The Intersection of Social Determinants of Health on HIT and Patient Outcomes

Health and health equity

NIs must understand the difference between health and health equity in order to use technology and patient data in the EHR to address the underlying causes of poor health. Health is when an individual has complete physical, mental, and social well-being. 4 Health is a dynamic state and goes beyond the absence of illness. Health is not healthcare.

Health equity refers to the fair and just opportunity to achieve health. 5 Providing for health equity requires valuing everyone equally; having a patient-centric focus; and removing obstacles to attaining health, such as poverty, discrimination, powerlessness, a lack of access to good jobs with a just wage, poor quality education, poor housing, unsafe environments, and poor healthcare. Health equity can be measured by the reduction and elimination of health disparities, especially in marginalized groups.

Regulatory compliance

NIs may present EHR data to demonstrate compliance with regulations, such as health equity. NIs will need to design discrete documentation paths to capture social risk data and create reporting tools to demonstrate organizational compliance and attestation of the commitment to health equity. The Centers for Medicare and Medicaid Services (CMS) published a framework for health equity with five priorities, the first being the expansion of standardized data collection, reporting, and analysis. 8 CMS can leverage quality improvement initiatives and tools to advance access to equitable care and coverage by ensuring comprehensive, interoperable, and standardized data collection. 8

For hospitals that report to the CMS Hospital Inpatient Quality Reporting (IQR) Program, CMS has mandated reporting two social drivers of health, referred to as SDOH quality measures, to address the HRSN of patients age 18 and older during the hospital encounter by 2024. Their primary aim is to obtain systematic patient-level data on social risks to facilitate a provider referral to community resources in a meaningful manner. The two measures are SDOH-1 (Screening for Social Drivers of Health [the number of inpatients screened]) and SDOH-2 (Screen Positive Rate for SDOH [positive screening rate for any of the five domains]). The five domains of SDOH quality measures are food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. 8 Although hospitals may use a self-selected screening tool, the CMS Innovation Center recommends using the 10-item Accountable Health Communities (AHC) HRSN Screening tool. 9

Effective January 2023, The Joint Commission added new and revised requirements to reduce healthcare disparities in the leadership and record of care (RC) standards. 10 The leadership standard recommends having a designated leader focused on health equity efforts. In addition, it requires organizations to collect data and perform data analysis on the most practical and relevant HRSNs for its patient population and, from the analysis, develop an action plan to reduce healthcare disparities. 10 In the RC standard, the record should contain information about race and ethnicity to understand the patient population better. 10

SDOH and outcomes

To optimize the build and design of data collection in the EHR and to satisfy regulatory mandates, NIs must understand the significance of SDOH on health outcomes, the mandated versus non-mandated HRSN domains, and the recommended screening questions. SDOH are the conditions where people are born, live, work, learn, play, and age. 11 These determinants encompass who people are based on factors outside of genetics and what people do within their health behaviors, lifestyle choices, social, economic, environmental factors, and clinical care. 12 Clinical care influences only 20% of the individual's health outcomes as compared with the social and economic health factors, which have the most impact on health outcomes in terms of longevity and quality of life as illustrated in the County Health Rankings' model of health (see County Health Rankings' Model of Health). 13

SDOH are part of the patient's story, and for holistic nursing care to be delivered, the nurse must seek to learn the whole story. 14 Social and economic factors may force a patient to delay healthcare decisions to meet basic needs such as food, utilities, and housing. Today, when clinicians open a patient's EHR, they are focused on addressing the patient's reason for the visit, health history, and diagnoses such as heart disease, diabetes, obesity, and depression. Capturing the patients' HRSN will provide the opportunity to see the contributing factors and challenges the patient faces to achieve optimal health.

Screening for HRSN seeks to understand the whole story. NIs may design a documentation path for screening various SDOH domains, including but not limited to tobacco use, alcohol and substance use, housing stability, depression, intimate partner violence (IPV), sexual activity, social support, stress, physical activity, community safety, transportation, food insecurity, access to care, quality of care, financial strain, and education. For this article, the five mandated screening domains from CMS (food insecurity, housing instability, utility difficulties, transportation needs, and interpersonal safety) will be highlighted.

