Contributed: Analyzing social determinants of health data to improve patient outcomes

Providers must go beyond just learning about a patient's SDOH to change the game; they must also support changes.
By  Dr. Elizabeth Kwo and Alyson Hoots
10:50 am

(Photo by SolStock/Getty Images)

Over the past few years, we’ve seen an acceleration of efforts and much needed innovations in the healthcare system, including the recognition of the importance of the social determinants of health (SDOH) on patient outcomes and care.

However, creating a truly connected ecosystem that addresses all aspects of a patient’s care (clinical and social) is only possible with the right supporting infrastructure. Providing the appropriate systematic and structural support is only a piece of the puzzle. Payers and providers need a complete picture (data and insights) and the ability to act (e.g., refer patients to community-based organizations). They also need the ability to show outcomes in a standardized and consistent manner, methodically measuring the effectiveness of independently deployed SDOH programs and interventions, to demonstrate results and long-term return on investment.

Even though we know SDOH contributes up to 80% of a patient’s health outcome, truly changing consumer mindsets and behavior to achieve "health" may require solving for more than systematic and structural barriers to care. For example, if we consider a low-income, food-insecure diabetic patient who lives in a food desert, even if the healthcare system could solve for the patient’s resource barriers (e.g., income to afford food or transportation to the grocery store), it doesn’t mean the patient will pick healthy fruits and vegetables over carb-heavy, processed foods. Solving for food insecurity doesn’t just mean getting patients food – it means empowering and supporting patients to know what to buy, how to cook it, what healthy portion sizes look like and how to make it last. Healthy behaviors are driven by mindset, experience and culture.

Therefore, creating a connected ecosystem to solve for systematic and structural barriers is only part of the solution. We must also place an emphasis on human-centered design and begin to build experiences that teach resilience and empower patients to live their healthiest lives.

Payers and providers now realize that assessing people in a more holistic way can make a huge difference in the health and wellbeing of an individual. To that end, SDOH and consumer behavior data is becoming as important as medical record information.

1. SDOH impact

The social determinants of health are the conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes. In recent years, payers and providers have begun to include SDOH in the process of predicting the evolution of an individual’s state of health. The CDC’s Healthy People 2030 uses a framework that outlines five key areas of SDOH: Health Care Access and Quality (e.g., access to healthcare), Education Access and Quality (e.g., graduation from high school), Social and Community Context (e.g., cohesion with community), Economic Stability (e.g., socioeconomic status), and Neighborhood and Built Environment (e.g., neighborhood crime and violence).

Understanding SDOH and consumer behaviors is crucial for providing quality care to patients, for optimizing payer costs and provider efficiency, and for improving patient health outcomes.

The impact of SDOH on health outcomes is widely written about in that it impacts up to 80% of health. There is also a strong relationship between SDOH and cost. According to the McKinsey 2019 Consumer Social Determinants of Health Survey, participants who reported food insecurity were 2.4 times more likely to report multiple emergency room (ER) visits. Because SDOH is so connected to health risk and outcomes, there are serious potential cost-saving opportunities for payers and providers to proactively address these factors.

2. Human motivation and technology-enabled behavior change

Maslow’s Hierarchy of Needs provides a theory for understanding human motivation. At the bottom of the five-tier pyramid are biological, physiological and safety needs (e.g., food, water, housing). The middle two tiers show psychological needs, all building blocks and prerequisites for the top tier, self-actualization, which represents the desire to achieve one’s full potential. Applied to healthcare, this hierarchy represents only some of the pieces of SDOH. For example, the bottom tiers could represent food, transportation or housing insecurity. How can we expect diabetic patients to store their insulin if they don’t have a refrigerator? How can we expect patients to complete preventative exams if they don’t have reliable transportation or the time off from work?

Solving for the systematic and structural barriers to care is only part of the solution. Even if we solve for things like food insecurity or transportation insecurity, humans may not behave in a way that’s beneficial for their health (e.g., drink water, sleep, eat nutritionally dense foods, meditate). Human behavior is complex and shaped by both external (community) and internal (mindset) influences. There is a huge opportunity for payers, providers, employers, government and communities to come together to solve for systematic and structural barriers to care. There is also an opportunity for us to embrace the digital revolution and leverage technology to not only remove barriers to care (e.g., telehealth) but to design experiences that bring in principles from behavioral economics, psychology, and intentional user interface (UI) and user experience (UX) design, to enable healthier mindsets and behavior.

3. Challenges of SDOH adherence to the healthcare system

Currently, the healthcare system doesn’t have a clear means to deal with and address SDOH. Part of this is due to the lack of and insufficient data interoperability. Data interoperability is a crucial aspect of SDOH integration, as it determines how important data about patients reaches the main stakeholders in the healthcare system. This data needs to be integrated in the stakeholder’s operating systems to trigger decisions and actions. These decisions and actions can turn into efficient tools that provide better care for patients and lower costs for payers.

Data interoperability requires that unstructured data be collected from different sources and included in the health records of patients. Payers and providers also need to have analytics capabilities to allow individual risk identification in a rather large pool of patients. The coding necessary to make data interoperability efficient exists, but it’s not specific enough to highlight the impact of SDOH on a patient’s health outcomes. Z-codes (a subset of ICD-10-CM codes) were introduced to help providers capture non-clinical health needs, but they do not capture all social needs, and even when providers use them there are large gaps.

