Developing electronic health record (EHR) strategies related to health center patients’ social determinants of health
Open accessAbstract
BACKGROUND: "Social determinants of heath" (SDHs) are nonclinical factors that profoundly affect health. Helping community health centers (CHCs) document patients' SDH data in electronic health records (EHRs) could yield substantial health benefits, but little has been reported about CHCs' development of EHR-based tools for SDH data collection and presentation. METHODS: We worked with 27 diverse CHC stakeholders to develop strategies for optimizing SDH data collection and presentation in their EHR, and approaches for integrating SDH data collection and the use of those data (eg, through referrals to community resources) into CHC workflows. RESULTS: We iteratively developed a set of EHR-based SDH data collection, summary, and referral tools for CHCs. We describe considerations that arose while developing the tools and present some preliminary lessons learned. CONCLUSION: Standardizing SDH data collection and presentation in EHRs could lead to improved patient and population health outcomes in CHCs and other care settings. We know of no previous reports of processes used to develop similar tools. This article provides an example of 1 such process. Lessons from our process may be useful to health care organizations interested in using EHRs to collect and act on SDH data. Research is needed to empirically test the generalizability of these lessons.
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Individual-level SDoH data collection remains evolving and is not yet consistently available across large populations.
“individual-level SDoH data collection remains evolving and not yet consistently available across large populations [95–98]”
From Machine learning-driven risk prediction for post-hospitalization diabetes case management: Integrating clinical and social determinants of health (2026) · cites this paper as [97]
The Background (page not available) says some patient-reported SDoH domains are not regularly collected by federally funded clinics and that CHCs have historically addressed patients’ needs through manual, ad-hoc approaches. This supports the claim that collection is still developing, but the paper does not establish availability across large populations generally; its evidence is focused on CHCs. (LLM, conf=0.79)
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Predictive modeling of housing instability and homelessness in the Veterans Health Administration
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Essentialism and Exclusion: Racism in Cancer Risk Prediction Models
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Partner-developed electronic health record tools to facilitate social risk-informed care planning
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- Authors
- Gold, R., Cottrell, E., Bunce, A., Middendorf, M., Hollombe, C., Cowburn, S., Mahr, P., & Melgar, G.
- Affiliations
- Kaiser Permanente (US)
- Venue
- The Journal of the American Board of Family Medicine
- Published
- 2017-07
- Volume
- 30
- Issue
- 4
- Pages
- 428-447
- ISSN
- 1557-2625 (ISSN-L)
- 1558-7118
- PMC
- PMC5618800
- OpenAlex
- W2737948908
- Cited by
- 215
- References
- 65
- Citations by year
- 2026: 15 · 2025: 28 · 2024: 15 · 2023: 35 · 2022: 24 · 2021: 30 · 2020: 22 · 2019: 21 · 2018: 21 · 2017: 3
- FWCI
- 25.15
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of the American Board of Family Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Kaiser Permanente
- 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 › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Keywords
- social determinants of health, electronic health records, community health centers, workflow integration, health information standardization, community resources
- MeSH terms
- Community Health Centers, Humans, Referral and Consultation, Electronic Health Records, Social Determinants of Health
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