Food insecurity

Food insecurity is a state of limited or inadequate food access. 15 Food is a household resource. Families with low and very low food security have trouble providing enough food for all family members at some time during the year. 16 The ability to obtain quality foods and enough food is reflected in the level of food security. In 2021, over 13.5 million households (10.2%) in the US were food insecure. 16 There are five characteristics associated with food insecurity: education, social networks, social capital, income, and employment. 17

Food insecurity is linked to an increased risk of chronic disease (CD) and has a stronger association with CD than household income. 18 In the US, single-mother, Black, and Hispanic households encounter higher food insecurity rates. 19 The prevalence of food insecurity is reduced among households with a family member who works full-time. 19 There is an interdependence between unemployment, consequential poverty, and the ability to buy foods high in nutritional value. 20 Foods contributing to obesity are typically "convenience" type foods that are commercially prepared, lower cost, and energy dense. 21

Using the AHC HRSN Screening tool, food insecurity is assessed through two items that gather how often the individual is worried about not having enough to eat because the food supply ran out or did not last before they had enough money to buy more or get more in the last 12 months. 9

Housing instability

An individual's ability to have and maintain safe and stable housing is critical in the hierarchy of social needs. Stability has many facets, including the quality and safety of housing, affordability of rent or mortgage, availability of utilities, poor or overcrowded conditions, and weatherization (such as insulation, heating, ventilation, air conditioning). 22,23 Individuals with disabilities or those experiencing a healthcare crisis may be at risk for economic hardship and job loss, increasing the risk of homelessness. 24 Higher rates of obesity and cardiovascular disease morbidity and mortality are seen in those experiencing housing instability. 25,26

The absence of affordable housing can create financial stressors with the inability to meet monthly rent or mortgage payments. 27 Higher rates of mental health disorders such as adjustment disorder, substance abuse, and major depression are seen in patients who have housing instability. 28 Individuals with a history of homelessness have twice the rate of alcohol and opioid abuse. 24 Patients who have housing instability are more likely to seek care in an ED and have twice the number of ED evaluations than patients with stable housing. 29 Homeless patients seen in the ED are more likely to be admitted to the hospital. 28 Readmission rates are significantly higher in surgical patients who are homeless. 30 Housing instability adds a layer of burden on the already strained healthcare system with the overutilization of ED and hospital resources. Access to stable housing can lower healthcare costs and improve health. 27

Substandard housing impacts health outcomes, especially mental health disorders related to anxiety, stress, and depression. 31 Communities in areas of concentrated poverty are disproportionately affected. 31 Environmental-related health conditions are consequences of substandard housing. These conditions include lead exposure and poisoning from peeling paint; asthma and respiratory infections from pest infestations, poor insulation, and mold contact. 31

Screening during an inpatient or ambulatory encounter can assess if a patient has a steady place to sleep, access to shelter resources, and challenges affecting the ability to pay rent or mortgage placing them at risk of losing housing. Using the AHC HRSN Screening tool, there are two items to address the patient's living situation as it relates to housing stability and environmental stressors from inadequate housing. 9

Utility difficulties

Utility or energy insecurity is a household measure and is defined as the inability to meet basic energy needs. 32 This insecurity may be due to affordability or access to services. Data from the 2020 Residential Energy Consumption Survey (RECS) showed lower-income households, renters, non-Hispanic Black, Native American, and Hispanic households were most impacted by energy insecurity. 33 A significant association was found between energy insecurity and poor sleep, respiratory, and mental health outcomes. 32 Using the AHC HRSN Screening tool there is one item addressing utility services (gas, electric, oil, or water) threatened to be shut off in the past 12 months. 9

In the US, most states have laws to delay or prohibit disconnecting utility services from low-income households when a medical necessity certificate is presented for the seriously ill, elderly, or disabled. Some states' policies are solely related to seasonal conditions such as temperatures dangerous to health, usually 32 [degrees]F (0 [degrees]C) or below. 34 Some health conditions are dependent on electricity to power medical devices or refrigerate medications such as insulin. The level of difficulty paying for utilities may be seasonally dependent impacting individuals in peak summer and winter months. 35 A medical certificate request is initiated from the resident contacting the utility company. A physician or advanced practice clinician must complete the certificate and send it to the utility company. Within the EHR, providing a mechanism to scan the certificate to a media file and creating a discrete documentation path to capture this HRSN may be another opportunity to obtain meaningful data on utility needs.

Transportation

According to the American Hospital Association, transportation impacts many areas of an individual's life. 22 Transportation is necessary to get from place to place and is a critical SDOH as it affects quality of life.

