Healthcare IT vendor Cerner is working to integrate social determinants of health screening into clinical workflows as a critical component for better managing population health outcomes.

Toward that end, the company plans to start offering a social assessment form in its inpatient electronic health record product, which is scheduled to be released by October. This tool is meant to help Cerner’s clients better screen for social determinants of health.

According to Tanuj Gupta, MD, senior director and physician executive for population health at Cerner, Meaningful Use Stage 3 makes it optional for certified HIT vendors to provide a way for EHR users to ask patients questions in four social determinant domains specified in the regulations and linked to Logical Observation Identifiers Names and Codes (LOINC).

However, Gupta observes that providers subject to the Centers for Medicare and Medicaid Services’ Comprehensive Primary Care Plus (CPC+) model are “required by January 1, 2019, to have that ability to ask those questions” regarding different social elements and aspects of a patient’s life.

“There’s nothing in the requirements that I know of that tells you how to use that information yet, but there’s at least that requirement,” he says. “We are working on at least, at a minimum, meeting this requirement for clients as a start.”

Gupta contends that the three pillars of integrating social determinants into the workflow are aggregating and normalizing the data, creating and applying intelligence to the population, and finally acting on that intelligence and measuring output.

While social determinants such as economic status and physical environment have a significant impact on health outcomes, clinical systems are not currently configured to collect that kind of information.

Also See: Leveraging social determinants of health data remains challenge

However, Gupta says that acquiring “more relevant data” can be acquired from patients directly through portals, direct surveys, emails, mobile apps, and potentially social media and phone calls.

“We can also collect data from the care team, either through their workflow management systems to date or even through telemedicine applications, and then we can go to other open data sources which we’re exploring now,” he adds.

When it comes to creating and applying intelligence to the population, Cerner wants to be able to create identification algorithms to look for patients with risk factors related to social determinants of health such as individuals at risk for food insecurity or an unsafe environment.

“We want to classify them into risk groups—generally low, rising and high risk—and then stratify them based on some other factors,” concludes Gupta. “Once you know this patient is at risk for a particular social factor, then we can attribute them to the right person on the care team.”

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