Jennifer Goldman, DO, chief of primary care of Hollywood, Fla.-based Memorial Healthcare System, worked with internal and external IT experts to have social determinants of health not only included in its Epic EHR system, but made it a prominent feature of clinical teams, case managers and others so it wouldn't be overlooked.
According to Dr. Goldman, social determinants of health make up 80 percent of a patient's overall health, and for far too long patients, who didn’t have access to affordable food, caregivers, transportation, childcare, stable housing or money for medication and co-pays would be labeled "non-compliant" if they didn't keep appointments or follow a post-visit care plan.
With more than 15 years of experience practicing community medicine, Dr. Goldman began advocating that these issues that impact health should not only be considered by medical teams in their patient interactions, but to include them into the EHR system so that Memorial could proactively connect staff to any and all hospital or community resources that could provide assistance to patients struggling with those issues.
Becker's spoke to Dr. Goldman about the process of working with her health system's IT teams to make this happen and why integrating social determinants of health into a hospital's EHR system is important to the overall health of patients.
Question: You worked with internal and external IT to have social determinants of health not only included in its electronic medical records, but to make it a prominent feature of clinical teams – what did this process look like and what kinds of people were involved in this process?
Dr. Jennifer Goldman: I was able to work with our internal IT department, which means our ambulatory IT specialists, the people who are experts in translating what we need clinically into something that works operationally within the IT space.
I also worked with Epic as we needed to use national resources to find out what's possible.
Q: How are you screening for social determinants of health?
JG: Our care team is made up of health coaches, case social workers and nurse navigators. We are in primary care, so we have incorporated these resources into our practices, whether it's on-site or remotely.
When we started our journey and screening for social determinants of health, we focused on patients who were going to the emergency room or the hospital on a very regular basis, and patients who had very uncontrolled chronic conditions like diabetes or high blood pressure.
Our next phase was to move screening and to revamp how our medical assistants were asking patients questions about the kinds of social determinants of health they are struggling with.
Lastly, we're going to operationalize screening across the healthcare system utilizing our Epic EHR system and MyChart. MyChart will help send out questionnaires to patients that allows them to complete prior to their visit.
This will be particularly helpful to our busiest specialists in offices where it's not been a priority.
Q: What kinds of social determinants are addressable?
JG: This really involves interplay between hospitals, the community and as well as all other organizations within the community who are looking to address social determinants and equity.
For example, there are other agencies working at the county level and state level that are working with organizations to address housing insecurity.
Healthcare providers can now link every single patient who has been positive for a social determinant of health and link them to a social worker, and that social worker can direct them to programs that are available to help them.
At our health system, we have a legal partnership that allows attorneys to take referrals from us and from our social workers to help patients with legal cases for free.
Q: What were the challenges of advocating for this/implementing this into the EHR?
JG: The challenges in terms of advocacy has to do with how you can make workflow easier, but I'm most proud of the fact that we've been able to integrate social determinants of health into the workflow for our clinicians without our clinicians having to do extra work.
That means that once somebody screens positive for a social determinant, a development tool pops up in front to show what the patient was positive for — housing insecurity, food insecurity, caregiver fatigue. A clinician can add that to the problem and at the same time, click a button that allows an email with an EHR of the patient to go directly to our social workers.
The second thing in advocacy has to do with really educating providers on how social determinants of health affects patient health outcomes.
In educating surgeons, I began to speak to them about the data that already exists and showed them that somebody who has lived without secure housing has a higher rate of having a complication, or a readmission to the hospital than somebody who doesn't have food or housing insecurity.
Being able to show data that we've already done nationally shows clinicians that if you pay attention to these things you can increase somebody's likelihood of having a conversation from a procedure that you're about to do. That's powerful for clinicians to really see the data from an advocacy standpoint.
Q: Now that you're asking patients social determinants of health questions, how have you seen this impact the care that they receive?
JG: I think that it's done a couple of things. Number one, is it really opened our eyes as clinicians to understanding what our patients are going through.
It's always been a pet peeve of mine, when a clinician uses the word non-compliance during a documentation of an office visit. And that's because you really don't have the ability to write down that they're not compliant with your recommendations when there's so many other things that are going on.
So when you're prescribing a complicated regimen of medications for somebody, and then you find out that they're living on a friend's couch, you realize how difficult it was to actually comply with the regimen.
It's something that we should be doing in healthcare anyway, that is customizing the treatments based on what our patients need.