What are the challenges and potential solutions for nurses when using technology to gather and utilize Social Determinants of Health (SDOH) information?

Challenges and Solutions for Nurses Using Technology to Gather and Utilize SDOH Information

Nurses face significant technological and systemic barriers when collecting SDOH data, including lack of standardized vocabularies, inadequate EHR integration, the digital divide affecting both patients and providers, and insufficient workflows for screening and referral—but these can be overcome through adoption of standardized data elements, leveraging existing frameworks like the Health Level 7 Gravity Project, and developing interprofessional care teams with dedicated informatics expertise.

Key Technological Barriers

Data Standardization and Interoperability Challenges

The most fundamental barrier is the lack of standardized vocabulary and data formats across health information systems. Varying data definitions, data formats, data encoding, and absence of standardized vocabularies limit the capacity of computer systems to transmit SDOH data seamlessly 1. The ambiguity of clinical concepts and terminologies makes standardization a laborious task demanding considerable time and specialized knowledge 1.

• Health systems struggle with highly variable data structures even for basic demographic factors like race and ethnicity across different EHR solutions 1
• Individual-level composite SDOH measures have not been adopted at scale, unlike area-level composites, because detailed individual-level SDOH collection has not been achieved systematically 1

EHR Integration and Workflow Issues

Healthcare systems widely adopt SDOH assessments through electronic health record screening questions, but implementation of associated workflows and interventions remains problematic. 2

• Health systems must create processes for screening, risk assessment, and ongoing identification of at-risk patients, requiring optimization of healthcare resources including expertise from informatics and technology 1
• Developing systems that facilitate routine data collection, storage, and retrieval of patient SDOH data for individual care planning remains a significant challenge 1

The Digital Divide

The rapid digital transformation, accelerated by the COVID-19 pandemic, magnified gaps in the digitally enabled ecosystem, creating barriers for both patients and providers. 1

• Limited access to broadband internet is associated with higher cardiovascular mortality at the state level 1
• The digital divide includes lack of access to broadband internet, affordable digital devices, and availability of user-centered digital health platforms like patient portals and telemedicine tools 1
• Digital health literacy—the ability to seek, understand, and appraise health information from electronic resources—varies widely among patient populations 1

Technology Access Disparities

Barriers to equitable SDOH data collection exist at multiple levels including the health system, payor, clinic, healthcare professional, and individual levels. 1

• Low participation in technology-enabled SDOH programs can result from lack of referrals, logistical issues including accessibility and timing, and lack of perceived benefit 1
• Patients with limited English proficiency or non-English language preference face compounded barriers when health information and consent forms are not available in formats easily understood 1

Evidence-Based Solutions for Nurses

Adopt Standardized Frameworks

Nurses should leverage the Health Level 7 Gravity Project, which provides consensus-based, comprehensive data standards specifically designed for SDOH data in EHR systems. 1

• The Gravity Project has developed standard vocabulary and coded terminology to represent SDOH concepts in EHRs and digital health technologies across clinical and community settings 1
• It provides FHIR-based implementation guides supporting nationwide exchange of SDOH data, with real-world pilot programs connecting clinical settings to community referral platforms 1
• The project's work is open source and technology-agnostic, enabling public use nationwide 1

Implement Systematic Screening Processes

Adopt standardized SDOH assessment tools as part of routine care and develop clinical triggers within EHR systems to alert providers when SDOH challenges may be present. 1

• Integrate SDOH assessment and data collection into routine care, similar to other risk factors 1
• Implement patient registration processes and electronic health record templates specifically designed for SDOH data capture 1
• A multilevel diabetes care intervention combining clinical outreach with SDOH screening and referrals to social needs support documented a 15% increase in receipt of services 1

Leverage Digital Health Technologies Strategically

Nurses should serve as technology champions within their practice, recognizing that digital health technologies can be effective modes of intervention delivery when properly implemented. 1

• Telehealth-based interventions produce A1C reductions of 0.30 percentage points compared with control, with outcomes comparable to or better than traditional in-person care 1
• Digital methods including mobile apps, websites, digital coaching, and SMS texting provide effective SDOH intervention delivery when engagement is maintained 1
• Diabetes care and education specialists need specialized knowledge about technology-enabled services to effectively implement these tools 1

Build Interprofessional Collaborative Teams

Design and implement interprofessional care teams that maximize patient access to varied perspectives and skill sets, specifically including informatics expertise. 1

• Interprofessional teams facilitate self-care and navigation across the healthcare system more effectively than individual providers 1
• Teams should include members with specialized clinical knowledge and behavior change principles, along with informatics specialists 1
• Collaborate with community partners to develop programs identifying patients with various SDOH needs 1

Address Health Literacy and Language Barriers

Healthcare systems must promote health literacy by ensuring information about services, test results, and other factors is available and understandable to diverse populations. 1

• Capture native languages spoken by patient populations to ensure health information is provided in formats most easily understood 1
• Provide culturally sensitive information, videos, and easy-to-read print material alongside technology-based resources 1
• Promote digital health literacy to facilitate access to telemedicine tools and evidence-based digital interventions 1

Utilize Existing Data Resources

Leverage the Agency for Healthcare Research and Quality SDOH Database, which maintains easily linkable SDOH-focused data elements corresponding to five key domains. 1

• Variables correspond to social context, economic context, education, physical infrastructure, and healthcare context 1
• Files can be linked using geographic data including county, zip code, and census tract 1

Critical Implementation Considerations

Avoid Common Pitfalls

When implementing SDOH screening, concerns exist that screening without sensitivity, cultural competence, or ready intervention may compromise therapeutic relationships and marginalize patients. 2

• Ensure screening is done with appropriate sensitivity and cultural competence 2
• Have clear workflows and available interventions before implementing widespread screening 2
• Recognize that SDOH assessments may not occur annually or be performed systematically even within integrated health settings 3

Recognize Ongoing Limitations

Despite improvements, SDOH code utilization data shows that systematic documentation remains incomplete, with only 28.8% of participants having at least one SDOH record over a 6-year period in one large integrated system. 3

• Much work is needed to develop universal screening tools and mandate routine SDOH evaluations 3
• Research examining effectiveness of interventions continues to be scarce, with most real-world interventions based on expert opinion rather than rigorous evidence 1