Using information exchange systems to advance health equity

An innovation I would like to see in my work capitalizes on existing community-based organizations and resources. Specifically, the innovation would entail the creation of an information exchange system that can be adapted to any electronic health record system used by a hospital. It would facilitate “e-prescriptions” for social need resources given to patients already identified through built-in risk stratification algorithms. The “e-prescription” would be sent directly to a community organization or resource to minimize any loss of pertinent information or lapse in follow-up. The hospital in turn would be able to close the loop directly with both the patient and the community organization.

However, social determinants of health (SDOH) screenings in the clinical setting would need to adequately address reported provider discomfort with accepting utility and execution of SDOH screenings as well as patient concerns about stigmatization and privacy.[i] There is already evidence demonstrating how electronic health record workflows can successfully be designed and implemented to identify and deliver social need resource referrals to patients.[ii] Such workflows can help mitigate time and technological constraints in addition to countering both provider and patient hesitancy by normalizing integration of SDOH data and response.

The proposed innovation has tremendous potential beyond increasing accessibility and transparency of health information. It also establishes an infrastructure to consolidate and streamline significant amounts of data to inform predictive modeling and artificial intelligence integration into health interventions. Without such an infrastructure, many hospitals are unable to effectively utilize SDOH data to design targeted and evidence-based health interventions. Yet, there is growing research pointing towards how machine learning models can in fact accurately predict inpatient and emergency department utilization based on SDOH data.[iii] This in turn empowers existing staff, such as care managers, to work at the height of their scope of practice to provide personalized and effective interventions.

Currently, there are platforms that consolidate existing community resources for use by healthcare systems. However, these platforms have several shortcomings including limited generalizability to other cities or states, lack of interoperability within different electronic health record systems, and inability to ensure that all community resource information is kept up to date in a systematic and reliable manner. These factors would serve as a potential obstruction to the implementation of a larger information exchange system at a hospital. On a larger scale, these factors reflect determinants related to the organization and facilities.[iv] In particular, insufficient financial resources, inadequate reimbursement for these extra efforts in the development of an information exchange system, and absence of a preexisting infrastructure.

To fully grasp the extent of barriers to implementation of the proposed innovation, determinants related to the adopting health professional also need to be taken under consideration. The medical profession is intrinsically linked to norms around hierarchy and who has ownership of patient care.[v] Power dynamics that such a work culture yields inevitably hinders the interdisciplinary collaboration that is required in this innovation. An information exchange system that seeks to address structural determinants of health inequity cannot be successful by only incorporating the insight and expertise of physicians. The broader perspective of nurses, techs, pharmacists, care managers, social workers, patient navigators, and other health care professions must be integrated too for the proposed innovation to be feasible.

Instead of relying on increased government “social welfare” or healthcare spending, the innovation would leverage supported partnerships among nonprofit organizations, private companies, and healthcare systems. The health systems exchange infrastructure would be mutually beneficial in reducing the utilization of services for hospitals while demonstrating the demand for services of both private companies and nonprofit organizations. It would also facilitate the ability of voluntary and public organizations to demonstrate the significant impact of their work which is often difficult when working with limited resources and technological capacity.

Ultimately, this innovation would address the issue of rising health care costs and disparities in health outcomes among vulnerable patient populations. As hospitals are moving towards value-based reimbursement, they are now increasingly incentivized to look for innovative solutions to reduce cost while preserving the health and well-being of these high-risk communities. The utilization of existing resources minimizes the upfront cost for hospitals while reducing the long-term utilization of health care services.


[i] Wallace AS, Luther BL, Sisler SM, Wong B, Guo J-W. Integrating social determinants of health screening and referral during routine emergency department care: evaluation of reach and implementation challenges. Implement Sci Commun 2021 21 2021;2(1):1–12. https://implementationsciencecomms.biomedcentral.com/articles/10.1186/s43058-021-00212-y. 10.1186/S43058-021-00212-Y

[ii] Buitron De La Vega P, Losi S, Sprague Martinez L, et al. Implementing an EHR-based Screening and Referral System to Address Social Determinants of Health in Primary Care. Med Care 2019;57:S133–9. 10.1097/MLR.0000000000001029

[iii] Clinical AI that prevents avoidable patient harm How to Take Action on Social Determinants of Health to Improve
Outcomes • 1 Making SDOH Actionable with Clinical AI. 2021; https://www. 10.1016/j.amepre.2015.08.024

[iv] M F, K W, T P. Determinants of innovation within health care organizations: literature review and Delphi study. Int J Qual Heal care  J Int Soc Qual Heal Care 2004;16(2):107–23. https://pubmed.ncbi.nlm.nih.gov/15051705/. 10.1093/INTQHC/MZH030

[v] A Resistance and Everyday View on Health Care Professionals

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