AMIA 2017 Annual Symposium | Washington DC, USA

Social and Behavioral

Determinants of Health
Fundamental informatics challenges for enriching Health IT
systems: National picture and role of vocabulary standards

Daniel J. Vreeman, PT, DPT, MS

Regenstrief-McDonald Scholar in Data Standards
Indiana University School of Medicine

Director, LOINC and Health Data Standards

@djvreeman Regenstrief Center for Biomedical Informatics

2017
 Overview

*
1. National Health IT perspectives on SDH
2. Interoperability as a key challenge
3. Role of vocabulary standards in SDH
4. Planning to incorporate standardized
SDH data elements in your EHR
*Thanks to Albert Taylor, MD from the ONC for this content

photo via Vernio77

Disclosure
Im the author of the book LOINC Essentials published
by Blue Sky Premise, LLC where I serve as President.

Not a NYT Best Seller. Net profit going to a special

charitable project: danielvreeman.com/build-a-school

PI on a contract from bioMrieux for LOINC content

Financial support for LOINC
Currently active awards:

CMS (HHSM-500-2016-00040C)
FDA
bioMrieux
NCATS (3UL1TR001108-04S1)
NIDDK (HHSN275201600752P)
NLM (HHSN276201400239P)
LOINC User Community
University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2017. www.countyhealthrankings.org. Used with permission.
 SDH Matter
Independent variable of health outcomes
Housing insecurity linked to lead poisoning, respiratory conditions
Food insecurity linked to hypertension, hyperlipidemia, overall poor
physical and mental health
Unemployment linked to overall poor health, heart disease or stroke

Assessment can lead to interventions such as

connecting with community-based organizations

Improving social needs impacts health outcomes

Bachrach D, Pfizer H, Wallis K, et al. Addressing Patients Social Needs: An emerging business case for provider investment. The CommonWealth Fund, The Skill
Foundation, and the Pershing Square Foundation. May 2014. Available online.
 Why in EHRs?
Inform care decision-making

Integrate them into care

pathways and CDSS
 Why isnt it?
SDH may be collected, but not available
(narrative, paper)

Where built as discrete elements, EHRs are

not using vocabulary standards nor
including them in structured exchange
mechanisms (HL7v2, C-CDA, FHIR)
Missed opportunities, limited sharability
across systems
 What might it enable?
More effective care
More effective population
management
Discover new linkages

photo via proimos

 Why
interoperability
matters
photo via proimos
Connecting Many Data Sources
Social and community determinants

Lifestyle and behavioral

Health history

Patient-generated
EHR
Genetics
Basic science
photo via Heather | cc-by-sa
 The rain forest canopy is a
seamless web through which
arboreal creatures efficiently
move to reach the edible
fruits without any attention
to the individual trees.
McDonald et al. Canopy Computing: using the Web in Clinical Practice. JAMA. 1998;280(15):1325-1329. photo via nosha | cc-by-sa
Reality:
patients move faster and further
than their health information
MO MONEY MO PROBLEMS
 data
It's like, the more money
we come across
The more problems we see
MO DATA MO PROBLEMS
Problems
Health IT systems often lack
common mechanisms for MO DATA MO PROBLEMS

exchanging data.

Even when they do, they use

different ways of identifying the
same concept.

Only way to overcome these problems is

with data standards
 Variation Abounds
CODE NAME
34626D Arterial BP Diastolic
39312D ABP Diastolic
ARTDIASBP Arterial Diastolic BP
nvArtBPS Arterial Blood Pressure Diastolic
DBP DBP
25284D BP (NIBP)
2737317 Diastolic Blood Pressure #1
6881D BP Diastolic
3800DBP BP
77934D BP Manual Diastolic
919109 Diastolic Blood Pressure
DiastBP DiastolicBP
PBPD PRE BLOOD PRESSURE DIASTOLIC
POBPD POST BLOOD PRESSURE DIASTOLIC
 Taming this
wicked problem

photo via tgerus | cc-by-sa

Syntax Standards
Messages, Documents, APIs
HL7v2, C-CDA, FHIR

Semantic Standards
Vocabulary/code systems
LOINC, SNOMED CT, RxNorm, CPT, ICD
No single vocabulary
standard covers it all
Screening and measurement: LOINC
Diagnosis (assessment): ICD, SNOMED CT
Interventions: SNOMED CT
Medications: RxNorm
Reimbursement: CPT
 Similar name, different meaning

meerkat meerkat mere cat meerkat

photo via CaptionTime
The universal standard for
identifying health measurements,
observations, and documents.

Est. 1994
 LOINC is a rich trove of 84,000+ standardized variables
Genetics Lifestyle

21654-9 CFTR gene targeted mutation analysis

24475-6 F2 gene c.20210G>A [Presence] 41950-7 Number of steps in 24 hour Measured

75547-0 Noninvasive prenatal fetal aneuploidy 75296-4 Carbohydrate intake 24 hour Estimated
and microdeletion panel based on Plasma cell- 82289-0 Rating of perceived exertion [Score]
free+WBC DNA by Dosage of chromosome-specific
circulating cell free (ccf) DNA 72166-2 Tobacco smoking status NHIS

82245-2 Chromosome region 22q11.2 deletion in 64098-7 Distance walked in 6 minutes

Amniotic fluid or CVS by FISH

Lab and clinical Environmental

82464-9 Mosquito count [#] in Environmental specimen

4548-4 Hgb A1c MFr Bld 67784-9 Individuals below poverty line Neighborhood
8462-4 Diastolic blood pressure 63736-3 Materials to which you were exposed in your
work or daily life
24725-4 Head CT
63805-6 How long did you handle paints or solvents
57021-8 CBC W Auto Differential panel - Blood yourself?

