Updated on: August 22, 2021

How Social Determinants of Health Documentation Impacts Health Equity

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Original story posted on: August 16, 2021

The government and private sector are addressing the importance of SDoH data to assess and alleviate healthcare disparities and inequities.

Advanced practice clinical documentation integrity (APCDI) plays an important role in ensuring accurate social determinants of health (SDoH) documentation. The government and private sector are addressing the importance of SDoH data to assess and alleviate healthcare disparities and inequities.

Both APCDI professionals and healthcare information management (HIM) professionals establish essential processes for measuring and integrating SDoH metrics into the electronic health record. This supports and promotes multidisciplinary facility and community collaborative partnerships.  

SDoH information and data is essential in the assessment of population health management as the healthcare industry pivots to ensure an unbiased public health system.

SDoH are non-clinical factors that influence health, such as socioeconomics, physical environment, food access, healthcare habits, and accessibility. As much as 50 percent of a patient’s health can be attributed to non-clinical factors.

With the advent of the COVID-19 pandemic, statistics have demonstrated a significant disparity within various population cohorts. The strategic incorporation of SDoH data – often from multiple, disparate, and siloed sources – can drive innovations in holistic healthcare and steer the response to the pandemic.

Through the identification of specific SDoH data, pathway developments should promote and ensure healthcare accessibility, preventative measures, and quality of care, while reducing administrative burden to providers and healthcare systems, as well as costs. Obtaining SDoH data by accurate documentation is critical for appropriate ICD-10-CM coding and specificity. Identification of SDoH factors can drive health equity. One commonly used definition of health equity is when all people have “the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance.’Achieving health equity, eliminating disparities, and improving the health of all groups is an overarching goal for Healthy People 2020, and a top priority for the Centers for Disease Control and Prevention (CDC). 

Health disparities exacerbated by COVID-19 prompted a newly created multisector initiative: the Consumer Technology Association and the Connected Health Initiative coalition includes big tech companies (i.e., Google, Microsoft), private tech companies, healthcare providers, and representatives of public agencies that aim to outline technology's role.  

Facilities need to assess their community needs regarding the impact of SDoH.

The University of Miami Health System (UHealth), an academic provider, took such an initiative to conduct research in the development of a plan to identify key stakeholders within a multidisciplinary milieu and leadership support needed to implement data collection, as it pertains to SDoH.

  • “The systematic collection of data on social risk factors within a large number of health systems is key to produce data that can improve our understanding of SDoH as they relate to quality of care and best strategies to modify or mitigate contextual factors that drive health disparities,” the project leaders said.

The following excerpt from the ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 demonstrate the important contribution HIM professionals can make to improve SDoH coding accuracy.  

14. Documentation by Clinicians Other than the Patient's Provider

  • For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider, since this information represents social information, rather than medical diagnoses. Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.

SDoH are important predictors in clinical care, and positive conditions are associated with improved patient outcomes and reduced costs. Adverse conditions have been shown to negatively affect outcomes, such as hospital readmission rates, length of stay, and use of post-acute care. Collection of SDoH data in an electronic health record (EHR) is imperative to address health disparities, and for the support of research necessary to assess the effects of SDoH on overall health. Lack of industry consensus on technical specifications and inconsistent standardized data add to the challenge of capturing accurate predictors of outcomes.

Effective Jan. 1, 2021, the Centers for Medicare & Medicaid Services (CMS) began aligning evaluation and management (E&M) coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT); this allows clinicians to choose the E&M visit levels based on either medical decision-making (MDM) or time.

The assessment of risk of complications, morbidity, or mortality within the use of moderate MDM E&M level code(s) allows for capturing of diagnosis treatment/management impacted by SDoH, considering a patient's socioeconomic factors – such as the treatment of a homeless diabetic.

One example from the CDC states that 1 in 4 adults with advanced chronic kidney disease (CKD) are food-insecure – food-insecure without hunger, food-insecure with moderate hunger, and food-insecure with severe hunger. ICD-10-CM coding options include Z59.4, lack of adequate food and safe drinking water, for reporting food insecurities. Raising awareness of food insecurities, asking, documenting, coding and reporting may help to target interventions to improve the health of people with CKD.  

In summary, documentation is imperative for the accurate assignment of SDoH ICD-10-CM -codes. SDoH information is imperative for disease management. Population health outcomes, as it pertains to the business of healthcare, encompasses consideration including but not limited to clinical, quality, regulatory, and fiscal issues. Facilities should consider applications and processes to capture consistent SDoH information and evaluate how this information in turn may provide a catalyst to initiate community outreach resources to promote improved patient care, outcomes, and mitigation of health inequities.

Physician advisors of clinical documentation improvement programs, in collaboration with multidisciplinary teams spearheaded by clinical documentation specialists and health information management professionals, are fundamental to ensure reliability of SDoH data. CDI tools to capture the social determinants of health should be a mainstay of our profession.

Mel Tully MSN, CCDS, CDIP

Mel Tully MSN, CCDS, CDIP is the vice president of clinical services and education at Nuance Communications. She has played an important role in the development and expansion of Advanced Practice CDI™ for more than 18 years. She is recognized for her expertise, vision, and promotion of CDI. She is a national speaker and author for compliance, clinical documentation integrity, value-base purchasing, patient safety (PSI) and inpatient quality reporting (IQR) initiatives.

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