As accountable care organizations and multi-sector groups seek to identify the causes of poor health in their communities, they are starting to develop social determinants of health (SDoH) screening tools within their EHRs to combine with clinical registry data.
In a recent webinar hosted by the Great Lakes Practice Transformation Initiative, Michael Hanak, M.D., associate chief medical informatics officer at Rush University in Chicago, described the SDoH screening implementation at Rush.
Dr. Hanak serves as Co-Chair of the Quality Committee of Rush University Medical Group. He also serves as a Vice President of the Illinois Academy of Family Physicians and is a member of their Health Equity Workgroup. Rush University is one of eight institutions participating in “Pursuing Equity,” a national collaborative with Institute for Healthcare Improvement. He serves on the Rush leadership team for this project and, for the last three years, served as the site principal investigator for the CMS Transforming Clinical Practice Initiative.
Hanak began by noting that the Chicago neighborhoods between Rush University Medical Center and Rush Oak Park have some of the highest levels of economic hardship, lowest life expectancy and highest unemployment rates in the region.
Rush partnered with the leadership of West Side ConnectED collaborative to implement an SDoH screening tool that asks patients about:
• Food Security
• Primary Care/Insurance
To some providers, this screening seems like an add-on or separate ask, Hanak said, but he stressed that the health system’s mission is to be a good steward of health for the community and find those not thriving and bring them into the fold. He said Rush is seeking to empower those at the front lines of care to better understand struggles of patients and bring that up and say we need to do something about it. “It is important that we include everyone in that,” he said. “It is not the work of a committee or group. It is important to remind people to think outside of what they see every day in the exam room.”
He said it is helpful that the SDoH work touches areas it was already focusing on such as hypertension and diabetes. “We also looked at making sure it was operationalized into daily workflow. He stressed that the work must include clinical and operational leaders. After a pilot has taken place, the return on investment will become more apparent, he added.
Of an initial 50 patients screened, it took an average of 3 minutes per screening. Of those screened, 33% screened positive for one or more need. Food insecurity was the most frequent need (25% of screened patients). Among patients with SDoH needs, 65% were on a hypertension registry; 30% were on the coronary artery disease registry and 30% fell in the highest-quartile cost (internal charges) for the Rush system.
Rush built the SDoH screening form into its Epic EHR workflow. With the information in Epic, he said, they could drive a better understanding how the social issues connect to clinical measures and what they should be focusing on.
Another step in the process involved working with Chicago technology firm NowPow. This was described in greater detail in a press release on the Rush website:
“After the provider completes the patient intake process, the Rush EMR combines the social data with the medical history into a patient profile that it sends to NowPow instantly and securely. Within seconds, NowPow’s software queries the company’s database of local community resources to identify where patients can receive needed services. NowPow then draws on its national database of clinical evidence to find how the most commonly diagnosed chronic conditions have been managed successfully in areas demographically similar to Chicago’s West Side.
NowPow then provides a curated list of resources and services — called a HealtheRx, a combination of a tech pun and the Rx symbol for prescriptions — that matches the patient’s needs. The technology enters the HealtheRx in the patient’s EMR, sends it to the identified community-based providers, and emails and/or texts it to the patient.
For example, outcomes data shows that people are more likely to manage diabetes successfully if they have sufficient access to fruits and vegetables, get frequent blood sugar screenings and receive foot care. So in addition to a prescription for a medication to regulate blood sugar, a patient with diabetes might also be referred to a Federally Qualified Health Center for free blood sugar screenings and foot care, and to a Greater Chicago Food Depository partner site for free healthy food.”
The deployment is not without challenges, Hanak stressed. He listed several:
• Clinician engagement (“not in scope of my care.”)
• Support staff burn-out. People might say, “not my job” and/or “not enough time.”
• Requires social work engagement for greater SDoH needs, which means more financial investment.
• Operational challenges: “Where and when and what’s the ROI?”
• Closing the loop on referrals requires personnel to follow cases if they are not fully integrated with EHR.
• Preferred social work resources may not be part of NowPow.
• Some screenings took a very long time
• Interpreter sometimes needed for screenings
• Patient preference to answer sensitive questions with doctor only
• Adequate training for all staff participating in screening
In a written answer to questions raised during the webinar, Hanak said Rush is currently performing this screening in the Emergency Department and more recently the ambulatory setting. “SDoH screening is not routinely part of our inpatient assessment for those admitted outside the ED. Certainly any patients requiring care management or social work engagement are being screened, but we aim to capture most of our inpatient volume by way of the process we have set up in the ED.”