:10.1016/j.ophtha.2023.06.007 · Cited by 21
Samuels‐Kalow, M. E., Molina, M. F., Ciccolo, G. E., Curt, A. M., Manchanda, E. C. C., de Paz, N., & Camargo, C. A. (2020) · Western Journal of Emergency Medicine · doi:10.5811/westjem.2020.3.45932 · Cited by 20
Association Between Neighborhood Disadvantage and Pediatric Readmissions
Nacht, C. L., Kelly, M. M., Edmonson, M. B., Sklansky, D. J., Shadman, K. A., Kind, A., Zhao, Q., Barreda, C. B., & Coller, R. J. (2022) · Maternal and Child Health Journal · doi:10.1007/s10995-021-03310-4 · Cited by 19
“1 3 Furthermore, ADI may help overcome barriers to integrate SDH into direct care (Gold et al., 2018).”
BackgroundReducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness Visit
Tipirneni, R., Ganguli, I., Ayanian, J. Z., & Langa, K. M. (2018) · Public Policy & Aging Report · doi:10.1093/ppar/pry048 · Cited by 19
Halbert, C. H., Jefferson, M. S., Allen, C. G., Babatunde, O. A., Drake, R. R., Angel, P. M., Savage, S. J., Frey, L. J., Lilly, M. B., Obi, T., et al. (2021) · JCO Clinical Cancer Informatics · doi:10.1200/cci.20.00131 · Cited by 19
Livingston, C. J., Titus, T. M., Yerokun, T. A., & Patel, N. M. (2025) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2025.01.005 · Cited by 18
Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes
Gold, R. B., Kaufmann, J., Gottlieb, L. M., Weiner, S. J., Hoopes, M. J., Gemelas, J. C., Torres, C. H., Cottrell, E., Hessler, D., Marino, M., et al. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2022.03.011 · Cited by 19
Self-citationNguyen, K. H., Cemballi, A. G., Fields, J. D., Brown, W., Pantell, M. S., & Lyles, C. R. (2022) · JAMIA Open · doi:10.1093/jamiaopen/ooac014 · Cited by 24
Moen, M., Doede, M., Johantgen, M., et al. (2022) · Journal of Advanced Nursing · doi:10.1111/jan.15485 · Cited by 17
Drake, C., Lian, T., Trogdon, J. G., Edelman, D. E., Eisenson, H., Weinberger, M., Reiter, K. L., & Shea, C. M. (2021) · BMC Cardiovascular Disorders · doi:10.1186/s12872-021-02149-5 · Cited by 18
“Efforts to better integrate these activities into routine clinical encounters and standard of care [6] include social needs EHR documentation strategies [33], innovative care models [34, 35], and cross-sector collaboration [36].”
BackgroundLangevin, R., Berry, A. B. L., Zhang, J., Fockele, C. E., Anderson, L., Hsieh, D. T., Hartzler, A. L., Duber, H. C., & Hsieh, G. (2023) · Applied Clinical Informatics · doi:10.1055/a-2035-5342 · Cited by 16
Provision of Social Care Services by US Hospitals
Iott, B. E., & Anthony, D. L. (2023) · Milbank Quarterly · doi:10.1111/1468-0009.12653 · Cited by 18
Addressing social needs in oncology care: another research-to-practice gap
Haines, E. R., Shelton, R. C., Foley, K. L., et al. (2024) · JNCI Cancer Spectrum · doi:10.1093/jncics/pkae032 · Cited by 16
Social and Mental Health Care Integration
Shields‐Zeeman, L., Lewis, C. C., & Gottlieb, L. M. (2019) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2019.1148 · Cited by 16
Self-citationTakada, S., Gorbach, P. M., Brookmeyer, R., et al. (2020) · AIDS Care · doi:10.1080/09540121.2020.1828798 · Cited by 16
“…social capital at the individual level by assessing their patient’s important relationships, as recommended by the National Academy of Medicine (Gold et al., 2018; Institute of Medicine, 2014); they may leverage social capital by discussing how norms and resources in those relationships may…”
BackgroundInfluentialBako, A. T., McCabe, H., Kasthurirathne, S. N., Halverson, P. K., & Vest, J. R. (2020) · Journal of Social Service Research · doi:10.1080/01488376.2020.1817834 · Cited by 16
“…including financial concerns, food insecurity, transport issues, language, social support, violence and safety, employment, and housing instability (Gold et al., 2018; Kaiser Permanente Social Needs Survey, 2019; Kusnoor et al., 2018; Lehnerer et al., 2019; Page-Reeves et al., 2016; Vest et al.,…”
BackgroundResultFrom Screening to the Receipt of Services: A Qualitative Examination
Schoenthaler, A., Gallager, R. P., Kaplan, S. A., & Hopkins, K. A. (2022) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2022.03.033 · Cited by 16
Metadata
- Authors
- Gold, R., Bunce, A., Cowburn, S., Dambrun, K., Dearing, M., Middendorf, M., Mossman, N., Hollombe, C., Mahr, P., Melgar, G., Davis, J., Gottlieb, L., & Cottrell, E.
- Affiliations
- Kaiser Permanente Center for Health Research (US)
- Ochin (US)
- Multnomah County Health Department (US)
- University of California, San Francisco (US)
- Venue
- The Annals of Family Medicine
- Publisher
- Annals of Family Medicine
- Published
- 2018-09
- Volume
- 16
- Issue
- 5
- Pages
- 399-407
- ISSN
- 1544-1709 (ISSN-L)
- 1544-1717
- PMC
- PMC6131002
- OpenAlex
- W2891941547
- Semantic Scholar
- ec90bbff459f6d579a5de4a0ee6586f1aebfa662
- Cited by
- 252
- References
- 55
- Citations by year
- 2026: 21 · 2025: 32 · 2024: 25 · 2023: 38 · 2022: 38 · 2021: 42 · 2020: 31 · 2019: 23 · 2018: 2
- FWCI
- 31.11
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- The Annals of Family Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (R18DK105463)
- 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 › Medicine › Family Practice › Primary Care and Health Outcomes
- Keywords
- social determinants of health, electronic health records, community health centers, social needs screening, referral documentation, implementation barriers, primary care, health policy
- MeSH terms
- Community Health Centers, Documentation, Feasibility Studies, Health Plan Implementation, Humans, Pilot Projects, Referral and Consultation, 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.
A language model drew the claims from the paper on 2026-10-28, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-28 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
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