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 N. Schorr

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


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
Issue number1
StatePublished - Mar 1 2019

Bibliographical note

Funding Information:
This informatics-policy project was completed by University of Minnesota School of Nursing Doctor of Nursing Practice students and faculty at the request of the Minnesota eHealth Initiative – Minnesota Department of Health, and the University of Minnesota Center for Nursing Informatics. The authors thank Dr. Martin LaVenture and Dr. Candice Garay. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Publisher Copyright:
© The Author(s) 2018.


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


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