Investments in social determinants will pay off, with better outcomes and value
Massachusetts General Hospital estimates that as much as 80 percent of a patient's health status stems from social and economic factors. Other calculations, such as those spotlighted in a recent Health Affairs report, put the number as high as 90 percent.
This isn't exactly a new concept. The idea that where we live and work is an essential component of our overall health has been around for a long time,
"Geography has been recognized as important to our health outcomes since 4000 B.C.," said Dr. Este Geraghty, chief medical officer of Esri. In Hippocrates' book On Airs, Waters and Places, after all, the father of medicine explored the idea that "where people come from determines how likely they are to be healthy," she said.
Fundamental factors such as income, access to nutrition, access to transportation, homelife, loneliness and more are key building blocks to a patient's health and wellness. So, of course, are pollution and other environmental factors.
More forward-thinking hospitals and health systems know this, and in recent years many have been launching innovative new initiatives to tackle these root causes and improve them wherever possible for the patients most in need.
Mass General, for instance, has launched a program called HAVEN, which is tailored to help patients who are victims of domestic violence. And its frontline staff take a proactive and person-centered approach to helping patients with language barriers or low health literacy with their medication management. (You can see interviews about these and other social determinant efforts in this MGH video, which is shown during training to all hospital staff.)
Clearly, helping with social determinants is a people-intensive effort, and depends on close personal interaction. It won't be solved with technology.
Technology can help. Consider the many collaborations between rideshare services and health systems, for example, or partnerships such as the one between Allscripts and Lyft, which enables physicians to easily dial up transportation for patients who need it from within their workflow.
Some regional health information exchanges have begun incorporating SDOH data into their platforms, helping providers more easily refer patients to community groups that could help them address social health needs.
But there are challenges too. Most electronic health records, as currently configured don't do a great job managing SDOH information in an optimal way.
It's not just a matter of adding a new data field into the EHR, as former Deputy National Coordinator for Health IT Dr. Jacob Reider told us earlier this year.
"Because what do we put in the field? If we make a field and it's free text, wow. Now we're creating all kinds of chaos because people are going to type in stuff that we wouldn't have expected. If we make it a field that's a checkbox and that maps to a semantic concept, then which semantic concept? Right? So, "food insecurity": How do I express that and is there a LOINC code for that? Well right now there isn't."
Some health systems have made strides in jury-rigging their EHRs to present social determinant data in useful ways. Mount Sinai, for example, has deployed a natural language processing algorithm to mine its unstructured clinical notes for new insights.
But much more work remains to capitalize on the momentum of recent years, and to ensure SDOH factors are addressed across the U.S. healthcare system.
Interoperability will be key. Writing in Health Affairs, former National Coordinator Dr. Karen DeSalvo and Mark Savage, director of health policy at the Center for Digital Health Information, made the case that, "by 2024, a nationwide learning health system must integrate non-clinical data and facilitate interoperability with non-clinical settings to account for sociodemographic factors such as the physical environment, nutrition, education, housing, and access to social services.
"Individual and population health depend upon much more than clinical care. Integrating social and environmental determinants is critical," they added. "The ONC’s proposed move to open, standardized APIs and to enable the export of EHI for population health services are steps in the right direction."
They also noted, however, that "equally critical next steps are missing. For example, the ONC proposes to add new elements to the U.S. Core Data for Interoperability. Given the extraordinary significance of social determinants of health, the ONC could add them now without further delay. … We must begin including social determinant data now to learn how best to integrate and use them on the road to a nationwide learning health system by 2024."
Those investments in money and energy are challenging, but they are worthwhile – especially as the country continues the monumental task of shifting to value-based care. Intervening with patients before they need acute care, fostering wellness wherever possible is a must-do, and SDOH are a key component. Technology will be a key enabler, but this is really boot-on-the-ground type work.
Some innovative efforts to tackle social determinants are already seeking to prove that those efforts will have ROI that's impossible to ignore. Consider the new partnership launched by Reider in his capacity as CEO of Troy, New York-based Alliance for Better Health.
Its Healthy Alliance Independent Practice Association bills itself as the first IPA focused exclusively on addressing social determinants. Through its partnership with insurer MVP Health Care, $800,000 will be invested to help community based organizations in the Albany region connect and coordinate with each other, and with medical providers, via Unite Us, a technology platform designed for referral and tracking around SDOH.
One major aim is to help CBOs better align their missions with local managed care organizations, who have similar goals of keeping their members healthy.
The endeavor "is the first step of demonstrating the business case" of attention to SDOH, said Reider. "And the data will show that we're right."
Focus on Social Determinants of Health
In September, Healthcare Finance News, Healthcare IT News and MobiHealthNews will take a look at the SDOH and how varied health systems, IT companies, Congress and others are addressing it.