Developing Electronic Health Record (EHR) Strategies Related to Health Center Patients' Social Determinants of Health

Rachel Gold, PhD, MPH; Erika Cottrell, PhD, MPP; Arwen Bunce, MA; Mary Middendorf, BS; Celine Hollombe, MPH; Stuart Cowburn, MPH; Peter Mahr, MD; Gerardo Melgar, MD


J Am Board Fam Med. 2017;30(4):428-447. 

In This Article

Abstract and Introduction


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.


Numerous health outcomes are influenced by the social and physical characteristics of patients' lives. These "social determinants of heath" (SDHs) can affect health via diverse mechanisms (eg, chronic stress, hampering patients' ability to follow care recommendations).[1] This impact is so great that addressing SDHs may improve health as much as addressing patients' medical needs.[2–21]

The Institute of Medicine (IOM) recommended that 10 patient-reported SDH domains (and 1 neighborhood/community-level domain) be documented in electronic health records (EHRs)[22,23] ( Table 1 ). These domains were selected based on evidence of their health impacts; their potential clinical usefulness and ability to put into action; and the availability of valid measures. Some of these domains (eg, race/ethnicity) are already regularly collected by federally funded clinics; others (eg, social isolation, financial resource strain) are not. The Centers for Medicare & Medicaid Services intended that the IOM's report inform stage 3 meaningful use EHR incentive program requirements. Related to this, the Medicare Access & CHIP Reauthorization Act of 2015 and Centers for Medicare & Medicaid Services' 2016 Quality Strategy both emphasize care providers identifying and intervening in SDH-related needs. In addition, the Health Resources and Services Administration and the Office of the National Coordinator for Health Information Technology have both indicated that SDH data collection should continue to expand as part of federally qualified health center reporting, and may become required for EHR certification.[24–29]

Systematically documenting patients' SDH data in EHRs could help care teams incorporate this information into patient care, for example, by facilitating referrals to community resources to address identified needs. This could be especially useful in "safety net" community health centers (CHCs), whose patients have higher health risks than the general US population.[23,30–39] Many CHCs already try to address patients' SDHs, but their approaches to doing so have historically been manual and ad hoc.[40–44]

EHRs present an opportunity to standardize the collection, presentation, and integration of SDH data in CHCs' clinical records.[45] Toward that end, a national coalition of CHC-serving organizations created the "Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences" (PRAPARE), which included a preliminary SDH data collection tool informed by the IOM's phase 1 report.[45] PRAPARE includes most of the IOM-recommended domains and a few additional questions specific to CHC populations. Building on PRAPARE and the IOM recommendations, our study team asked CHC stakeholders about their opinions on how to optimize SDH data collection, documentation, and presentation in CHCs' EHRs, and on how they would like to use EHR tools to act on identified SDH-related needs, for example, by making referrals to community resources. This article describes our process and its results. We know of no previously published reports of processes used to develop EHR-based SDH data collection, summary, and referral tools, and therefore we present this article as an example that may inform others.