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Substantial Barriers Exist for Integrating SDOH Data Into EHRs


While the integration of social determinants of health (SDOH) into electronic health records (EHRs) may be feasible, substantial barriers to adoption exist.

Integrating social determinants of health (SDOH) into electronic health records (EHRs) has the potential to help providers get a better picture of a patient’s health and, in turn, improve health outcomes. However, according to a new study, while the integration of SDOH into EHRs may be feasible, substantial barriers to adoption exist.

Several organizations and policies, including the National Academy of Medicine and the Medicare Access and CHIP Reauthorization Act of 2015, have endorsed standardized SDOH documentation, which has particular importance for community health centers.

“Such documentation is especially relevant to community health centers, whose vulnerable patients are likely to experience social and economic risks associated with poor health,” wrote the study researchers.

Watch below for more on gaps remaning in how technology can help address SDOH from the study's lead author Rachel Gold, PhD, MPH, investigator at the Kaiser Permanente Northwest Center for Health Research and lead research scientist at OCHIN.The article continues under the video.

However, despite this relevance, the researchers observed significant barriers to uptake and implementation, including provider perception that the EHR-based SDOH data create a fragmented view of the patient and could make data collection more difficult.

The team implemented a suite of SDOH data tools in 3 Pacific Northwest community health centers in June 2016 as part of a pilot study to document and summarize SDOH screening results and make SDOH referrals, as well as to assess the adoption of the tools by community health centers. The 3 clinics screened a total of 1130 patients through July 2017.

Each clinic initially screened a limited population of patients and then scaled up to incorporate a larger number of patients and more complex patients. All 3 clinics adapted their workflows as they saw fit, used paper-based SDOH screening questionnaires that then needed to be inputted into the EHR, and tried to minimize the primary care provider’s role in SDOH documentation and SDOH-related referrals.

Nearly all (97%-99%) of patients indicated a potential SDOH need in at least 1 SDOH domain, of whom 211 (19%) received a SDOH referral. Referral workflows varied across the clinics. Whereas Clinic A referred patients to community services chosen from the referral tool linked to a SDOH-related diagnosis code, Clinics B and C routed most referrals to community health workers or similar staff.

During the study period, researchers identified both facilitators and barriers to the adoption of these tools into EHRs. Facilitators to using the tools included a clinic champion wo was trusted, EHR-savvy, able to customize EHR views to support workflows, and willing to use adoption data to integrate workflows.

Key barriers included perceptions that EHR-based SDOH data tools created a fragmented view of the patient, with relevant data in multiple places; could add a layer of difficulty to collecting and acting on SDOH data, due to lack of staff EHR expertise and the tools’ customized nature; and necessitated a data entry step if SDOH information were collected on paper. Clinics also reported that referral workflows were too time-consuming, especially when no follow-up was planned; until questions asking whether patients desired follow-up for SDOH were added, the high positive screening rate resulted in unmanageable follow-up workload.

Reflecting on these findings, the researchers recommend that when planning for implementation, providers should ensure new staff are trained on SDOH workflows, ensure the correct staff have security access to the tools for the envisioned workflow, and consider conducting a staged rollout of SDOH documentation to help identify needed changes. If workflows involve paper-based data collecting, providers should specify staff and the timeframe for data entry, and documentation should identify if patients with a SDOH-related need say they want assistance, they added.


Gold R, Bunce A, Cowburn S, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018;16(5):399-407. doi: 10.1370/afm.2275.

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