Electronic health records do not accurately reflect some social determinants of health, a new study published in JAMA found.
Screenings of food insecurity, housing instability and financial strain in adult primary care were found to reach varying levels of accuracy. The results of 826 patient self-reports revealed that EHR questionnaires were successful at highlighting patients battling food insecurity while those experiencing housing instability or financial strain were less likely to be flagged. If not identified, patients who could benefit the most from additional resources may be missed.
“This is an area of care that's really critical but kind of outside the classic clinical care model,” co-principal investigator of the study Joshua Vest, Ph.D., told Fierce Healthcare. “Physicians and nurse practitioners didn't go to school for this; they didn't train on how to deal with these issues. It really requires thinking outside the traditional healthcare paradigm for both screening and then working on referrals.”
From January to September 2022, patients were plucked from 11 primary care clinics in Indianapolis and Gainesville, Florida, to receive a follow-up questionnaire in either English or Spanish after responding to an EHR-based survey. Of patients offered surveys during clinic visits, 74% responded; of those reached by phone, only 4.2% responded.
The results between EHR-based surveys and follow-up questionnaires created by researchers helped reveal the accuracy of the former. Results between the two modes were comparable when it came to food insecurity but not when looking at housing instability or financial strain.
Vest said this gap was due to the U.S. Department of Agriculture’s (USDA's) long history of assessing Americans' food insecurity through telephone surveys.
The USDA has been measuring the extent and severity of food insecurity and hunger since 1995. Questions assessing hunger have undergone refinement over the nearly 30 years of the assessment in order to reach the most accurate reflection of need.
“The food screening tool has a kind of long history in usage in a broader context, so there's been a lot of work around it and trying to make it as tight and as efficient as possible,” Vest said. “Moving into this individual space is a newer area for it, but it was something I thought would be a little bit more successful.”
The USDA defines food insecurity as “a household-level economic and social condition of limited or uncertain access to adequate food.” The department currently estimated that 34 million people, including 9 million children, in the U.S. are food insecure. In 2021, 53 million people utilized food-support programs. Throughout the country, every county has food insecurity.
In September 2022, the White House reconvened its conference on hunger, nutrition and health for the first time in half a century. The event united a slew of health and wellness organizations to accumulate $8 billion in commitments to address the issue across various sectors.
EHR screening tools around housing were better at identifying people who had no risk than people who were actually at risk. Housing insecurity as assessed by the U.S. Census Bureau revealed that 3.7 million people reported housing insecurity in 2021.
However, Harvard University’s annual housing report (PDF) showed that in 2022 rent increased 12% and home prices increased at least 9% in 33 major markets. The report also stated that increased housing programs made available to patients led to “fewer unplanned hospitalizations and greater adoption of preventive care.”
“The goal is always to find people in need to get them to the services they want,” Vest said. “To do that, you have to be able to effectively screen. Organizations are spending a lot of time, a lot of effort and a lot of money on screening activities. Without understanding screening performance, it becomes really hard to understand what the organizational impacts are going to be.
Vest added, "As we move forward to more and more emphasis on population health, on prevention, on dealing with upstream factors, with helping patients avoid costly care, these are one of the big drivers. It's not surprising that organizations looking for ways to reduce cost, reduce unnecessary utilization, actually improve patient's health and wellbeing, are trying to understand and identify patients with these risks.”
As a previous local health practitioner, Vest said he is a strong believer in prevention and the role of social determinants. Vest is now a professor of health policy and management at the Fairbanks School and a research scientist at the Regenstrief Institute.
The institute researches health innovations to improve patient outcomes in a plethora of areas including interoperability of EHR systems, improving patient-physician communications and usability of remote patient monitoring systems.
This month, the Regenstrief Institute welcomed new CEO Rachel Patzer as chosen by the institute’s partner Indiana University (IU) School of Medicine, the largest medical school in the country.
“Data is critical, but it won’t improve health on its own. You must connect with the community to use that data in order to make an impact, and Dr. Patzer has shown her ability to do that during her time at Emory,” said Tatiana Foroud, executive associate dean for research affairs at the IU School of Medicine and vice chair of the Regenstrief board of directors, in a press release. “Dr. Patzer’s experience in establishing the connection between methodology and clinical practice will be key to making a meaningful impact on the health of people in our state, our nation and around the world.”