Patients in Context — EHR Capture of Social and Behavioral Determinants of Health

Abstract
There is substantial evidence that a number of social and behavioral factors contribute to the onset and progression of disease and affect mortality. Among these factors, only smoking and use of alcohol are commonly addressed in clinical practice. Other social and behavioral factors, including low income, low levels of education, lack of exercise, and stress, have been largely ignored by physicians because they are considered outside the scope of medical practice. However, accumulating evidence has linked these factors to the onset and progression of arthritis, asthma, and diabetes, and cardiovascular disease, as well as overall mortality. Calls have been made for organized medicine to address these factors. Several developments, including increasing use of electronic health records (EHRs), have provided the opportunity to do so. The use of EHRs has increased in recent years; more than 70% of office-based US physicians use an EHR system. Digitized information on standard measures of social and behavioral determinants can be obtained and stored. The authors of this commentary were cochairs of an expert committee of the Institute of Medicine (IOM) who were asked to recommend social and behavioral determinants that should be incorporated into EHRs and to evaluate methods to effectively include such information, as well as ways to overcome barriers to use of EHR data. Members of the committee were social scientists, clinicians, public health experts, and informatics experts. The committee reviewed data in the literature to identify social and behavioral determinants strongly associated with health that could be effectively evaluated for inclusion in EHRs. The committee developed a concise panel of measures covering 12 social and behavioral domains that can be asked by physicians and then incorporated into EHRs. The panel included questions on race or ethnic group, level of education, finance-resource strain, depression, physical activity, use of tobacco, use of alcohol, and social connection or isolation. The authors anticipate a minimal effect on physician workflow in light of the measures being primarily self-reported by patients and necessary to assess only at the initial intake visit. Special attention must be given to privacy, security, and access. The benefits of adopting and using this measurement panel are substantial; health care costs can be reduced, and patient-centered and accountable care can be provided. It is hoped that the panel of social and behavioral determinants recommended for inclusion into EHRs by the IOM Committee will be adopted by physicians and health systems.