Sharing SDOH Data for Improved Population Health Management

With the healthcare industry steadily moving toward more holistic, preventive care delivery, health systems have increasingly recognized the critical role the social determinants of health play in the well-being of individual patients and broader population health management.

“Social determinants are a major component of what predicts and influences an individual’s health outcomes, as well as the outcomes of populations,” Brian Dixon, PhD, director of public health informatics at Regenstrief Institute and Richard M. Fairbanks School of Public Health at Indiana University – Purdue University Indianapolis (IUPUI), told HealthITAnalytics.

“We know that life expectancy is highly related to a person's zip code – that if people live in an environment where they feel unsafe, they're less likely to go out or exercise. We also know that a person's social networks influence their behavior, as well as their health – either their eating patterns, their consumption of alcohol, or their use of tobacco products.”

While it’s safe to assume that every healthcare professional knows the physical impact of the social determinants of health (SDOH), most organizations aren’t at a place where they can easily access and share this essential data, Dixon noted.

There are no set standards for collecting SDOH in the EHR, which can make it difficult for providers to identify and address the social factors influencing a patient’s condition.

“At an individual level, the best way to gather social determinants data is to interview the patient and ask them a series of questions, which requires doctors to manually enter that data into their EHR or clinical notes,” he said.

“Because we want to be able to extract information from electronic health records, there's a move towards standardizing that information. Physicians would have to enter that structured information just like they do everywhere else in the EHR – as part of drop-down menus or in certain fields, which can add to documentation burdens for providers.”

Collecting SDOH information on a broader scale also has its obstacles.

“At a population level, providers can access social determinants data through various data sources that are increasingly becoming open to the public. Unfortunately, these data sources often come in multiple files, leaving health IT experts to manually integrate this information into their organizations’ systems,” Dixon said.

To expand access and sharing of SDOH data, Regenstrief Institute recently partnered with the Indiana Health Information Exchange to launch the Indiana Network for Population Health (INPH).

INPH will aim to provide key stakeholders with comprehensive information on housing stability, food access, transportation, and other non-medical data.

“The Indiana Network for Population Health will be focused on meeting the population health needs of providers, payers, and our public health organization partners,” Dixon said.

“Through INPH, Regenstrief will do the work of pulling SDOH data in, and then connecting it to the clinical data that we have available through the information exchange. Our partners don't have to do all that work themselves, and they can leverage this data that is available and already connected to the patient's home zip code.”

With this new network, providers across the state will be able to access and leverage SDOH data more easily, leading to better outcomes and enhanced population health management.

“Information exchanges are very good at conducting information management. That’s their primary role in any community setting: Bringing different data together and making it available to all the people who need to care for individual patients or patient populations,” said Dixon.

In addition to making data more accessible to healthcare organizations, information exchanges can also provide visualizations of the data and organize the data in a way that makes it more understandable, Dixon explained.

“Let's say there are 50 variables that are available for a given patient or a group people with diabetes. I could just make all 50 of those variables available to the provider in a big long report,” he said.

“But the other thing that I could do, as a health information exchange, is create a better report design – a dashboard or a map with visual information about those social determinants for my partners. That way, when a physician logs in to the HIE or gets a report from the HIE, the information is already organized in a way that's more readable and digestible.”

The data gathered and shared through INPH will help Regenstrief and its partners improve population health in several areas, Dixon noted.

“We plan to use and make the data available for three main purposes. One is patient care. We want to make the information available to our clinical partners so that they can incorporate it into their EHR and make more informed clinical decisions,” he said.

“The second is population level surveillance – building dashboards at the population level and using this information to improve public health.”

The team aims to develop data dashboards to help public health departments monitor patients with a certain disease or diagnosis, and understand which individuals are engaged in care.

“Public health officials can look at this information by age, sex, or race to understand who's getting treatment. They can also view this information geographically to see if there are pockets of the population not getting the treatment, and they can work with providers in that area to expand treatment access,” Dixon said.

The third use of this data will be for research and further refinement of population health initiatives, Dixon stated.

“We're going to make the data available for researchers to look at, for example, people with diabetes – where they are geographically located, diabetic control of those populations over time, access to care, and screening for diabetes at population level,” said Dixon.

“Leaders can use that research to help guide community-based interventions or other work that can improve outcomes at the population level.”

The Indiana Network for Population Health will help facilitate the seamless exchange and collection of SDOH data, resulting in more comprehensive patient care and population health management.

“We're very excited about this new initiative. It will help us meet the needs of patient populations, and align with the health system’s broader move towards population health,” Dixon concluded.