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Social Determinants of Health Measures, Baked into the EHR, Are Improving Patient Care

Analysis  |  By Scott Mace  
   November 02, 2022

The Memorial Healthcare System is focusing on food, housing, and transportation to help reduce unnecessary ED visits and boost care quality.

A Florida health system is putting social determinants of health (SDOH) right into the electronic health record problem list, where doctors can see and act on them.

Spearheading this initiative is Jennifer Goldman, DO, chief of Memorial Primary Care at the six-hospital Memorial Healthcare System, based in Hollywood, Florida. In this interview with HealthLeaders, Goldman explains how SDOH is embedded in the EHR and used to improve outcomes. This interview has been lightly edited for brevity and clarity.

HealthLeaders: How important is the role of data these days in the practice of medicine?

Jennifer Goldman: It's inseparable for primary care as we've transitioned from a fee-for-service to a value-based care approach. It's imperative that our teams know what's going on with those patients.

[In the past], it wasn't that we didn't care, but we didn't have the data, and we also didn't have the payment structure to make it possible. Now with value-based care, we have both. The care teams utilize that information to reach out to patients who haven't had an appointment and ensure that they come in. It's that kind of proactive management that is inseparable from data and data analytics.

Jennifer Goldman, DO, chief of Memorial Primary Care, Memorial Health System. Photo courtesy Memorial Health System.

As a result of having that data, we started something called a shadow schedule, where instead of booking directly on a provider's schedule and needing to have an open slot for a walk-in, we would have an empty schedule every single day that we just set out for walk-ins, for same day appointments, whether that was telehealth or face to face.

We've noticed a sharp increase not only in the number of patients that were requesting appointments via that system, but we also saw over 830 walk-in patients, same-day patients, in the last month alone. And we noticed a commensurate decrease in the number of ED visits. We would only be able to have that insight and that information because of the data that we proactively looked for.

HL: A JAMIA report from 2021 found there is no consensus on which SDOH measures should be captured in the EHR. How do you decide which ones to add?

Goldman: That's an ongoing discussion in our system. We utilize Epic, which has a social determinants of health wheel, which is just a graphic representation of the varieties of determinants of health that somebody is dealing with. And the major challenge for us in our organization was to determine which ones we were going to prioritize and start with.

We don't know if all of them truly impact health equally, but we do know that there are three that are a priority not only for us, but for Medicaid. If we can do something about these, we can probably impact more in a person's health than if we address resources elsewhere. Those are food, housing, and transportation. Substance abuse is a huge social determinant of health, but we already have a process for that, where we already screen everybody for that when they come in. The three social determinants of health we focus on are traditionally outside the wheelhouse of any physician. Those are things that we just did not ask people.

HL: How do you capture the data about the need, and how do you match the need with the actual service?

Goldman: We utilize the Epic release social determinants of health wheel. And we ask first our health coaches, our nurse navigators, and in some cases our social workers to review these determinants for the patients that were on their high-risk panel, patients that have significant ER visits or who are ill with multiple different chronic conditions.

We focused first on that population. Case managers were asking some of those questions anyway, but they were asking them in a non-capturable, non-standardized way. We standardized the way that we were capturing that data so that we could run analytics on it and show that information in the EHR to physicians. If our providers don't know that the patient they're treating right now is homeless or doesn't have access to healthy food or doesn't have access to transportation, that would probably impact their decision-making in terms of what treatment they were going to prescribe for that person.

We built something called an alert or a best practice advisory, where if somebody screened positive for homelessness, food insecurity, or transportation need, that would pop up [in front of] the clinician. And we took that a step further, because sometimes pop-ups in the EHR are negatively looked at. I never wanted to have an empty best practice advisory, where the doctor would have to do five more clicks to document that in the EHR. We drop the code for that specific social determinant of health into the problem list and into what we call a visit diagnosis.

We also included documentation that the patient was going to be automatically sent to our care team for follow-up in terms of how to access resources. We did that by having an automated in-basket so that it didn't hinge on a physician or a nurse practitioner or PA remembering to involve a social worker. This would happen automatically. We work with our community resources, such as the Broward County Task Force on Homelessness, and many other housing resources, as well as transportation assistance. With food, we work with multiple local food banks. We do direct connections with people we call and get those resources for them, instead of just handing a piece of paper to a patient.

HL: When did these processes go live, and what are the outcomes like so far?

Goldman: These alerts went live six months ago, and the outcomes have been significant. We've tripled the number of ICD-10 codes in the EHR for social determinants of health. That means that our physicians are documenting three times more on homelessness and food insecurity and transportation than they were previously. So we know that it's being captured.

We know that interventions are being done because we can track that as well. And we know that all those social determinants of health that we're screening for, all those patients ended up getting a referral to the care team and the care team contacted them and gave them the resources that they need. We're in the process of measuring outcomes, which ultimately is the most important thing. We're looking at data for no-show rates for appointments.

HL: What are the success factors for you in your job as a leader in this effort?

Goldman: Number one is making a difference in the community that we treat. Having the data to show that we are making a difference in our community is a success factor that's huge. More granular than that is ensuring that all our physicians are on board with this, number one, and number two, understand the why behind asking all of these soft issues in a medical visit, and make it easy for everybody to screen and document patients for social determinants of health without our doctors feeling like they have extra work to do.

Third would be our performance in our value-based care contracts. How successful are we in our quality measures, which we have done successfully every year, also ensuring that our patients are not utilizing services that they don't need, making sure that we're available so that people don't need to seek care in the emergency room for something that's not an emergency, and also ensuring that we're making sure that people don't need to go unnecessarily to specialists for care if the primary care doctor can address those issues.

HL: What about the other social determinants of health -- child care, money for medication, and so on?

Goldman:  We absolutely want to expand into that. There are ways to do that over time. For every appointment, our medical assistants are now going to be screening for the social determinants of health. We're also moving into a way that our patients can answer these questions in the lobby, as they're waiting for their appointment, or at home as they're waiting for their telehealth appointment. And I want to be careful not to put forth technology to replace human beings in these questions that we're asking when not everybody has access to that technology just yet.

“We standardized the way that we were capturing that data, so that we could run analytics on it, and show that information in the EHR to physicians. ... We're documenting three times more on homelessness and food insecurity and transportation than we were previously.”

Scott Mace is a contributing writer for HealthLeaders.


A shadow schedule enables same-day walk-in or telehealth appointments, decreasing no-shows and ED overuse.

Social determinants of health, captured by staff through the Epic EHR, end up populating problem lists, putting those factors in front of doctors with minimal extra work for physicians.

The health system generates automated in-baskets to connect patients with resources for needed social services.

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