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

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.