Health care providers are looking at a new and heavy lift as they move to accountable care and value-based reimbursement. Within the next decade or so, providers will no longer simply provide medical care when needed — they will be looking further to make sure that that care works and is necessary, to promote wellness, and to ward off the need for care whenever possible. Aside from being the right thing to do, the financial health of provider organizations depends on it.

Here's a big problem: Beyond genetics and biology (for which providers can help patients by staying alert and arranging for routine screenings), only 20 percent of patients’ health status is determined by clinical care, according to an analysis from the Robert Wood Johnson Foundation in collaboration with the University of Wisconsin Population Health Institute. Until recently, providers of that care haven't had to consistently take into account the other factors that determine health. Now they do.

So, what are those other factors? Personal health choices like tobacco use, diet and exercise account for 30 percent, according to the study. We can use apps and other consumer technology to steer patients to better choices; and of course, their care team will keep reminding them to quit smoking and lose weight.

Up to half of patients’ health

What’s left? The 40 percent that’s due to factors like income, education, size and quality of the social circle, literacy and language fluency, and other more intangible factors, and the 10 percent attributable to environmental factors like air and water quality and the availability of adequate housing and transportation. Together, these are called social determinants of health, or SDOH.

These SDOH factors have a major impact on patients’ overall health and on their ability to seek treatment and adhere to a care plan. If there's no supermarket in your neighborhood, following a healthy diet becomes significantly more challenging and expensive. If you are afraid to walk outside or can’t negotiate bumpy pavement, your exercise routine is likely to suffer. If your household is full of smokers or your neighborhood is next to a steel mill, it will be challenging to control your asthma. If you can’t read, you can’t read your doctor’s instructions; and if you live alone, there’s no one to read them to you. If you don’t have a car and have trouble walking to the bus, getting to the doctor becomes an almost insurmountable obstacle.

A 2014 study published in the journal Health Services Research looked at 30-day readmission rates for patients with acute myocardial infarction, heart failure or pneumonia, and linked them to publicly available county data from the Area Resource File, the U.S. Census Bureau, Nursing Home Compare, and the Nielsen Pop-Facts datasets. The study found that almost half of the variation in readmission rates among hospitals could be explained by where they were located — residents of some counties were more likely to be readmitted regardless of the quality of care they had received at the hospital.

SDOH impacts can be surprising. For example, a paper published in JAMA Cardiology in August 2017 revealed that only 18 percent of people who suffer cardiac arrest in a predominantly black neighborhood will receive CPR from a bystander, compared with 47 percent of people in a predominantly white neighborhood. A similar gap existed for use of defibrillators.

When it comes to social spending — the type of spending that might mitigate some of the problems caused by SDOH disparities — the United States is toward the bottom of the rankings among developed countries, according to an analysis from the Brookings Institution published in partnership with the University of Southern California Schaeffer Center for Health Policy and Economics last February. If you add what we spend on medical care, both publicly and privately funded, plus social care spending, the U.S. is in the middle of the pack of countries. For example, France, Sweden, Germany and the Netherlands spend more on medical care and social care combined than the U.S., and have better health outcomes for their populations. In the U.S., our “health care” expenditures are very skewed toward medical care, with underinvestment in social care.

The provider community is increasingly aware that it needs to take SDOH more fully into account as it cares for patients, especially as the pressure grows for providers to bear greater financial risk for outcomes. A recent Deloitte survey showed that more than 88 percent of hospitals do at least some screening for social needs, and that number jumps to 94 percent for larger hospitals and 93 percent for disproportionate-share hospitals. But that screening may be ad hoc rather than systematic, or limited to certain groups of patients. The survey also showed that 72 percent of respondents don't have a dedicated fund to address social needs even when they know about them, and action is spotty.

We must do better, and we can.

Addressing the social factors that influence health is a complex challenge. The factors are diverse, and at times moving the needle significantly seems almost impossible. However, these factors can be addressed. The Health Research & Educational Trust, for example, has started to produce a series of reports that guide provider efforts to improve SDOH by developing and leveraging community partnerships.