Part of a value-based arrangement could include a payer and provider agreeing to pool their data together to create a more holistic view of the patient. This would enable more effective population health strategies and more effective management of an individual. This is happening today, but on a local level. We need to understand SDOH impacts on our members to better understand their potential risk, and tailor treatment plans to optimize their outcomes, considering not only their clinical history, but their social situation as well. There needs to be better and more robust coding for administrative claims data.

4. What has been done so far

The challenges entailed by interoperability have limited data sharing for a long time, often on the account of high costs, complex maintenance involved and slow operations. It is important that data is used in an ethical and secure way, for the purposes of providing services and delivering value to the end user without compromising their trust. Users should have full control over how their data is shared, with whom, and how it’s used. Several new initiatives and tools are being developed that would make accessing this information easier for payers and providers so they can provide better care and experiences for their patients and members. Below are a few examples:

  • Fast Healthcare Interoperability Resources (FHIR) is facilitating the exchange of healthcare information electronically between independent clinical systems. FHIR created a common language that allows clinicians and organizations to share information, including EHRs (electronic health records), and is continually adjusting to new web technologies.
  • CARIN Alliance is a multisector collaborative working to advance consumer-directed exchange of health information.
  • Blue Button is a data service that makes it easy for Medicare enrollees to download, share and save their health records on any device. This makes communication between patients and their care providers easy and real time.
  • Gravity Project (SIREN) is a project that aims to create standards for representing SDOH data via coded information. This collaborative effort is focused mainly on removing barriers in accessing healthcare caused by food insecurity, housing conditions and transportation access.
  • Higi Smart Health Stations are devices designed to track biometric information. The stations are deployed throughout communities to help screen, identify health risks and needs, and connect consumers with appropriate services. 

5. Insufficient connection with community-based organizations

Continued partnerships with community organizations and other payers and providers will go a long way to address SDOH.

Sharing data with community-based organizations such as homeless shelters is just as important as exchanging information between patients and care providers. Since a large part of the healthcare system is used for handling eligibility data and claims, sending information to communities that reflect the impact of SDOH on its members’ state of health is more of a data challenge than a cost one. Communities all over the country have different structures and cultural backgrounds with different approaches to serve their members. Therefore, the resources that target interoperability could create a common data language that would ensure proper delivery and interpretation of medical information.

Health plans are working to get much more accurate and knowledgeable about how to triage and satisfy a population around behavior change. As providers transition to a value-based framework, integrating SDOH into value-based contracting will become more common. Providers will have to make time to talk about SDOH with their patients.

Lack of incentives

The healthcare system currently lacks clear policies to integrate SDOH capabilities. There is a need to enable compliance with various systems’ requirements and improve adherence from the various partners involved in this system. There is also a lack of incentives to integrate SDOH data, including the ability to assess and address social needs at scale. Reimbursement is often done differently by each clinic and hospital, which is not cost-efficient for any of the parties involved. A standard reimbursement policy would attract improved screening practices and a more unitary coding, which can lead to a more efficient addressing of SDOH.

SDOH data integration into health records is vital for understanding the conditions outside the standard clinical care that affect a patient’s health and for taking steps to address these conditions.


In the past years, SDOH integration has benefited from more support and commitment coming from healthcare major stakeholders. The steps taken in this direction must be continued by:

  • Collecting, sharing and integrating data:
  • collect data from unstructured sources, standardize it and turn it into actionable information
  • use this data to understand and remove the obstacles that prevent patients from accessing quality healthcare
  • explore the potential of integrating behavior and consumer data and intentionally design experiences for consumers that not only get them the resources they need when they need them, but also coach and guide them to build habits and mindsets that promote health
  • share data with care beneficiaries, care providers and decision makers
  • define common guidelines and language so that all stakeholders work from a common understanding.
  • Evaluating the results:
  • implement a common set of KPIs (key performance indicators) to track the progress status and results of SDOH integration
  • define continuous improvement measures to ensure that all partners in the healthcare system bring their contribution to addressing SDOH.
  • Establishing reliable partnerships:
  • define partnerships between all those involved in assessing and addressing SDOH from both public and private sectors
  • promote policy changes and propose new payment models to bring innovators closer to payers and patients
  • partner with truly disruptive digital startups who can push the envelope on delivering the next generation of healthcare, with SDOH at the center
  • create a properly trained clinical human resource, including first contact care providers and workers in local communities.

SDOH integration is a long-term process that often requires a change of funds allocation, platform design and, most importantly, mindset. The struggle of humans who lack essential living means such as housing and proper access to quality healthcare is an issue that must always be communicated by community leaders to all participants in the healthcare system. This ensures that all involved are informed and able to work together, either in small day-by-day steps or in big leaps like fundamental changes in the public insurance system.

About the authors: 

Dr. Liz Kwo is currently the deputy chief clinical officer at Anthem and a faculty lecturer at Harvard Medical School, and previously cofounded and served as CEO of telemedicine second-opinion company InfiniteMD. She received an MD from Harvard Medical School, an MBA from Harvard Business School and an MPH from the Harvard T.H. Chan School of Public Health.
Alyson Hoots is a Senior Product Manager with Anthem's Digital team who specializes in addressing the social drivers of health through digital solutions.


The latest news in digital health delivered daily to your inbox.

Thank you for subscribing!
Error! Something went wrong!