Skip to Main Content

By Geoff Caplea, MD, FAAFP, Allscripts Vice President of Clinical Affairs and Chief Medical Officer

The social determinants of health (SDOHs), or the circumstances in which people are born, live, learn, work, and play, have a profound effect on health outcomes. From food insecurity and unstable housing to lack of transportation access and low levels of health literacy, SDOHs are generally considered to influence 80% of patient outcomes, while clinical care is responsible for the remaining 20%.

The challenge before the health IT community is twofold: first, we need to improve our ability to identify detrimental SDOHs, design effective interventions, and consistently apply those interventions to high-risk populations. But we also need to maximize the value of our clinical care so we are doing everything possible around the 20% of outcomes we can more directly control.

To succeed with these dual objectives, we must continue developing a collaborative, interoperable, and user-friendly system that serves patient needs proactively and holistically — both within the walls of the clinic and in the larger community.

We know that’s easier said than done. But we also know how powerful it can be when we work together seamlessly across the continuum of care.

Let’s take the example of Mr. Whitmore, a recent widower in Raleigh, North Carolina who lives with COPD. Mr. Whitmore doesn’t drive and he’s on a fixed income, so getting his groceries and medications on a regular basis can be difficult.

Just a few short years ago, his primary care provider, Dr. Singh, would have been largely on her own to identify Mr. Whitmore’s socioeconomic and clinical needs. She would have to do all of the legwork to find local resources, coordinate referrals, and ensure that her patient has the health education he needs to make informed decisions every day.

Now, with the growing focus on data-driven, whole-person care, Dr. Singh has more of the tools she needs to stay one step ahead of Mr. Whitmore’s concerns.

For example, an algorithm in her EHR might flag Mr. Whitmore’s increasingly poor breathing indicators. A clinical decision support tool may recommend enrollment in a COPD management program to help him control his chronic disease. As part of the program, Dr. Singh might have a conversation about her patient’s non-clinical challenges, supplemented by the PRAPARE questionnaire to better identify specific SDOH factors and make sure they are documented appropriately in the EHR.

But with a new generation of digital tools, Dr. Singh can also go a step further. Instead of simply documenting Mr. Whitmore’s challenges, she can actively intervene.

She could search a local coordinated care network, such as NCCare360, and electronically refer Mr. Whitmore to a transportation service. Dr. Singh might also educate Mr. Whitmore about how air quality affects COPD symptoms and teach him how to use a third-party mobile app that tracks the air quality index every day. He could sign up for the patient portal and message Dr. Singh with questions instead of waiting for his next appointment to make a positive change.

Better health for Mr. Whitmore and millions of patients like him starts with robust, predictive tools in the EHR to deliver high-quality clinical care. And thanks to a burgeoning network of complementary health IT tools, our capabilities can extend into the community to address the other 80% of our patients’ needs.

As an industry, we still have more work to do before this scenario becomes an everyday occurrence. We need to continue collaborating on data standards and building interoperable pathways between EHRs and third-party apps and initiatives. We must keep making it easier to document SDOHs and access relevant insights in an actionable manner. And we need to continue aligning incentives to support whole-person care for all patients.

Can we achieve these goals? Yes, we certainly can. We are already making excellent progress. Now we must take what we know and use it as a launchpad for future innovation and discovery. By combining the power of EHRs with additional health IT tools and strategies, we can build a better system that improves outcomes for entire communities.

Learn more about SDOH and key drivers of change for your hospital.

About the Author


Geoff Caplea, MD, FAAFP, Allscripts Vice President of Clinical Affairs and Chief Medical Officer at Veradigm, an Allscripts business