Identifying social risk via a clinical social history embedded in the electronic health record

Area of Science:

• Clinical Informatics
• Social Determinants of Health
• Pediatric Care

Background:

• Social determinants significantly impact health outcomes, yet social history is often underutilized in clinical practice.
• Effective integration of social history into routine care is crucial for addressing patient needs beyond clinical diagnoses.

Purpose of the Study:

• To evaluate the effectiveness of a novel electronic health record (EHR) template for documenting social risk factors in newborns.
• To determine the rates of social risk documentation and the prevalence of identified risks.

Main Methods:

• A retrospective review was conducted on 639 well-infant visits.
• A standardized social history template embedded within the EHR was utilized.
• Documentation rates, completion percentages, and prevalence of social risks were analyzed.

Main Results:

• Over 80% of clinicians documented asking at least one social history question.
• The most frequent question concerned financial stability ("making ends meet"), while personal safety was least common (79% vs. 57%).
• Approximately 30% of caregivers reported at least one social risk, with 11% reporting two or more.

Conclusions:

• An EHR-embedded social history template significantly increases documented social risk screening in pediatric visits.
• This approach effectively identifies a substantial proportion of families experiencing social risks, enabling targeted interventions.
• Routine screening for social determinants of health is feasible and valuable in newborn care settings.