Social determinants of health (SDoH)—the socioeconomic and place-based factors that influence an individual’s health and well-being—are a concern for many Americans. These complex and interconnected variables are widely acknowledged as main drivers of health disparities and inequities. An approach by healthcare providers, hospitals, and communities that takes into account social determinant risk has the potential to improve health outcomes, reduce medical costs, and facilitate the transition to value-based care.
Social determinant data captured in electronic health records may help to identify individuals at risk, enable social services referrals and outreach efforts, inform clinical decision-making and population health management, and support research. In this retrospective cohort analysis, de-identified patient data sourced from the electronic health record Practice Fusion, a Veradigm™ offering, were used to generate real world evidence that is actionable and meaningful to a discussion of social determinants in chronic disease. In ambulatory patients who were newly assigned social determinant codes, Adjustment Disorder was the top-ranking code for each of the chronic condition cohorts. More than two-thirds of patients with chronic conditions were assigned codes related to Social and Community Context. Most patients in all but one of the chronic condition cohorts were assigned codes by primary care practitioners. In two of the cohorts, approximately one-quarter of patients received codes from pediatricians. For patients with chronic medical conditions and social risk, electronic health records may afford deeper understand of the barriers that hinder treatment or contribute to care plan non-adherence. Studies using real-world data may offer insight into the challenges of and opportunities for caring for individuals with complex health and social needs.
Read the SDoH Whitepaper