Bridging the Gap Between Social Determinants and Electronic Health

Records for Patient and Public Health

Robert A. Hahn, Ph.D., M.P.H.Community Guide Branch

Division of Epidemiology, Analysis and Library Sciences

CDC

Center for Surveillance, Epidemiology, and Laboratory Services (proposed)Division of Epidemiology, Analysis, and Library Services (proposed)

The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position

of the Centers for Disease Control and Prevention

Disclaimer

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Agenda

1. What are social determinants?2. Current limits to social determinant

intervention research. 3. Bridging the gap in two directions.

a. Social determinants to health recordsb. Health records to social determinants

4. The common link: Residence

3

Social determinants of health

Upstream elements of a society’s organization and process, such as education, housing, transportation, occupation, the system of justice, that causally affect the societal distribution of disease and health. Social determinants may affect health by distributing risk and protective factors for disease and injury, pathological agents and environments, and resources for prevention and treatment.

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Logic Model: Interventions to Address the Health of Disadvantaged Populations for the Improvement of Health for All

Forms of Inequitable Determinant Distribution

Racism SexismClassism

Multiple forms of inequitable distribution based on age, disability, immigration status, etc.

Societal Distribution of Health Determinants

Social Determinants of Health

Health

Equity

Health-related Equity Outcome

Societal Divisions/ Organization/ Structure-Hierarchy/ Process

Physical environment and its regulation

HABITAT: Neighborhood Living Conditions

Opportunities for Learning & Developing Capacity

Community Development & Employment Opportunities

Public finance, taxation

System of justice

Public services (e.g., transportation, sanitation, recreation, social services)

Health Promotion, Disease/ Injury Prevention/ Healthcare

Political/Economic Structure and Process

Underlying Social Forces

Health

for All

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Goals for Social Determinant Data and Research

1. Improve care of patient with EHR.

2. Improve community/public health with EHR-generated information.

3. Etiological research, e.g., assessing poverty or lack of education as causes of reduced longevity.

4. Monitoring trends in social determinants, e.g., changes in education achievement gaps by race and income.

5. Evaluating social determinant interventions, e.g., the effect of high school completion programs on long term health outcomes.

Long-term Improvement of population health

Short-term Improvement of patient/community health

6

Guide to Community Preventive Services Reviews of Educational Interventions to

Promote Health EquityPast 4 years, systematic reviews of educational programs, e.g.:

Early childhood education

Full-day vs. half-day kindergarten

Out-of-school time academic programs

High school completion

School based health centers

Extended school day and year

Underlying question: Can social determinant interventions be used to promote health equity?

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Range of Variables Considered in Reviews of Educational Interventions to

Promote Health Equity Intervention characteristics, e.g., contents, intensity,

duration.

Student participation, e.g., proportion enrollment, program completion rate.

Educational outcomes, e.g., standardized achievement tests, levels of school completion, school grades.

Quality of school, e.g., high school completion rates, average test scores, teacher: student ratio or classroom size, hours of instruction.

School demographics, e.g., proportion minority, proportion receiving free or reduced-price lunch, community.

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Mean Adjusted Odds Ratio for General HS Completion Programs, by Program Type

Wilson SJ, Tanner-Smith EE, Lipsey, MW, Steinka-Fry, K, Morrison, J. Dropout prevention and intervention programs: Effects on school completion and dropout among school aged children and youth. Campbell Systematic Reviews 2011:8

Control Completio

nRate

76.0

73.4

81.6

53.8

81.0

92.9

83.6

72.3

80.9

83.7

70.3

91.0

Percent Gain

5.6

6.7

7.7

15.5

8.8

3.6

8.3

13.7

10.4

9.4

15.9

6.3

Weighted mean OR = 1.72 (95%CI 1.56, 1.90)

n = unique comparison pairsk = number of samples

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Major Challenge in Educational Intervention Reviews for Health Equity

Outcomes assessed are primarily educational, e.g., changes in reading or math achievement scores, or rates of high school graduation, not health outcomes

To draw conclusions about health outcomes, we have to:

make assumptions about the education—health link. Assumptions are frequently challenged and difficult to prove.

use evidence from other studies.

Linkage to heath outcomes would provide an enormous advance in this research

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Challenges of Linkage for this Committee: From EHR to Social Determinants

Inclusion of extensive set of social determinant data in EHR is undesirable and unnecessary; would be a large burden for health care system.

Use LINKAGE. Linkage should be purpose-driven, i.e., what are the goals, what question asked, what to be achieved?

Requires common, shared identifiers. Useful linkages may be either for the

individual in the record, e.g., years of school completed, or for an aggregate associated with the individual, e.g., quality measures of the school, or the poverty level in the census tract. (E.g., Krieger, www.hsph.harvard.edu/thegeocodingproject/)

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Residence(Address/census tract)

Allows linkage to community resources (and their absence), depending on data from other sources.

The Key Linkage Variable: Povert

yTransportatio

n

Employment/Industry

Justice

Fiscal resource

s

Housing/Physical

environment

Education

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The Residence Connection

Residence

Health characteristi

cs of students and

families

Education

School-based health centers

Early childhood education

High school

completion programs

Community Characteristi

cs

Extended day/year school time

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Summary: A Gap Separates EHR and Social Determinants of Health

Merits bridge building in both directions.

EHR cannot include large arrays of social determinant data.

EHR can link to wide variety of social determinant data.

Linking requires common variables. Because residence commonly

defines resources, it provides an optimal link between EHR and social determinant data.

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Community Guide

Discussion