Transportation creates social and financial opportunities by connecting people to employment, education, childcare, community and church activities, goods and services, recreational parks, and healthcare. 22,36 In the US, healthcare services are delayed due to a lack of transportation. 37 This can result in a patient not receiving a timely diagnosis for an acute condition, poor management of CD, lack of adherence to medication and treatment plans, and increased ED use.

Access to transportation can be a vehicle to wellness. 22 Vulnerable populations, who carry the highest burden of CD, are impacted disproportionately. 38 Data collected from the National Health Interview Survey from 1997 to 2017 showed that those who lived below the poverty line had functional limitations, received Medicaid, or were Hispanic had greater odds of reporting a transportation barrier. 37

The AHC HRSN Screening tool contains one item to assess how often the individual has missed appointments, meetings, work, or getting things necessary for daily living in the last 12 months. 9 Providing transportation services, such as bus passes, transport vouchers, and rideshare, alone is not enough to improve health outcomes, but offering multicomponent interventions does. 38,39

Hospitals and health systems can integrate support for transportation options into strategic planning as part of the organizational commitment to health equity and action plans. Collaboration with community partners and programs, investment in integrated resources into the EHR, and establishing an infrastructure to support a referral loop can lead to improved health and lower costs. The referral loop mechanism starts with identifying a need through screening and matching the need to a community resource partner within the EHR. It ends with the patient using the intervention to meet an HRSN, such as transportation to a follow-up appointment with a provider.

Interpersonal safety

Interpersonal safety includes the screening of an individual's exposure to IPV and elder abuse in adults. 9 The World Health Organization defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation." 40

According to the CDC, IPV may have occurred with current and former partners and qualifying episodes vary in severity and frequency. 41 One in three women and one in four men are affected by IPV, with a significant number of victims reporting exposure before the age of 18. 41

IPV is related to serious health conditions and has economic consequences. 41 Survivors of violence may experience posttraumatic stress disorder, major depression, suicidality, and substance use disorders. 41,42 Additional health outcomes impacted by IPV, which may become chronic, include conditions affecting body systems: cardiac, reproductive, nervous, skeletal, and digestive systems. 41 Individuals who have experienced IPV are at higher risk for participating in unhealthy behaviors such as binge drinking, smoking, and sexual activity. 41 There are negative effects of IPV on maternal health outcomes globally. These include increased odds of postpartum depression, preterm births, low birth weight, and less breastfeeding in the year after birth. 43

Screening for IPV in healthcare settings can identify patients who are currently experiencing abuse or victims of past abuse and is deemed a clinical best practice. 44 Clinicians should use a trauma-informed care approach to recognize, acknowledge, and respond appropriately to survivors. 45 Organizations must ensure protocols are in place to respond to a disclosure of abuse to ensure the patient is safe and resource materials are provided. 45

The AHC Screening tool addresses safety, with one item to assess violence and abuse. The item asks how often family and friends have hurt the patient on a 5-point Likert scale ("never" to "frequently"). 9

Clinical, data collection workflows

NIs are integral in the design and build of discrete data collection tools to optimize the screening for and documentation of social risks in the EHR.

Structured data fields, such as flowsheet documentation, are widespread tools used to capture data from specific clinical observations and objective measures to improve patient and organizational outcomes. NIs provide expertise in clinical practice and informatics; expert understanding of operational workflow and the delivery of healthcare; data, information, and knowledge management for individuals and systems; leadership and organizational strategy; influence in healthcare policy; scientific research and discovery; integration of sociotechnical framework; and learning across the healthcare spectrum. 46

NIs utilize expertise in the clinical and informatics space to integrate the collection of SDOH data into interdisciplinary clinical workflows. The four key components of nursing informatics practice are data, information, knowledge, and wisdom, thus providing a framework to guide the build and design to collect SDOH data in the EHR. 47 Using discrete fields allows information to be categorized and extracted to use data to inform services needed. NIs translate the data to standard terminologies by "mapping" to allow information processing which supports interoperability. For example, they may use ZIP code data to locate transportation deserts among patient populations. 48,49

Geocoding, a spatial-related database, is used to translate physical patient addresses to SDOH data and is commonly used to leverage health-related data. 49 Also, mapping SDOH data to Z codes can help improve quality, care coordination, and referrals; identify community needs; and monitor SDOH intervention effectiveness. 50 Z codes are factors not associated with a disorder that influence an individual's health status. 50 Although there is no requirement to document factors that influence health status using ICD-10 Z codes, these can be used to understand better the link between health conditions and healthcare utilization. 24 Ensuring Z codes related to socioeconomic and psychosocial circumstances (Z55-Z65) are documented and mapped in the EHR enhances the accuracy of risk assessment and final coding (see Z-code categories).

