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Putting “health” in the electronic health record: A call for collective action

        Statement of the Problem

        The American Academy of Nursing (Academy) endorses the capturing of social and behavioral determinants of health in the electronic health record (EHR). For this to happen, action must be taken to identify specific social and behavioral determinants of health (SBHD) to be included in a parsimonious panel to foster standardization and promote interoperability.
        Despite rapid technological advancements in the U.S. health system, care remains fragmented, uncoordinated, costly, and yields poor population health outcomes. Clinical care currently accounts for only 20 percent of health outcomes. To improve care and population health outcomes, healthcare providers must address other factors, including social determinants of health. To do this, we must first focus on addressing the variability in capturing and documenting social determinants in order to use this health data to benefit patients.
        Timing for action is now to leverage the recommendations within the Institute of Medicine (IOM) 2014 report Capturing Social and Behavioral Domains and Measures in Electronic Health Records (Phase 1 and Phase 2) (
        Institute of Medicine (IOM)
        Capturing social and behavioral domains and measures in electronic health records, Phase 1.
        ,
        Institute of Medicine (IOM)
        Capturing social and behavioral domains and measures in electronic health records, Phase 2.
        ) and to inform the regulations for the third stage of meaningful use incentive program. Meaningful Use Stage 3 is in development, and implementation for this stage is expected to start in 2017.
        This Policy Brief provides the Academy's recommendations for “collective action” required of multiple stakeholders to include social and behavioral determinants of health to really put “health” in electronic health records to improve care and health outcomes. Multiple stakeholders include, but are not limited to, patients, families, population aggregates, providers, healthcare organizations, professional organizations, and industry partners.

        Background and Significance

        The increasing focus on the relatively poor health status of the U.S. population and unsustainable high costs of health care prompted implementation of new incentive structures such as the Patient Protection and Affordable Care Act (ACA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). Despite strong evidence that social and behavioral factors influence health, they have not been consistently addressed in clinical care.
        Several barriers to adoption of the IOM's Phase 2 recommendation have been identified as targets to address. The Phase 2 recommendation calls for implementation of a standardized assessment panel of approximately 20 questions addressing: Alcohol use; Race/Ethnicity; Residential address; Tobacco use; Median household income; Depression; Educational attainment; Financial resource strain; Intimate partner violence for women of reproductive age; Physical activity; Social isolation; and Stress. Discussion of these barriers follows:

        Lack of Commitment to Standardization of Clinical Practice, Documentation and Data

        An overarching barrier is the reliance on technology platforms at the expense of practice platform to achieve the “triple aim” of improving the patient experience of care, improving the health of populations and reducing the capita of cost of health care (
        TIGER Report
        The leadership imperative: TIGER's recommendations for integrating technology to transform practice and education.
        ,
        • Wesorick B.
        Essential Steps for Successful Implementation of the EHR to Achieve Sustainable, Safe, Quality Care.
        ,
        • Wesorick B.
        • Doebbling B.
        Lessons from the field: The essential elements for point-of-care transformation.
        ). Not understanding the necessity of balancing the technology-practice platform polarity is a major barrier to appreciating and adopting standardization of practice standards and data. Several national calls for action for “sharable and comparable” data to support practice and translational research have also been identified which would include data related to the SBDH (
        Big Data Proceedings Report
        Capturing nursing information for big data research and improve health outcomes.
        ,
        • Clancy T.
        • Bowles K.H.
        • Gelinas L.
        • Androwich I.
        • Delaney C.
        • Matney S.
        • Westra B.
        A call to action: Engage in big data science.
        , ,
        • Westra B.L.
        • Latimer G.E.
        • Matney S.A.
        • Park J.I.
        • Sensmeier J.
        • Simpson R.L.
        • Delaney C.W.
        A national action plan for sharable and comparable nursing data to support practice and translational research for transforming health care.
        ). Of most significance, even when standardization is provided in EHRs based on evidence, the tendency for local customization is prevalent and therefore has an impact on consistency in clinical practice, documentation and the ability to use clinical data for research (
        • Bowles K.
        • Potashnik S.
        • Ratcliffe S.J.
        • Rosenberg M.
        • Shih N.W.
        • Topaz M.
        • Naylor M.D.
        Conducting research using the electronic health record across multi-hospital systems: Semantic harmonization implications for administrators.
        ).

        Lack of Consistency and Ease of Use of Clinical Workflow within EHR Technology

        Usability and clinical application design of EHR technology has long been a concern for nurses at the point of care which calls for more clinician engagement and research into designs of systems (
        • Staggers N.
        • Troseth M.
        Usability and clinical application design.
        ,
        TIGER Report
        Designing usable clinical information systems: Recommendations from the TIGER usability and clinical applications design collaborative team.
        ). Patient and clinician safety depends on the sound design of health IT including usability, interoperability and assuring the appropriate balance of standardization and customization (
        Institute of Medicine (IOM)
        Health IT and patient safety: Building safer systems for better care.
        ). Poor ease of use and customization can prevent the development of a widespread solution such as a national standard to capture social and behavioral determinants of “health” in EHRs.

        Need for Increased Patient Empowerment and Culture of Trust

        Respectful engagement with patients using personal health data is critical to the adoption of SBDH. A study on targeted patient populations using personal health records (PHRs) has shown that while patients care about privacy, they are more concerned about being able to access and use their health information in ways they choose (
        Robert Wood Johnson Foundation Report (RWJF)
        Project HealthDesign: Rethinking the power and potential of personal health records.
        ). At national levels, work is being done to adopt patient engagement strategies moving clinicians from information providers to supporting patients in their own e-community and providing resources for successful patient and family engagement (, ).

        Action Items

        Recommended Action Item for Vendors

        The Academy calls on EHR vendors to provide mechanisms for documenting IOM recommended social and behavioral determinants of health, mapped to standardized terminologies such as SNOMED-CT (Systemized Nomenclature of Medicine-Clinical Terms) and LOINC (Logical Observation Identifiers Names and Codes).

        Recommended Action Item for Health Systems

        The Academy calls on health systems to include social and behavioral determinants of health to be addressed in their documentation standards; implementation of patient engagement strategies such as promoting opportunities for patients to contribute to their personal information and data; and to link care needs to community health and social resources.

        Recommended Action Item for Nurses, Physicians and Other Clinicians

        The Academy calls on clinicians to take a stand on adopting the SBHD common assessment standard, and use the information as the foundation to collaborate in developing a plan of care that is individualized for each patient across the continuum of care.

        Recommended Action for Funders

        The Academy calls for funders to prioritize funding for research that includes assessing the impact of social and behavioral determinants of health into electronic health records.

        Acknowledgment

        We gratefully acknowledge the American Academy of Nursing's Informatics & Technology Expert Panel leaders Michelle R. Troseth, MSN, RN, DPNAP, FAAN, Thomas R. Clancy, PhD, MBA, RN, FAAN, Jane Englebright, PhD, RN, CENP, FAAN, and Dee McGonigle, PhD, RN, CNE, FAAN, ANEF for authoring the policy brief. We acknowledge the assistance of Lillee Gellinas, MSN, RN, FAAN, Patricia Brennan, PhD, RN, FAAN, and Eileen Sullivan-Marx, PhD, RN, FAAN as well as the expert panel 2014 Chairs from Quality, LGBTQ, Military/Veterans, Bioethics and Building Healthcare System Excellence, and all Informatics & Technology expert panel members who contributed to the Policy Dialogue and review of this policy brief.

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