Harnessing SDOH with data

Information technology plays a critical role in these efforts. Specifically, information technology can assist providers by:

  • Capturing and analyzing data on SDOH for a population and/or a community.
  • Supporting the workflow of the care team as they help patients achieve better health outcomes through both clinical and social care plans.
  • Enabling patients to obtain and manage resources that help them address their social needs.

In this column, we’ll talk about the role of information technology in capturing and analyzing data on SDOH. Our next column will address the other two roles.

There are two ways to think about capturing data on SDOH. First, screening tools help collect patient-specific data to develop a more personalized understanding of an individual.

The federal Meaningful Use program gave a boost to this type of data capture by requiring certified vendors of electronic health records to add capabilities for collecting SDOH in 2015 Edition Certified EHRs: social, psychological and behavioral data, education level, financial resource strain, alcohol use, exposure to violence (either domestic or in the community) and social connection and isolation.

The Meaningful Use data model of SDOH joins other efforts to outline the data that should be collected. The Robert Graham Center’s Social Deprivation Index, Virginia’s Health Opportunity Index, and Connecticut’s Health Equity Index are alternative methods that organizations may be able to adapt to their unique needs.

This information gathered directly from patients is a start, though it's a challenge to determine the best place in the workflow to capture the data and to train clinicians or design systems to elicit honest answers to often sensitive questions.

These questions may need to be asked more than once since some factors can change over time. But at least some of the current generation of EHRs can help facilitate the process, and apps that allow patients to supply their own data to their EHR can supplement the data capture process.

But even assuming we gather all this individual patient information accurately, providers may still want broader context. The second way to think about capturing data on SDOH involves integrating other population-level data sources (such as agricultural, climate or census data) with clinical and claims data sources. For example, if we know that a certain ZIP code is associated with certain socioeconomic characteristics, we can wrap that knowledge into our assessments of patients who live in that ZIP code and get more accurate assessments of overall risk.

Fortunately, context is everywhere, from payers’ claims information to the Census Bureau to state and local databases like the ones used in the readmission study mentioned above. A number of companies have products that can help providers access and analyze external data, combine it with their existing patient data, and use it to monitor progress, allocate resources and create partnerships to address specific social obstacles to care.

With the aggregated data, the provider community can apply analytics to:

  • Look for links between geographical “hot spots” that have high medical costs and relevant SDOH in those areas.
  • Identify patients with risk factors related to SDOH.
  • Classify patients into groups based on health outcomes, utilization, cost or other relevant factors and divide them into low risk, rising risk and high-risk subgroups.
  • Link rising risk and high-risk patients to the appropriate community resources or care provider to help them mitigate their risks.

Providers can apply analytics to entire communities to do a comprehensive community health needs assessment. They can assess gaps in social and clinical needs, select priority community health issues and plan improvement strategies.

For example, a study of the data might reveal a large prevalence of homelessness in a geographic area that is also a “hot spot” for high medical costs. Public libraries often become a safe place for homeless people to take shelter. The health system and the public library may be able to work together on programs to address health issues and homeless issues. If a geographic region has lower-than-average availability for affordable housing due to restrictive zoning, the health system might partner with a law firm to help address zoning issues in the area. The results of these community-level, non-clinical interventions on health outcomes could be continually measured and reviewed through analytics.

To be continued

In the next column, we will discuss how IT can help providers develop and execute care plans that use SDOH, and make such planning an integral part of the clinical workflow. In addition, we will review patient use of IT to address the social determinants that they face.

Even though providers should not have to bear the entire responsibility for creating healthier environments for their patients, right now they have a lot to gain by embracing that responsibility, and a lot to lose by not doing so. It is time to get started.

Editor’s note: The American Hospital Association’s Task Force on Ensuring Access in Vulnerable Communities recommends addressing SDOH for preserving access to health care services. A report from the task force, including case examples and best practices, is available at

John Glaser, Ph.D., is senior vice president of population health with Cerner in Kansas City, Mo. He is also a regular contributor to H&HN’s website. Tanuj K. Gupta, M.D., MBA, is senior director and physician executive of population health with Cerner.

The opinions expressed by the authors do not necessarily reflect the policy of the American Hospital Association.