Structured and unstructured social risk factor documentation in the electronic health record underestimates patients' self-reported risks

OBJECTIVES: National attention has focused on increasing clinicians' responsiveness to the social determinants of health, for example, food security. A key step toward designing responsive interventions includes ensuring that information about patients' social circumstances is captured in the electronic health record (EHR). While prior work has assessed levels of EHR "social risk" documentation, the extent to which documentation represents the true prevalence of social risk is unknown. While no gold standard exists to definitively characterize social risks in clinical populations, here we used the best available proxy: social risks reported by patient survey.

MATERIALS AND METHODS: We compared survey results to respondents' EHR social risk documentation (clinical free-text notes and International Statistical Classification of Diseases and Related Health Problems [ICD-10] codes).

RESULTS: Surveys indicated much higher rates of social risk (8.2%-40.9%) than found in structured (0%-2.0%) or unstructured (0%-0.2%) documentation.

DISCUSSION: Ideally, new care standards that include incentives to screen for social risk will increase the use of documentation tools and clinical teams' awareness of and interventions related to social adversity, while balancing potential screening and documentation burden on clinicians and patients.

CONCLUSION: EHR documentation of social risk factors currently underestimates their prevalence.