Social determinants of health – the food, shelter and security attributes of patients that exist outside of care settings – contribute disproportionate risks for disease, hospital readmissions and a lack of access to quality healthcare among vulnerable populations, including people on Medicare.

Consider that medical care may only account for between 10% and 20% of health outcomes, while a patient's neighborhood and environment, economic stability and education, social and community context and individual behavioral factors account for 80% to 90% of health outcomes, according to Rick Krohn, principal at HealthSense, an expert in connected health and a HIMSS Innovation Author.

The opportunity to impact the healthcare outcomes of populations via SDOH lays in the ability "to incorporate unstructured, non-traditional health data into the patient record," he wrote for Healthcare IT News during the pandemic.

SDOH data is a matter of interoperability, as it is often intentionally trapped. 

"It's a multi-layered problem, beginning with awareness – there is an incomplete understanding of the value and catalogue of SDOH data for clinical care and population health management," Krohn said.

Providers only have the background information that they can see right in front of them while in the room with the patient. Would a diagnosis or care plan change if the clinician truly knew the patient beyond their symptoms and medical record?

Dr. Ben Zaniello, chief medical officer at PointClickCare, has encountered SDOH data interoperability problems in all of his healthcare ecosystem experiences – on the provider, payer and technology developer sides. 

Zaniello says the broader healthcare ecosystem is focused on creating technology infrastructures to support whole person care, and he unpacks the data challenges associated with WPC – what is needed to drive patient behavior, boost health outcomes and controls healthcare costs.

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Talking points:

• Managing aspects outside of patient symptoms to succeed in a patient's care.
• Balancing breaches with the "well-meaning gates" that limit sharing access to data.
• Improving care coordination and visibility and not "spelunking in the EHR."
• Where post-acute coordination encounters behavioral health regulation 42 CFR part 2.
• How the competitive side of healthcare drives using HIPAA and tech gaps to not share data.
• Three pathways to a whole person care reality.

More about this topic:

Health equity hindered by SDOH coding roadblocks

Going beyond SDOH to reduce readmissions

Social determinants of health may help predict sepsis readmission

The data challenges of SDOH, and how to overcome them

Major new report calls for better integration of social determinants of health

Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.