CAPTURING SOCIAL & BEHAVIORAL DOMAINS & MEASURES IN
CAPTURING SOCIAL & BEHAVIORAL DOMAINS & MEASURES IN ELECTRONIC HEALTH RECORDS: PHASE 2 Nancy E. Adler, PhD Committee Co-Chair William W. Stead, MD Committee Co-Chair Committee on Recommended Social & Behavioral Domains & Measures for Electronic Health Records (EHRs) BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE COMMITTEE MEMBERS NANCY E. ADLER, PH.D. (Co-Chair) University of California, San Francisco
WILLIAM W. STEAD, M.D. (Co-Chair) Vanderbilt University CHRISTOPHER B. FORREST, M.D., PH.D. ERIC B. LARSON, M.D., M.P.H., M.A.C.P. University of Pennsylvania and Children's Hospital of Philadelphia Group Health Research Institute JAMES S. HOUSE, PH.D. University of Michigan KIRSTEN BIBBINS-DOMINGO, PH.D., M.D. University of California, San Francisco GEORGE HRIPCSAK, M.D.,
M.S. Columbia University PATRICIA F. BRENNAN, R.N., PH.D. University of Wisconsin-Madison ANA V. DIEZ-ROUX, M.D., PH.D., M.P.H. MITCHELL H. KATZ, M.D. Department of Health, County of Los Angeles KAREN MATTHEWS, PH.D. University of Pittsburgh School of Medicine DAVID A. ROSS, SC.D. Public Health Informatics Institute The Task Force for Global Health DAVID R. WILLIAMS, PH.D.,
M.P.H. Harvard School of Public Health Drexel University School of Public Health Study Fellow DEIDRA CREWS, M.D., Sc.M., FASN IOM Gilbert S. Omenn Anniversary Fellow Johns Hopkins University School of Medicine 2 COMMITTEE CHARGE THE COMMITTEE WAS ASKED TO: Identify domains for consideration by ONC for Stage 3 meaningful use; Determine criteria for selection; Identify domains and measures for inclusion in all EHRs; Consider implications of incorporating recommended measures into all EHRs; and
Identify Issues in linking other data systems. 3 TIMELINE PHASE 2 PHASE 1 4 TIMELINE PHASE 1 PHASE 2 PHASE 1
2 4 6 USEFULNESS FEASIBILITY ACCESSIBILITY 6 USEFULNESS INDIVIDUAL POPULATION HEALTH RESEARCH
7 CANDIDATE DOMAINS SOCIODEMOGRAPHIC DOMAINS BEHAVIORAL DOMAINS Sexual orientation Race/ethnicity Country of origin/U.S. born or non-U.S. born Education Employment Financial resource strain (Food and housing insecurity) Dietary patterns Physical activity Tobacco use and exposure Alcohol use PSYCHOLOGICAL DOMAINS
Health literacy Stress Negative mood and affect (Depression, anxiety) Psychological assets (Conscientiousness, patient engagement/ activation, optimism, self-efficacy) INDIVIDUAL-LEVEL SOCIAL RELATIONSHIPS & LIVING CONDITIONS Social connections and social isolation Exposure to violence NEIGHBORHOODS & COMMUNITIES Compositional characteristics 8 TIMELINE PHASE 2
STANDARD DOMAIN MEASURES Self-Efficacy: NIH Toolbox (10 Q) 3 Race/Ethnicity: OMB (2 Q) Race/Ethnicity: U.S. Census (2 Q) Optimism: LOT-R (6 Q) Education: Educational Attainment (2 Q) Dietary Pattern: Fruit and Vegetable Consumption (2 Q) Physical Activity: Exercise Vital Signs (2 Q) Tobacco Use: NHIS (2 Q) Social Connection and Isolation: NHANES III (4 Q)
Readiness Neighborhood and Community Compositional Characteristic: Residential address (1 Q) Sex Orientation: Self identity (1 Q) 2 1 Health Literacy: Chew et al (2008) (3 Q) Employment: MESA (1 Q) Financial Strain: Food Insufficiency (1 Q) Anxiety: PROMIS-7a (7 Q) Financial Strain: Overall Financial
Resource Strain (1 Q) Stress: Elo et al. (2003) (1 Q) Depression: PHQ-2 (2 Q) Alcohol Use: AUDIT-C (3 Q) Depression: PROMIS-8b (8 Q) Anxiety: GAD-7 (7 Q) Conscientiousness: Big Five Inventory (1 Q) Neighborhood and Community Compositional Characteristic: Census Tract-Median Income Stress: ACE (11 Q) Sex Orientation: Behavior (1 Q) Patient Engagement/ Activation: PAM
Country of Origin: U.S. Census (2 Q) Exposure to Violence: Intimate Partner Violence: HARK (4 Q) Self-Efficacy: Self-efficacy Scales for Specific Behaviors Financial Strain: Housing Insecurity (1 Q) 1 Physical Activity: Accelometer 2 Usefulness NOTE: Bolded items are domains that are already frequently collected.
