Why IT is crucial for tracking social determinants of health

Each visit to a physician involves data collection. From the moment patients walk in the door, data is collected by registration, the billing department, the provider and in other areas. These data pieces all converge to become part of the whole view of the patient.

In the past, data collected was more focused on past medical history, disease states and strictly medical issues. In recent years, however, the realization that social determinants of health are critical indicators of a patient’s success or failure to comply with a treatment plan is finally gaining acceptance in the healthcare industry – especially for at-risk populations.

These factors help providers gain deeper insights into a patient’s background so they can tailor healthcare services directly to their individual circumstances, ultimately reducing costs through care coordination and preventative care.

The challenge lies in the lack of interoperability across the multiple platforms in which the patients’ data is collected and stored, including ACOs, IDNs, health systems and their associated EMRs, patient portals and more. This lack of data access leaves providers unable to see the whole picture when it comes to their patients—anything from missing an appointment, to not knowing if a patient could afford his medication or even whether he is compliant with his medication regimen.

With the advent of master data management (MDM), all the pieces of the puzzle can be aggregated into one place, enabling a “golden view” of the patient. A next-generation MDM solution enables healthcare organizations to match data across multiple systems to create a single, unique and accurate patient record.

With today’s onslaught of social determinant data, more pieces of the patient puzzle are being discovered and considered. According to Dale Sanders, president of technology for Health Catalyst, “With a few rare exceptions, healthcare delivery systems have never had to deal with the socioeconomic and social determinants of health to the degree that public health systems have faced.”

But times are changing, as evidenced by the move to value-based care, and the recent overhaul of the Department of Health and Human Services, announced on July 11, which has restructured all major public-assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP) and WIC (Women, Infants and Children) to be moved under the HHS’ Administration for Children and Families (ACF) umbrella.

According to the Healthy People 2020 initiative from the US Office of Disease Prevention and Health Promotion, social determinants of health are “conditions and environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Examples can include social support, public safety, safe housing, access to food, access to healthcare, education, transportation, access to technology, literacy, exposure to crime, violence and poverty.

In recent years, more focus has been placed on social determinants of health. According to the Robert Wood Johnson Foundation, “80 percent of clinical outcomes are attributable to the social determinants of health.” According to a July 2017 JAMA article, the average life expectancy is 15 to 20 years shorter in low-income communities than in more affluent communities.

A study by the CDC confirms these findings and goes on to note, “Individuals that fell into that low-income category had the worst health outcomes compared to all other income level categories across a variety of chronic diseases and illness including strokes, diabetes, chronic arthritis, hearing, vision, teeth loss, chronic bronchitis, and more.”

As social determinants of health have increasingly become part of the medical sphere over the years, patients are now being viewed as not just a medical condition or diagnosis, but as individuals whose circumstances have been shaped by their financial, religious, physical and social environments.

When organizations implement MDM, social determinants data can be accessed and patients can expect better outcomes because:

• Data is pooled from multiple data points or electronic medical records to offer the most complete picture possible. The provider knows about past medical problems as well as income status, safe housing and access to food. They are aware if their patient has a high-risk occupation (working in an industrial environment with exposure to asbestos, for example) that may predispose them to certain medical conditions (mesothelioma, lung and other cancers, asbestosis) and can recommend more frequent screening exams.
• Patients have a higher level of trust because they feel their provider knows their situation and cares about their health. If a provider recommends a certain screening test because they know about a patient’s occupational hazards based on access to this type of data, the patient feels cared for and it is easier to establish trust and promote compliance with recommendations, ultimately leading to better outcomes.
• When patients engage with healthcare providers early, a provider may be able to predict and prevent a hospitalization or disease state. If a patient’s family member has Type II diabetes, the provider may take steps to help prevent the patient and other family members from going down the same path. Providers may recommend earlier screening tests and make a referral to a dietician to encourage lifestyle changes that may help prevent the disease altogether.

Ignoring social determinants of health can be detrimental to both patient outcomes and to revenue. For example, it’s not uncommon to hear of ACOs missing their shared savings targets by hundreds of thousands of dollars because they lack a holistic view of patients’ ability to gain transportation to an appointment for costly treatment or procedures.

It is because of situations like these that more and more organizations are investing millions to focus on social determinants of health. Intermountain Healthcare and UnitedHealthcare recently announced they are investing $12 million and $1.95 million, respectively, because, as Ellen Sexton, CEO of UnitedHealthcare Community Plan of Wisconsin noted, “It’s difficult for people to improve their health, build primary care relationships and address preventive healthcare needs if they can’t feed their families or don’t have stable housing.”

With MDM, providers are now able to:

• Gain insights to maximize revenue and minimize costs. If providers know how many patients in their profile have a certain chronic medical condition, take a certain medication, or need transportation to appointments, they can aggregate this data and determine the most effective treatment plan or suggest a screening test that may prevent a hospitalization, and reduce overall costs.
• Be proactive versus reactive. Providers can make better decisions for their patients based on having more information—if a provider knows what type of shelter, food, and employment a patient has, he or she can change treatment plans, and help prevent diseases or adverse events based on that knowledge.
• Track outreach to change social behavior. The motivators for a low-income smoker to quit may be entirely different from those of a high-earning smoker. MDM enables tracking of nuances such as motivation factors, preferred mode of communication (email, phone call, traditional mail), and native language to enable better understanding of the patient that can increase revenue, decrease costs, improve patient care, and promote trust between patient and provider.

Value-based care is the new reality for healthcare. Utilizing a next-generation MDM solution will be key to maximizing revenue, managing high-risk patient populations, optimizing cost savings, and providing the best quality care to patients.