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ONC: Hospitals Need to Put SDOH Data to Use

Analysis  |  By Eric Wicklund  
   July 31, 2023

An ONC data brief finds that most hospitals are collecting data on social determinants of health, and many are using technology to gather that information, but a lot fewer are collecting that data regularly.

More than 80% of hospitals recently surveyed by the American Hospital Association are collecting data on social determinants of health (SDOH), many through their EHR platform and health information exchanges. Yet only half of those hospitals are collecting data regularly.

The information, gleaned from the AHA's Information Technology Supplemental Survey and contained in an analysis by the Office of the National Coordinator for Health IT (ONC), suggests healthcare providers are aware of the value of collecting SDOH data, but many either can't or aren't putting it to use.

Social determinants (or drivers) of health are non-clinical factors that can affect one's health and wellness, including family and housing issues, employment, transportation, food insecurity, and cultural and societal pressures.

"If left unaddressed, the social needs experienced by an individual may lead to poor health outcomes and more time spent in hospitals and interacting with the healthcare system," ONC staffers Wei Chang, Chelsea Richwine, and Samantha Meklir wrote in a recent blog post accompanying the ONC data brief. "Hospitals, therefore, are uniquely situated to help address social needs and mitigate social risk factors by screening for social needs, assisting with transitions of care, and making connections to social service organizations."

According to the AHA survey, administered in 2022, some 83% of hospitals are doing just that, with nearly 75% using a structured screening tool to collect that information, 36% using free-text notes, almost 30% using diagnosis codes, and 20% using non-electronic methods.

Some 60% of hospitals collecting SDOH data are getting some of that information from external sources, the survey found. Those sources include HIEs (46%), other healthcare organizations (28%), social service or community-based referral platforms (22%), and community/social service organizations (18%).

As for how they're using the data, 72% of hospitals collecting SDOH are using the information to inform discharge planning, while 67% cited clinical decision-making, and 65% cited referrals to social service groups. In addition, 48% of the hospitals are using the data for population health analytics, 46% to inform community needs assessments or other equity issues, and 42% for quality management purposes.

These tools and tactics are crucial to improving access to care and clinical outcomes among underserved populations, yet the survey finds that healthcare providers serving those populations aren't necessarily addressing SDOH.

According to the survey, 54% of hospitals collecting SDOH data are doing so on a regular basis, yet lower-resourced providers, such as small, critical access, rural, and independent hospitals, were "significantly less likely" to regularly collect data.

In their blog, Chang, Richwine, and Meklir note that the Centers for Medicare & Medicaid Services (CMS) recently added two SDOH data elements to the Inpatient Quality Reporting (IQP) program. That's one step in the right direction toward compelling providers to collect and use that data.

"While much attention has been devoted to screening—a critical first step to understanding patients’ health-related social needs—additional focus is needed on effective usage of data collected through screening since not all patients who screen positive for social needs are successfully connected to the resources they need," they wrote. "This may be attributable to a number of challenges providers face in using social needs data, including a lack of standardized referral processes and sustainable financial resources, which speaks to a need for building partnerships with community-based partners and increasing their capacity to respond at the community level, and tracking changes in health outcomes following the identification of social needs."

"Looking ahead, more work is needed to capture social needs data in an actionable way so that this information can be used to support shared decision making and address social needs, with the ultimate goal of improving individual and population health," they concluded.

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


According to an ONC analysis of the American Hospital Association's Information Technology Supplemental Survey, 83% of hospitals were collecting SDOH data in 2022, yet only 53% were collecting it regularly.

Roughly three-quarters of hospitals collecting data are using structured screening tools, while 35% are using free-text notes, about 30% are using diagnosis codes, and 20% are using non-electronic methods.

Some 60% of hospitals are pulling in SDOH data from external sources, and just under half are taking advantage of health information exchanges.

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