james m. anderson center for health systems excellence james m. anderson center for health systems...
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James M. Anderson Center for Health Systems ExcellenceJames M. Anderson Center for Health Systems Excellence
Recommended Social and Behavioral Domains and Measures for Electronic
Health Records
Robert S. Kahn, MD MPH
Cincinnati Children’s Hospital Medical Center
November 25, 2013
Achieving Potential
Esteem and Respect
Belonging
Safety and Security
Physiological
What We See in Clinic Hierarchy of Needs How We Respond
• Unemployment• Lack of high school degree• Ex-offender reentry issues
• Food insecurity• Denial/delay of public benefits• Utility shut offs• Poor housing conditions
• Inadequate education services• Domestic violence• Adult mental health issues
• Distressed/depressed parents• Lack of parenting role models
Henize, Kahn
Benefits
Housing
ParentalDepression
Domestic Violence
Food Insecurity
Social Risk Screening
School Related Screening
EHR Referrals: Legal Aid Society
Current Month Referrals Oct. 2013
Last Month ReferralsSep. 2013
Last 12 Month Referrals
Nov. 2012 - Oct. 2013
Last 12 Month
Monthly Average
Last 12 Month Monthly Average
Rate of Referrals per 1000 Well Child Visits
SITESAll 83 71 774 65 24
PPC 59 49 577 48 31Fairfield 12 17 124 10 17Hopple 12 5 73 6 11
PROVIDERSAll 83 71 774 65
Resident 32 19 279 23Attending/Other 47 51 465 39
Social Worker (Direct) 4 1 30 3
Social Worker (Facilitated)* 14 19 155 13
Current Month Opened Cases
Oct. 2013
Last Month Opened Cases
Sep. 2013
Last 12 Month Opened Cases
Nov. 2012 - Oct. 2013
Last 12 Month
Monthly Average
% of Last 12 Month Monthly Average
CASE TYPEAll 56 40 608 51
Health/Income 17 17 188 16 31%Housing 24 16 249 21 41%Family 7 2 68 6 11%
Education 8 5 85 7 14%Misc. Legal 0 0 18 2 3%
*Referral preceded within 72 hours by
physician visit
Tracking of EHR-based Legal Aid Referrals
Referrals to the Health Department
Change in physician behavior
Percent with household food insecurity identified
Change in physician behavior
0
5
10
15
20
25
30
EHR driving social determinants focusAsthma admission rate per 1000 children, by neighborhood
EHR data driving focus on broader social risks
2-3 risks
Days from the index admission
1 risk
2-3 risks
0 risks
Pro
port
ion
wit
hout
reu
tili
zati
on
d
Days from the index admission
*Risks: census tract extreme poverty, adult educational attainment, median home value
Risks* Rate of asthma reutilization at 1y
0 30%
1 38%
2-3 45%
Broader social risks informing clinical care: Census tract-level risks and asthma reutilization risk
Additional considerations
• Intergenerational information from parents’ EHR– Prenatal/obstetric history– Family history (e.g., smoking, obesity)
• Information from school’s database– Grades, missed school days, suspensions
EHR-related studies in social determinants
• Beck AF, Sauers H, Kahn RS, Yau C, Weiser J, Simmons JM. Improved documentation and care planning with an asthma-specific history and physical. Hospital Pediatrics 2012; 2:194-201.
• Beck AF, Simmons JM, Huang B, Kahn RS. Geomedicine: area-based socioeconomic measures for assessing risk of hospital reutilization among children admitted for asthma. American journal of public health 2012;102:2308-2314.
• Burkhardt MC, Beck AF, Conway PH, Kahn RS, Klein MD. Enhancing accurate identification of food insecurity using quality-improvement techniques. Pediatrics. Feb 2012;129:e504-510.
• Beck AF, Klein MD, Schaffzin J, Tallent V, Gillam M, Kahn RS. Identifying and treating a cluster of substandard housing using a medical-legal partnership. Pediatrics. 2012; 130:831-8 .
• Beck AF, Simmons JM, Sauers HS, Sharkey K, Alam M, Jones C, Kahn RS. Connecting at-risk inpatient asthmatics to a community-based program to reduce home environmental risks: care system redesign using quality improvement methods. Hospital Pediatrics 2013;3:326-334.
• Klein MK, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children – outcomes from a successful partnership between professions. Journal of Health Care for the Poor and Underserved. 2013; 24:1063-1073.