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How to Design an SDOH Tool That Clinicians Will Actually Use

Analysis  |  By Eric Wicklund  
   April 08, 2024

The Mayo Clinic is working on an AI tool that will integrate with the EHR, prompting clinicians to identify and address both SDOH and clinical bias.

Researchers at The Mayo Clinic in Arizona are developing an AI tool within the EHR that will help clinicians identify and address social determinants of health—including when their own actions contribute to clinical bias.

The health system is partnering with TruLite Health to create a platform that will enable both clinicians to identify SDOH and take steps to address access and care gaps. The AI tool, called Truity, mines patient data for signs of health inequity and develops patient-specific recommendations for care management.

“It incorporates so many factors, including social determinants of health, in a real-time, easily accessible platform that is available to the clinical team [and] to the patient,” says Nathan Delafield, MD, FACP, an internal medicine physician at the Mayo Clinic who’s working on the technology.

Delafield, who’s working with two other researchers to get the tool ready for implementation later this year, says health system leaders are anxious to take on some of healthcare’s biggest access challenges but not at the expense of adding more task to already overworked providers.

“For decades, our healthcare system has been challenged by the gradual acknowledgement of healthcare disparities, without meaningful, tangible solutions to address them,” he says. “But evidence would suggest that most physicians are ill-equipped to meaningfully address them.”

Research by Deloitte indicates that health inequities cost the U.S. healthcare industry about $320 billion a year, and that price tag could top $1 trillion by 2040 if the industry doesn’t take action. That would include understanding why health systems spend thousands of dollars more per year to treat minorities for a variety of chronic conditions than to treat white patients with the same health concerns.

Healthcare organizations are making it a priority to address SDOH, but many have struggled to find the right strategy. Some are developing tools that address specific challenges like food insecurity, while others create separate platforms to address SDOH from outside the EHR, requiring providers to take extra steps to include that in care management.

Delafield says the Mayo Clinic is taking its time with this technology to make sure it’s integrated into a provider’s regular workflow.

“We want to be really diligent” about taking the time to study workflows and make this interoperable with minimal disruption, he says, rather than developing a tool that “becomes another source of excessive clicks.”

The technology, he says, will be designed to analyze patient data from a wide variety of sources to not only identify the barriers to care but also common clinical practices that may lead to health inequity. This would give clinicians an opportunity to learn how health inequity may be created or sustained by a doctor’s actions.

And it will also be made available to patients, he says, “so that patients will understand that these things are being considered as we’re evaluating their overall healthcare.”

Aside from giving providers patient-specific care management recommendations, the platform will also be designed to connect patients with health coaches employed by TruLite Health. Over time, Delafield says, as Mayo Clinic providers learn how to identify and address SDOH and clinical bias, they’ll likely develop the skills to become health coaches themselves.

“I think we will see some clinical change [and] some behavioral change that will improve clinical outcomes,” he says.

Eric Wicklund is the associate content manager and senior editor for Innovation, Technology, and Pharma for HealthLeaders.


Health systems are increasingly interested in identifying and addressing social determinants of health, but haven’t found the right strategy that clinicians can use.

Researchers at the Mayo Clinic are working with digital health company TruLite Health on an AI tool embedded in the EHR that can alert clinicians to SDOH and help clinicians develop care management plans to address those barriers.

The platform would also help clinicians better understand and address clinical bias, or actions they take that may influence health inequity.

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