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Readers Write: Social Determinants of Health and Interoperability

March 1, 2023 Readers Write No Comments

Social Determinants of Health and Interoperability
By Jada Parker

Jada Parker is a public health graduate student at George Washington University.


Social determinants of health (SDOH) have a huge impact on population health. SDOH can be defined as the conditions and environments where individuals are born, live, learn, work, play, worship, and age. Political determinants of health, such as voting patterns, government makeup, and policies, have led to SDOH and the resulting population health inequities.

SDOH can be divided into five domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social community context. These factors heavily influence health, functioning, and overall quality of life. Care management and community partnerships allow healthcare organizations to address patients’ social needs in areas such as housing, food security, financial assistance, and intimate partner violence.

Health IT can help physicians and clinicians address and understand how SDOH impact their patients’ overall health. Investments in health IT can also support care management in better addressing SDOH to improve patient health.

Interoperability across IT systems plays a pivotal role in addressing SDOH. When organizations can share patient healthcare data, community partnerships are strengthened and providers are able to provide more streamlined referrals to and better coordination with social service resource providers. Resource providers and care management teams are better able to help patients manage chronic conditions as well through care coordination with healthcare providers allowed by interoperability.

Patients who are experiencing homelessness provide a prime use case of how interoperability facilitates care coordination to address SDOH. Homelessness heavily influences overall health, as it may interfere with a patient’s ability to take their medication as prescribed. Homelessness can also result in multiple hospital readmissions for a number of reasons, including poor health management and that a night at the hospital may provide better conditions than a night at a shelter or outside.

Care coordination, improved by interoperability, allows physicians to make social care referrals and share information with necessary outside resource providers. Without interoperability between health IT systems, much of the burden of obtaining and keeping up with paper referrals and records falls on the patient.

Organizations like Administration for Community Living (ACL) provide IT solutions to support healthcare and community-based organizations partnering in order to provide social and whole-health care for the elderly and individuals with disabilities. ACL incorporates open application programming interfaces to provide resource directories through their Open Referral Initiative. These types of IT solutions streamline the referral process, improve care coordination, and strengthen community partnerships .

SDOH data gaps pose limitations to interoperability. However, there are emerging standards for using and sharing SDOH. The Gravity Project is working to define SDOH information so that it may be documented and shared across digital health and human service platforms. ONC Health IT Certification Program and ONC Interoperability Standards Advisory provide many of the current interoperability standards.

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