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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
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Modeling Patients' Progression through Health-Related Social Needs.

Haleigh Kampman1, Ofir Ben-Assuli2, Joshua Vest1,3

  • 1Health Policy and Management, Indiana University, Indianapolis, Indiana, United States.

Applied Clinical Informatics
|September 19, 2025
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Summary
This summary is machine-generated.

This study tracked health-related social needs (HRSNs) over time using hidden Markov modeling. Most patients remained in low-risk states, while high-risk individuals faced persistent challenges, highlighting the need for interventions.

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Area of Science:

  • Health Services Research
  • Social Determinants of Health
  • Computational Health

Background:

  • Health-related social needs (HRSNs) significantly impact patient outcomes.
  • Longitudinal characterization of HRSN experiences is crucial for effective interventions.
  • Understanding population-level transitions between risk states is essential for public health strategies.

Purpose of the Study:

  • To characterize the longitudinal experience of health-related social needs (HRSNs) in a patient population.
  • To identify distinct risk states associated with various HRSNs.
  • To analyze patient transitions between these risk states over time.

Main Methods:

  • Utilized hidden Markov modeling (HMM) on electronic health record data from 2018-2020.
  • Employed natural language processing (NLP) to extract data on food, legal, transportation, employment, financial, and housing needs.
  • Compared characteristics and transition frequencies between identified risk states.

Main Results:

  • Five hidden states effectively modeled longitudinal HRSN experiences.
  • 80% of 48,055 patients fell into low-risk states (1 and 2); 17% were medium/high risk; 3% were very high risk.
  • Low/very high-risk patients transitioned states infrequently (approx. every 1.5 years), while medium/high-risk patients transitioned annually.

Conclusions:

  • Patient experiences of HRSNs can be longitudinally categorized into distinct risk states.
  • Low-risk patients may possess resources to maintain health, while very high-risk patients struggle with persistent needs.
  • Early screening and timely interventions are recommended to address persistent HRSNs and mitigate harm.