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Using Data to Understand Social Determinants of Health

June 10, 2024

RHIA, RHIT, CCS, CDIP and AHIMA-Approved ICD-10 CM/PCS Trainer, Vice President of Coding, Enterprise Division, Coronis Health, Jackson, MI

The Centers for Medicare & Medicaid Services (CMS), the World Health Organization and other governing bodies have made the pursuit of equitable health outcomes a fundamental goal worldwide. However, achieving health equity requires more than just advancements in medical technology and access to healthcare services. It demands a comprehensive understanding and addressing of the social determinants of health (SDOH). 

Social determinants of health are the conditions in which people are born, live, work and age. Key factors include socioeconomic status, education, physical environment, employment, social support networks and access to healthcare services.

Here are a few examples of the social determinants of health, which can influence health equity:

  • Income and social protection
  • Education Unemployment and job insecurity 
  • Working life conditions
  • Food insecurity Housing, basic amenities and the environment 
  • Early childhood development 
  • Social inclusion and nondiscrimination 
  • Structural conflict 
  • Access to affordable health services of decent quality

On Jan. 1, 2024, CMS began requiring healthcare organizations to screen for five social risk drivers, a task that was voluntary in 2023. Healthcare teams are expected to ask patients questions pertaining to the five domains at any point during their hospital inpatient stay with yes/no answers and a field to note if patients were unable or declined to answer.

CMS is introducing two new inpatient quality reporting measures in 2024: screening for SDOH and positive rate for SDOH. Healthcare teams screening for SDOH will assess how many patients aged eighteen and older were screened and report the positive rate.

Healthcare professionals must be able to recognize and address these determinants to ensure that all individuals can attain their highest level of health. Leveraging data gathering techniques is essential for understanding and addressing these determinants effectively. 

Data serves as a powerful tool for uncovering patterns, trends and disparities related to social determinants of health. By collecting and analyzing relevant data, healthcare professionals can gain insights into the social, economic and environmental factors that influence health outcomes within communities. 

Electronic health records (EHRs) offer a valuable platform for integrating SDOH data into clinical practice. Healthcare professionals can utilize EHR systems to capture information on patients’ socioeconomic status, housing stability, access to transportation and other social factors. By standardizing data collection processes and incorporating SDOH metrics into EHR templates, providers can systematically gather valuable information. 

Incorporating SDOH screening tools and surveys into routine clinical assessments enhances data gathering efforts. These tools enable healthcare professionals to systematically identify patients’ social needs and vulnerabilities. Screening instruments such as the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) tool offer structured frameworks for gathering data on SDOH domains, facilitating comprehensive assessments and targeted interventions to address underlying determinants effectively. 

Population health data sources provide valuable insights into community level SDOH trends and disparities. Analyzing population health data enables healthcare systems to develop targeted strategies that address the unique needs of diverse communities, promoting health equity on a broader scale. Collaboration and data sharing among healthcare organizations, community agencies, and government entities are essential for comprehensive SDOH data gathering. By sharing data and resources, stakeholders can enhance their understanding of local SDOH dynamics and coordinate efforts to address systemic barriers to health equity.

Data gathering is integral to understanding and addressing social determinants of health effectively. By harnessing data from diverse sources, healthcare professionals can identify disparities, inform targeted interventions and advocate for policy changes that promote health equity. Empowering healthcare professionals with robust data gathering tools and resources is essential for advancing efforts to address SDOH. 

New SDOH Reporting Requirements Expected to Impact HI Workflow, Staffing,

Laura Legg, RHIA, RHIT, CCS, CDIP and AHIMA approved ICD-10 CM/PCS Trainer, is a HIM professional with experience in acute care hospital coding, auditing and CDI. Ms. Legg serves as Vice President of Coding for the Enterprise Division of Coronis Health and has worked in a variety of positions across her career. She is passionate about the industry and mentoring new HIM professionals. Laura has a bachelor’s degree in Health Information Administration from Stephens College in Columbia Missouri.

Laura is an active member of HFMA, AHIMA, AAPC and the National Association for Revenue Integrity. She speaks regularly at regional and national AHIMA events, is an advisory board member for Briefings for Coding Compliance and is an AHIMA mentor. She can be reached at

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