Social determinants of health: the IOM’s vision for the future of care

Public health has long recognized the correlation between health and certain social and behavioral variables that range from ZIP code to income bracket. However, these variables, termed “social determinants of health,” have not traditionally been part of the clinical patient experience. An article recently published in the New England Journal of Medicine (subscription required to view) points the way forward for integrating these determinants into clinical interactions, succinctly summing up last year’s Institute of Medicine report on social and behavioral determinants of health.

The article sets forth the idea that, once patients provide information related to key social and behavioral determinants of health, that information can trigger a response from the provider that helps mitigate negative health consequences. For instance, if a patient is identified as being at risk for intimate partner violence, a provider may then recommend resources like domestic violence hotlines, a shelter, or free legal counsel provided through a local nonprofit—essentially writing a non-traditional “prescription” and putting the patient in the hands of trained professionals who can take over his or her care.

The IOM report suggests a framework for implementing this kind of system, presenting scales that have been validated by research and that can reliably measure variables like stress and depression. These scales would form the foundation of patient-submitted questionnaires, which patients could fill out quickly, perhaps even on a tablet or other device, in a waiting room along with other paperwork. Only if a questionnaire triggers a threshold for a particular variable would a provider need to address it.

Determinants of health can range from an individual’s access to walkable public spaces and markets that sell healthful foods to behaviors like smoking. Image credit: CDC, Debora Cartagena, Amanda Mills

If the patient responses were then linked with the provider’s EHR, the system could prompt the provider with key information, depending on the triggered threshold. For example, a patient who fulfilled the risk threshold for tobacco use could trigger a list of nearby smoking cessation programs, which the clinician could then give to the patient. As I mentioned in a recent blog, doctors at Boston Medical Center are already engaging in this kind of proactive clinical care by writing “bicycle prescriptions” for lower income patients leading sedentary lifestyles. If this style of care can be standardized and automated, the health outcomes could be enormous.

Of course, implementing a system like this one would be an ambitious task requiring buy-in from clinicians, EHR vendors and other stakeholders. But, if the IOM’s vision is successful, it could turn EHRs into the cementing agent between public health and health care, delivering the best practices and implicit knowledge of population health research into the hands of health care providers and potentially reducing the prevalence of diseases linked to key social determinants.