8633-0 QRS duration 67640-3 My teachers believe that I can do well in my

school work
 Standardized Assessments and Collections

Vreeman DJ, McDonald CJ, Huff SM. Representing patient assessments in LOINC. AMIA Annu Symp Proc. 2010;832-836. PMID: 21347095 .
Vreeman DJ, McDonald CJ, Huff SM. LOINC - A Universal Catalog of Individual Clinical Observations and Uniform Representation of Enumerated Collections. Int J Funct Inform
Personal Med. 2010;3(4):273-291.
Social, psychological and behavioral howRU
observations - 2015 Edition Health IT Living with HIV (LIV-HIV)
Certification Criteria set
Morse Fall Scale
Adverse Childhood Events
My Mood Monitor
Borderline Symptom List - 23 Item
Neuro-QOL
Brief Interview for Mental Status (BIMS)
PROMIS (e.g. Social Isolation item bank)
Confusion Assessment Method (CAM)
PhenX (eg. Social Environments domain)
Core behavioral health terms (SAMHSA)
PHQ
Edinburgh Postnatal Depression Scale
VR 12 and 36
FACIT
Geriatric Depression Scale (GDS)
Humiliation, Afraid, Rape, and Kick
questionnaire
HIV Signs and Symptoms Checklist

10,000+ patient assessment terms

Adding more all the time
loinc.org/sdh
 Standardized Data Exchange
LOINC inside HL7 Version 2

CE (coded element)
means the answer
Observation Identifier:
will be coded this is a overall financial resource strain question

OBX||CE|76513-1^How hard is it for you to pay for the very

basics like food, housing, medical care, and heating
[CARDIA]^LN||LA15832-1^Very hard^LN

LN means this code Answer Identifier:

is from LOINC
very hard! (trouble!)
Standards make
health data more
portable and
understandable to
different computer
systems.
 Collect once. Use many.
Clinical care, public health reporting, quality
management, clinical and epidemiological research, etc

photo via pagedooley | cc-by

 Social Isolation Assessment
from NHANES, as recommended in 2015 EHR Cert Criteria

1. Are you married or living with someone in

a partnership?
2. In a typical week, how many times do you
talk on the phone with family, friends or
neighbors?
3. How often do you get together with
friends or relatives?
4. How often do you attend church or
religious services?
5. How often do you attend meetings of the
clubs or organizations you belong to?
 Social Isolation
from NHANES representation in LOINC

76506-5 Social connection and isolation panel

63503-7 Are you now married, widowed, divorced, separated, never married
or living with a partner?

76508-1 In a typical week, how many times do you talk on the telephone
with family, friends, or neighbors? {#}/wk

76509-9 How often do you get together with friends or relatives? /wk

6510-7 How often do you attend church or religious services? /a

76511-5 Do you belong to any clubs or organizations such as church

groups unions, fraternal or athletic groups, or school groups?

76512-3 Social isolation score [NHANES] {score}

Use these to compute Social Isolation Score (76512-3)

(has mortality hazard ratio similar to smoking)

Pantell M et al. Social isolation: a predictor of mortality comparable to traditional clinical risk factors. Am J Public Health. 2013 Nov;103(11):2056-62. Epub 2013 Sep
12. PubMed PMID: 24028260.
 If this, then that

If

{Social Isolation Score} < 2

Then

initiate {social isolation care plan}

Electronic Quality Assessment
% Patients for whom cognitive assessment performed
71492-3 Total score [SLUMS]
54614-3 Brief Interview for Mental Status - summary score [BIMS]
71493-1 Total score [IQCODE]
71722-3 Total score [AD8]
72106-8 Total score [MMSE]
72172-0 Total score [MoCA]
72173-8 Total score [BOMC]
72233-0 Total score [Mini-Cog]

% Patients for whom social isolation screening performed

62933-7 PhenX - social isolation protocol
77800-1 PROMIS short form - social isolation 4a - version 2.0 raw score
77799-5 PROMIS short form - social isolation 6a - version 2.0 raw score
77798-7 PROMIS short form - social isolation 8a - version 2.0 raw score
77849-8 PROMIS social isolation - version 2.0 Tscore
28212-9 Social isolation [CCC]

76512-3 Social isolation score [NHANES]

The same thing is possible for key metrics on food

insecurity, housing, stress, physical activity, etc
 Same data for

Informing clinical care

Population health analytics / registry
Electronic quality measure analysis
Observational/epidemiological research
 Developing a plan for
incorporating standardized
SDH data elements in your EHR
Tips and questions to ask yourself
Interoperability is
ultimately about people
who want (their health IT
systems) to work together
and understand each other
photo via scarlatti2004_images | cc-by-sa
Not all juice is worth
the squeeze
Start here:
professional consensus, saves time, actionable, business value,
people are already doing it!

photo via elwillo | cc-by

Vocabulary
standards grow
because USERS ask
(you dont need to invent a new one)
Starter questions
Am I using the right social needs screening/assessment tool?
Who owns these assessment tools?
Are there intellectual property issues with their use?
Which clinical vocabulary should I use (am I focused on
coding screening, diagnosis, or interventions)?
How do I get new codes?
How will these new codes be organized, stored, made
available?
How do I integrate them into my EHR?
Application questions
How will we put these data to use (CDS, CQI)?
Which other care team members would benefit (and
how might we share this information with them)?
What resources (e.g. from ONC, SDOs, SIREN, other
experts) are available to help?
How might I participate in the stakeholder community
as we continue learning best practices?
What are future innovation opportunities?
 Take home lesson:
Once represented in data standards,
SDH data elements can be shared
and understood by diverse IT
applications for the benefit of
many in the health ecosystem.

photo via IMLS DCC | cc-by