Implementing an EHR-based Screening and Referral System to Address Social Determinants of Health in Primary Care

Social determinants affect health, yet there are few systematic clinical strategies in primary care that leverage electronic health record (EHR) automation to facilitate screening for social needs and resource referrals. An EHR-based social determinants of health (SDOH) screening and referral model, adapted from the WE CARE model for pediatrics, was implemented in urban adult primary care.

This study aimed to: (1) understand the burden of SDOH among patients at Boston Medical Center; and (2) evaluate the feasibility of implementing a systematic clinical strategy to screen new primary care patients for SDOH, use EHR technology to add these needs to the patient's chart through autogenerated ICD-10 codes, and print patient language-congruent referrals to available resources upon patient request.

This observational study assessed the number of patients who were screened to be positive and requested resources for social needs. In addition, we evaluated the feasibility of implementing our SDOH strategy by determining the proportion of: eligible patients screened, providers signing orders for positive patient screenings, and provider orders for resource referral guides among patients requesting resource connections.

In total, 1696 of 2420 (70%) eligible patients were screened. Employment (12%), food insecurity (11%), and problems affording medications (11%) were the most prevalent concerns among respondents. In total, 367 of 445 (82%) patients with ≥1 identified needs (excluding education) had the appropriate ICD-10 codes added to their visit diagnoses. In total, 325 of 376 (86%) patients who requested resources received a relevant resource referral guide.

Implementing a systematic clinical strategy in primary care using EHR workflows was successful in identifying and providing resource information to patients with SDOH needs.