From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB).
J Am Board Fam Med. 2020 May-Jun;33(3):463-467. doi: 10.3122/jabfm.2020.03.190206.
Clinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.
临床医生关注患者的健康社会决定因素（SDH）；然而，他们不确定如何有效地收集患者层面的 SDH 数据并进行干预，而不会增加当前的行政负担。设计得当的临床登记册提供了将邻里 SDH 数据与电子健康记录中的临床数据集成的解决方案，使人们能够了解社区因素，从而指导患者护理。联邦和州政府有兴趣根据 SDH 调整报销，这进一步强调了需要制定将 SDH 和临床数据集成的策略。人口健康评估引擎（PHATE）就是一个基于登记册的 SDH 数据集成解决方案的范例，它可以调整支付，有助于公共卫生监测，围绕热点（质量差距或疾病失控）组织护理，评估患者风险，并与社区组织建立联系。PHATE 还允许通过纳入 PHATE 课程来进行居住培训，以满足社区健康能力的里程碑。这些功能提高了价值，其在教育和医疗服务中的实用性将受益于进一步的研究。
