Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study

Karen A Monsen, Joyce M. Rudenick, Nicole Kapinos, Kathryn Warmbold, Siobhan K McMahon, Erica Schorr

Research output: Contribution to journalArticle

Abstract

Background: Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH. Objective: We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies. Methods: We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases. Results: In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p =.005). SBDH documentation in EHRs differed based on the presence of a nursing terminology. Conclusions: The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.

Original languageEnglish (US)
Pages (from-to)39-47
Number of pages9
JournalProceedings of Singapore Healthcare
Volume28
Issue number1
DOIs
StatePublished - Mar 1 2019

Fingerprint

Social Determinants of Health
Electronic Health Records
Terminology
Documentation
International Classification of Diseases
Systematized Nomenclature of Medicine
Health

Keywords

  • Omaha System
  • Social determinants of health
  • behavioral determinants of health
  • electronic health records
  • nursing terminologies

Cite this

Documentation of social determinants in electronic health records with and without standardized terminologies : A comparative study. / Monsen, Karen A; Rudenick, Joyce M.; Kapinos, Nicole; Warmbold, Kathryn; McMahon, Siobhan K; Schorr, Erica.

In: Proceedings of Singapore Healthcare, Vol. 28, No. 1, 01.03.2019, p. 39-47.

Research output: Contribution to journalArticle

@article{bd96d5e40ffc4042b72b7a18133151c4,
title = "Documentation of social determinants in electronic health records with and without standardized terminologies: A comparative study",
abstract = "Background: Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH. Objective: We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies. Methods: We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases. Results: In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p =.005). SBDH documentation in EHRs differed based on the presence of a nursing terminology. Conclusions: The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.",
keywords = "Omaha System, Social determinants of health, behavioral determinants of health, electronic health records, nursing terminologies",
author = "Monsen, {Karen A} and Rudenick, {Joyce M.} and Nicole Kapinos and Kathryn Warmbold and McMahon, {Siobhan K} and Erica Schorr",
year = "2019",
month = "3",
day = "1",
doi = "10.1177/2010105818785641",
language = "English (US)",
volume = "28",
pages = "39--47",
journal = "Proceedings of Singapore Healthcare",
issn = "2010-1058",
publisher = "SingHealth Academy",
number = "1",

}

TY - JOUR

T1 - Documentation of social determinants in electronic health records with and without standardized terminologies

T2 - A comparative study

AU - Monsen, Karen A

AU - Rudenick, Joyce M.

AU - Kapinos, Nicole

AU - Warmbold, Kathryn

AU - McMahon, Siobhan K

AU - Schorr, Erica

PY - 2019/3/1

Y1 - 2019/3/1

N2 - Background: Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH. Objective: We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies. Methods: We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases. Results: In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p =.005). SBDH documentation in EHRs differed based on the presence of a nursing terminology. Conclusions: The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.

AB - Background: Electronic health records (EHRs) are a promising new source of population health data that may improve health outcomes. However, little is known about the extent to which social and behavioral determinants of health (SBDH) are currently documented in EHRs, including how SBDH are documented, and by whom. Standardized nursing terminologies have been developed to assess and document SBDH. Objective: We examined the documentation of SBDH in EHRs with and without standardized nursing terminologies. Methods: We carried out a review of the literature for SBDH phrases organized by topic, which were used for analyses. Key informant interviews were conducted regarding SBDH phrases. Results: In nine EHRs (six acute care, three community care) 107 SBDH phrases were documented using free text, structured text, and standardized terminologies in diverse screens and by multiple clinicians, admitting personnel, and other staff. SBDH phrases were documented using one of three standardized terminologies (N = average number of phrases per terminology per EHR): ICD-9/10 (N = 1); SNOMED CT (N = 1); Omaha System (N = 79). Most often, standardized terminology data were documented by nurses or other clinical staff versus receptionists or other non-clinical personnel. Documentation ‘unknown’ differed significantly between EHRs with and without the Omaha System (mean = 26.0 (standard deviation (SD) = 8.7) versus mean = 74.5 (SD = 16.5)) (p =.005). SBDH documentation in EHRs differed based on the presence of a nursing terminology. Conclusions: The Omaha System enabled a more comprehensive, holistic assessment and documentation of interoperable SBDH data. Further research is needed to determine SBDH data elements that are needed across settings, the uses of SBDH data in practice, and to examine patient perspectives related to SBDH assessments.

KW - Omaha System

KW - Social determinants of health

KW - behavioral determinants of health

KW - electronic health records

KW - nursing terminologies

UR - http://www.scopus.com/inward/record.url?scp=85070288230&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85070288230&partnerID=8YFLogxK

U2 - 10.1177/2010105818785641

DO - 10.1177/2010105818785641

M3 - Article

AN - SCOPUS:85070288230

VL - 28

SP - 39

EP - 47

JO - Proceedings of Singapore Healthcare

JF - Proceedings of Singapore Healthcare

SN - 2010-1058

IS - 1

ER -