3 COMMITTEE JUDGMENT 1= 2= 3= 12 CORE DOMAINS & MEASURES WITH SUGGESTED FREQUENCY OF ASSESSMENT DOMAIN/MEASURE MEASURE FREQUENCY Alcohol Use Race and Ethnicity Residential Address
Tobacco Use 3 questions 2 questions 1 question (geocoded) 2 questions Screen and follow up At entry Verify every visit Screen and follow up Census Tract-Median Income Depression Education Financial Resource Strain Intimate Partner Violence Physical Activity Social Connections & Social Isolation Stress 1 question (geocoded)
2 questions 2 questions 1 question 4 questions 2 questions 4 questions 1 question Update on address change Screen and follow up At entry Screen and follow up Screen and follow up Screen and follow up Screen and follow up Screen and follow up NOTE: Domains/Measures are listed in alphabetical order; domains/measures in the shaded area are currently frequently collected 13 in clinical settings; domains/measures not in the shaded area are additional items not routinely collected in clinical settings. FINDING
5-1 Four social and behavioral domains of health are already frequently collected in clinical settings. The value of this information would be increased if standard measures were used in capturing these data. 14 RECOMMENDATION 5-1 The Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services should include in the certification and meaningful use regulations the standard measures recommended by this committee for four social and behavioral domains that are already regularly collected: race/ethnicity, tobacco use, alcohol use, and residential address. 15
FINDING 5-2 The addition of selected social and behavioral domains, together with the four domains that are already routinely collected, constitute a coherent panel that will provide valuable information on which to base problem identification, clinical diagnoses, treatment, outcomes assessment, and population health measurement. 16 RECOMMENDATION 5-2 The Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services should include in the certification and meaningful use regulations addition of standard measures recommended by this
committee for eight social and behavioral domains: educational attainment, financial resource strain, stress, depression, physical activity, social isolation, intimate partner violence (for women of reproductive age), and neighborhood median-household income. 17 BENEFITS Benefits of including recommended measures in all EHRs include: MORE EFFECTIVE TREATMENT MORE EFFECTIVE POPULATION MANAGEMENT DISCOVERY OF LINKAGES 18
IMPLEMENTATION ISSUES SELF-REPORTED DATA LINKING DATA PRIVACY PROTECTION RESOURCE CONSIDERATIONS 19 FINDING 7-1 Standardized data collection and measurement are critical to facilitate use and exchange of information
on social and behavioral determinants of health. Most of these data elements are experienced by an individual and are thus collected by self-report. Currently, EHR vendors and product developers lack harmonized standards to capture such domains and measures. 20 RECOMMENDATION 7-1 The Office of the National Coordinator for Health Information Technologys electronic health record certification process should be expanded to include appraisal of a vendor or products ability to acquire, store, transmit, and download self-reported data germane to the social and behavioral determinants of health. 21
FINDING 7-2 The addition of social and behavioral data to EHRs will enable novel research. The impact of this research is likely to be greater if guided by federal prioritization activities. 22 RECOMMENDATION 7-2 The Office of the Director of the National Institutes of Health (NIH) should develop a plan for advancing research using social and behavioral determinants of health collected in electronic health records. The Office of Behavioral and Social Science Research should coordinate this plan, ensuring input across the many NIH institutes and centers. 23
FINDING 7-3 Advances in research in the coming years will likely provide new evidence of the usefulness and feasibility of collecting social and behavioral data beyond that which is now collected or which is recommended for addition by this committee. In addition, discoveries of interventions and treatments that address the social and behavioral determinants and their impact on health may point to the need for adding new domains and measures. There is no current process for making such judgments. 24 RECOMMENDATION 7-3 The Secretary of Health and Human Services should convene a task force within the next three years, and
as needed thereafter, to review advances in the measurement of social and behavioral determinants of health and make recommendations for new standards and data elements for inclusion in electronic health records. Task force members should include representatives from the Office of the National Coordinator for Health Information Technology, the Center for Medicare and Medicaid Innovation, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Institutes for Health, and research experts in social and behavioral science. 25 POTENTIAL NEXT STEPS JOURNAL ARTICLES REPORT DISSEMINATION
TOOL DEVELOPMENT 26 THANK YOU SPONSORS: The National Institutes of Health Blue Shield of California Foundation California HealthCare Foundation Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services The Department of Veterans Affairs The Lisa and John Pritzker Family Fund Robert Wood Johnson Foundation Substance Abuse and Mental Health Services Administration 27 BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE
QUESTIONS THE FULL REPORT IS NOW AVAILABLE FOR FREE DOWNLOAD AT: iom.edu/ehrdomains2 28 BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE MEASURE VERSUS METRIC Example: Physical activity MEASURE METRIC Exercise Vital Sign Metabolic equivalent task minutes (METs)
1. On average, how many Light intensity 1.1-2.9 days per week do you Moderate intensity 3.0-5.9 engage in moderate to Vigorous intensity >=6 strenuous exercise? (0-7) 2. On average, how many minutes do you engage in exercise at this level (blocks of 10 min) 29 STANDARD MEASURE Example: Tobacco Use RECOMMENDED SELF REPORTED MEASURE STAGE 2 MEASURE NHIS Questions
1. Have you smoked at least 100 cigarettes in your entire life? SNOMED Codes Current every day smoker Current some day smoker Former smoker Never smoker Smoker, current status 2. Do you NOW smoke cigarettes every day, unknown some days or not at all? Unknown if ever smoked Heavy tobacco smoker Light tobacco smoker 30
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