A Local Perspective into Electronic Health Record Design, Integration, and Implementation of Screening and Referral for Social Determinants of Health.

The use of the electronic health record (EHR) system to identify and address social determinants of health (SDOH) in vulnerable patients is still lacking, and examples for customizing the EHR to meet the workflows of clinical and administrative professionals are missing. We custom designed and built into the Epic EHR a SDOH screening tool integrated with a community resource network management (CRNM) software-as-a-service (SaaS) platform to systematically identify and address SDOH in Medicare and Medicaid beneficiaries across multiple clinical care settings. We further describe our workflow redesign and EHR implementation process to maximize SDOH screening and referral efficiency. The SDOH EHR solution has been operationally used over three years by staff to screen 111,486 Medicare and Medicaid beneficiaries, identify 7,878 SDOH, and refer 6,103 high-risk beneficiaries to community resources. Transforming an EHR into a catalyst software to support SDOH screening and referral in a clinical setting is an interdisciplinary process that benefits from various technical, administrative, and clinical experts that provide subject matter knowledge into all phases of the build.