NIs support and integrate patient-centered, evidence-based practice into documentation paths. 51 Designing and building clinical documentation paths to support nursing care, including the mandatory screening and assessments by regulatory agencies, should aid documentation quality and support meeting compliance metrics. Structured flowsheets provide discrete fields to capture the required information to populate in dashboards to measure compliance for SDOH 1 and SDOH 2 health equity measures. SDOH screening can be embedded into the admission assessment workflows for nurse documentation. Screening questions can be shared with the patient using a self-reported survey during hospitalization in the patient's health record portal. SDOH documentation may have predefined rules and logic for data transformation and assist in user decision support. An example is creating required documentation for the five SDOH domains, visual cues, or alerts (interruptive or passive) when documentation is missing before discharge. Interruptive "pop-up" alerts, which require a response during the workflow before moving to the next clinical documentation, should be used judiciously to avoid alert fatigue.

NIs contribute to the design and build of interfaces to create referral loops to community resources that aid in measuring impact. 2 Standardization and interoperability of data are paramount to improving health equity. Having unstructured data such as clinical notes in the EHR could be problematic when extracting meaningful data. Interoperability, Health Insurance Portability and Accountability Act (HIPAA) compliance, and cost are challenges that exist with sharing data using a referral platform to noncovered entities such as community-based support groups, which are nonclinical in nature. 52-54 Knowledge of efforts using a national public collaborative to develop data standards to advance interoperable SDOH data, like the Gravity project, is key to understanding the ethical framework in the development and exchange standards of patient-level SDOH data in clinical care. 55

Investing time and resources can expand digital health technology, health information exchanges, and patient portals to improve patient experience and engagement.

The role of NIs continues to expand to adopt new innovative technologies, such as artificial intelligence (AI), to address and bridge the health equity gap. NIs will need to leverage AI to summarize and provide context to SDOH data while eliminating bias in a way that does not overwhelm nurses with extraneous information. 2

Conclusion

SDOH are nonhealthcare factors that affect health outcomes. NIs aid in supporting the data collection within the EHR in a way that brings information and knowledge together to improve health equity. Designing and building structured flowsheets to capture data promote the use of analytical science and provide compliance with reporting and benchmarking.

NIs aim to gain wisdom from the data to acknowledge understanding and apply the information with compassion.

REFERENCES

1. Nursing Informatics: Scope and Standards of Practice. 3rd ed. American Nurses Association; 2022. [Context Link]

2. National Academies of Sciences, Engineering, and Medicine (NASEM). The future of nursing 20-30: charting a path to achieve health equity. 2021. http://nap.nationalacademies.org/25982 . [Context Link]

3. Bickford CJ. The Professional Association's perspective on nursing informatics and competencies in the US. Stud Health Technol Inform. 2017;232:62-68.

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4. World Health Organization (WHO). 2023. http://www.who.int/about/governance/constitution#:~:text=Health%20is%20a%20state%20of%20complete%20physical%2C%20mental,race%2C%20religion%2C%20political%20belief%2C%20economic%20or%20social%20condition . [Context Link]

5. Centers for Disease Control and Prevention (CDC). What is health equity. 2022. http://www.cdc.gov/nchhstp/healthequity/index.html . [Context Link]

6. Keenan W, Sanchez CE, Kellogg E, Tracey SM, edsNational Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Roundtable on the Promotion of Health Equity; Forum for Children's Well-Being: Promoting Cognitive, Affective, and Behavioral Health for Children and Youth. Achieving Behavioral Health Equity for Children, Families, and Communities: Proceedings of a Workshop. Washington (DC): National Academies Press (US); February 13, 2019. DOI: 10.17226/25347

7. Robert Wood Johnson Foundation (RWJF). 2017. http://www.rwjf.org/en/insights/blog/2022/11/we-used-your-insights-to-update-our-graphic-on-equity.html .

8. Centers for Medicare and Medicaid Services (CMS). CMS framework for health equity. 2023. http://www.cms.gov/about-cms/agency-information/omh/health-equity-programs/cms-framework-for-health-equity