Atrium Health merges SDOH data into its Cerner EHR to improve care, trim costs

The North Carolina health system expects to see a decrease in emergency department utilization and readmission rates.
By Bill Siwicki
01:37 PM
Atrium Health merges SDOH data into its Cerner EHR to improve care, trim costs

Atrium Health's Carolinas Medical Center.

Since the 1980s, social determinants of health have been examined from more of an academic and research perspective. Evidence-based literature suggests social and economic factors such as income, ZIP code, access to transportation, language, genetics, diet, cultural beliefs and education all influence a person’s overall health.

In the past five years or so, health systems have begun to pay attention to social determinants as a way to address healthcare disparities and improve the health of their communities.

Atrium Health, based in Charlotte, North Carolina, with more than 40 hospitals and more than 900 care locations, has prioritized SDOH as it seeks to to impact its patient populations and improve patient health outcomes.


First, Atrium Health, in partnership with others, set out to better understand its patient population – and it used analytics technology to do so.

“Through a geo-mapping process, Atrium Health mapped out data from a census tract level, as well as pooled information from multiple resources including the U.S. Census-American Community Survey, and state and federal data on minority health, and overlaid patient-level data,” said Ruth Krystopolski, senior vice president of population health at Atrium Health. “In 2016, this process became the basis of a Community Health Improvement Study.”

"While access to care and other services is key, utilizing technology with community-endorsed initiatives will improve the health of your patients in your community."

Ruth Krystopolski, Atrium Health

That CHIS allowed Atrium Health to gather information about specific factors that inform the clinical landscape of its patient service area. The online interactive map assessed 12 social determinants of health indicators at the neighborhood level within a 10-county service region.

“An index summarized the neighborhoods with the highest disparities and demonstrates the areas with the greatest social and economic needs,” Krystopolski explained.

“The results indicated that patient data with mapping shows neighborhoods with higher rates of obesity,” she said. “The areas of higher social need are likely to have higher rates of diabetes, unnecessary emergency department utilization and readmissions.”


The proposed Cerner technology solution used the vendor’s electronic health record and population health IT to allow Atrium Health to record valuable SDOH data for standardized and accessible interventions to address the needs identified in counties the health system serves.

“The goal was to formalize and reduce variation: What has been historically informal conversations or separate visit notes are now integrated into clinical workflows to match patient needs to appropriate and accessible resources in the community,” Krystopolski explained.

“These appropriate resources can be found through Atrium Health’s Community Resource Hub – powered by Aunt Bertha, a platform that allows providers, care managers and social workers to make referrals and connect patients to engaged partners and organizations in the community offering social services.”

Services include free and reduced-cost legal assistance, transportation, housing and food, among other resources.


There is a variety of electronic health records systems on the market today, from vendors such as AdvancedMD, Allscripts, athenahealth, CareCloud, Cerner, eClinicalWorks, Epic Systems, GE Healthcare, Greenway Health, McKesson, Meditech and NextGen.


Atrium Health implemented a pilot program to screen for social determinants, including food insecurity, using the PRAPARE tool developed by the National Association of Community Health Centers.

“Ten of our clinics implemented week-long trials of screening patients with an EHR-embedded PRAPARE survey,” Krystopolski recalled – referring to the National Association of Community Health Centers’ Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.

“Clinic staff and providers collaborated with evaluators to design screening flows that met clinic needs,” she said. “Methods included screening at check-in using a paper survey, screening by the nursing staff, and screening by the physician directly into the tool through the EHR.”

Additionally, Cerner has partnered with Atrium Health to provide an extension of the Cerner HealtheCare care management platform to Faith Community Health nurses out in the community. This allows for more integrated, aligned care and social service provision between patients and community-based organizations outside of clinical walls.


The process evaluation of the pilot used Proctor Implementation Outcome Metrics and Consolidated Framework for Implementation Research. While early pilot results are promising, evidence-based literature suggests that Atrium Health expects to see a decrease in emergency department utilization and readmission rates, Krystopolski said.


“Atrium Health has learned many technological, clinical and community-based lessons during our journey to provide better access to resources for our patients and community,” Krystopolski advised. “This is no longer an individual health system’s problem – It is vital to competitor systems’ success as well.”

Knowing one’s community’s needs is only half the battle, she said. Improved communication between health systems will help move the needle on SDOH factors, she added.

“Additionally, community engagement is key; utilizing grassroots community organizing from both the public and private sector is necessary to address social and economic disparities and ensure the community is linked to culturally competent resources – technology will only take you so far without the appropriate connections,” she explained.

“While access to care and other services is key, utilizing technology with community-endorsed initiatives will improve the health of your patients in your community,” Krystopolski continued. “Lastly, consider clinic culture for workflow implementation and ease of use for similar technology.”

Providers should also consider how the technology impacts a provider’s time required to screen for social determinants and barriers with the organization’s specific patient population, such as low health literacy and linguistic challenges, she said. Having provider champions to lead and implement the work was critically important and a key factor of Atrium Health’s success, she concluded.

Twitter: @SiwickiHealthIT
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