Feb 19, 2019 | Jim Shalaby
Social Determinants of health are defined as “the conditions in which people are born, grow, work, live, age, and the wider set of forces and systems shaping the conditions of daily life” (1). Social Determinants play a major role in a person’s overall health, and are responsible for most health inequalities (2).
So why are we, a company focused on knowledge-driven workflows and clinical decision support (CDS), talking about Social Determinants?
Over the past several years, as more and more people recognize the burden placed on point-of-care clinicians by an overabundance of CDS alerts, the notion of “the 5 Rights of CDS,” as first articulated by Dr. Jerome Osheroff (3), has seen growing popularity. The essence of the 5 Rights are simply that one size does not fit all, that we have to consider other (often more effective) models for delivering recommendations to the clinical team – we have to deliver the right information, to the right person, in the right intervention format, through the right channel, at the right time in workflow.
We propose that there is a comparable “5 Rights of Social Determinants,” and that recognizing this opens the door to a new paradigm in personalized health.
Before getting into the “5 Rights of Social Determinants,” we want to briefly highlight a few of the major challenges in this domain:
 There is an overabundance of Social Determinants. Hundreds and hundreds of variables are known to affect health. Dozens and dozens of organizations have designed sets of Social Determinants, addressing such factors as education, employment, physical environment, socioeconomic status, and social support networks.
 Semantic normalization across the sea of Social Determinants is very problematic. How can we algorithmically determine, for example, the relationship between “Employment = Absent,” “Unemployed = Present,” “Hours worked per week = 0?” How can we compare “How often do you get together with friends” with “How many social interactions do you have per week?” Social Determinants are often complex sentence-like concepts. Furthermore, they can be context-dependent (e.g. only relevant within the context of a validated questionnaire given at a specific time in a chronic condition life-cycle).
 Clinician burden is a barrier to the capture and management of Social Determinants. No single provider has the time and knowledge to manage the complex web of Social Determinants. While a primary care physician may assess employment status, and use it for risk prediction, that same physician may be ill-equipped to help resolve identified employment issues.
We believe that, similar to The 5 Rights of CDS, there is no one-size-fits-all solution for capturing and managing all the Social Determinants that are relevant to a person. Social Determinants are pervasive, and different variables come into play at different stages of life, health, chronic diseases, etc. Some variables are ideally captured at the time a chronic condition is diagnosed to aid in risk stratification. Some variables are ideally captured repeatedly, by the patient, over the course of a chronic condition to signal new factors that might predict a decline in treatment efficacy. Some variables are captured at the point of care by a primary care physician, whereas some are better captured by the patient via a mobile application.
To help emphasize this position,“The 5 Rights of Social Determinants” entails capturing and managing the right information, by the right person, in the right setting, through the right channel, at the right time in workflow. We illustrate these rights through the following scenario, which shows how different Social Determinants (in bold font) become relevant over the course of a chronic disease, and how different factors are often best managed by different members of the care team.
Scenario – Applying the 5 Rights
Doctor DoGood works in a clinic committed to managing the whole patient, including their Social Determinants. The clinic has developed  a Diabetes Risk Stratification Screening Instrument, which includes zip code and questions assessing income level, education level, perceived barriers to care, etc;  a list of social programs with different eligibility criteria;  a defined treatment intensification approach based on risk.
When a patient is first diagnosed with Type 2 Diabetes, Dr DoGood will administer the Diabetes Risk Stratification Screening Instrument and use the results to assign the patient into a risk group with the corresponding treatment intensification plan. For patients found to be at moderate risk of poor glycemic control with standard treatment, Dr DoGood will add the following interventions:  Home blood glucose monitor;  Home blood glucose monitoring App, configured to ascertain key Social Determinants that may alert to impending poor glycemic control (such as Yes/No questions “I’ll have difficulty filling my next prescription” and “I’ll have difficulty keeping my next office visit”);  Referral to Diabetes Case Manager;  Follow up office visits, including blood glucose checks every 2 weeks;  Social services consult (to explore transportation issues, and to explore medication payment issues).
All Type 2 Diabetes patients have their blood glucose tracked over time, at differing frequencies depending on a patient’s individual treatment plan. For all patients, where there is evidence of increasing blood glucose despite previously being controlled, the trend in body weight is assessed, along with further questioning about diet, eating habits, and activity.
Patients at moderate risk of poor glycemic control with standard treatment submit average weekly blood glucose levels via a home monitoring device and are seen in the office every 2 weeks. In addition, these patients have surrogate indicators (frequency of blood glucose observations as a marker of compliance with blood glucose monitoring; frequency of medication dispense events as a marker of medication compliance) computed and provided to Dr DoGood monthly.
When the Diabetes Case Manager receives notification that a patient has noted via their App that they perceive difficulty filling their next prescription, or when Dr DoGood receives notification that the frequency of medication dispense events is lower than expected, they will follow up with the patient for a more targeted exploration.
As this scenario suggests, capturing all of the social determinants of health is an exercise for an entire care team (including the patient as a member of the care team), at different points of care. Leaving it as the responsibility of a single person within a single workflow leaves much on the table.
There is no one-size-fits-all model for Social Determinants – no single value set of Social Determinants, no single caregiver responsible for managing all identified factors, no single time or setting for data capture, no single set of interventions that will apply to all patients.
In future blogs, we plan to explore The 5 Rights of Social Determinants in more detail, and show how a tool such as Sapphire can, particularly when leveraging our unique semantic normalizer and workflow automation solution, provide opportunities for implementing the diversity of approaches needed for identification and management of Social Determinants.