September 12, 2017

Hurricanes Prompt Urgent Focus on Documenting Social Determinants of Health: Part I

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EDITOR’S NOTE: This is the first in a two-part series on the coding and documenting of social determinants of health (SdoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged cities of Texas and Florida.

Hurricanes Harvey and Irma provide good illustrations of how important it is to document and code the social determinants of health (SDoH). There are multiple predictive models using demographic (U.S. Census), social, and economic data. In healthcare, data is collected either from the financial databases (for which ICD-10 data is key) or from more labor-intensive methods such as chart review and other studies.

There is unrealized potential for real-time data collection within the clinical documentation integrity (CDI) and medical coding communities. In these days and weeks ahead, coinciding with the post-disaster recovery efforts in both Texas and Florida, it is very important that healthcare professionals capture this information for several reasons. These include the following:

1. Data snapshots in time. In days gone by, journalists and photographers have documented wars and disasters, which has helped future generations learn from the past. In this generation, the added dimension of data has evolved. Clinical documentation integrity specialists (CDISs) and medical coders need to make sure that SDoH information gets into data so that this information will be of value for future generations. Consider, for example, the following:

Problems related to other psychosocial circumstances: Z65.5, Exposure to disaster, war and other hostilities; Z64.4, Victim of crime and terrorism (if the patient is a victim of looting;

Employment: Many will be either temporarily unemployed (Z56.0), have to change jobs (Z56.1), or be under threat of job loss (Z56.2) as businesses are impacted. They may experience physical and mental strain related to work (Z56.8). They may be militarily deployed to assist (Z56.82);

Occupation: They may be exposed to toxic agents, as in the case of the area where explosions shook a flooded chemical plant near Houston last week (Z57.5);

Problems related to housing and economic circumstances: Lack of adequate food and safe drinking water (Z59.4); insufficient social insurance and welfare support (Z59.7);

Other problems related to primary support group, including family circumstances (Z63): Absence of a family member due to military deployment (Z63.31) as military first responders are called up; Disappearance and death of family member (Z63.4) as patients present to health systems with anxiety symptoms related to waiting for updates on their family members status; dependent relative needing care at home (Z63.6), which can either be a chronic issue or temporary, as families are displaced. Social systems can be impacted as people respond to stress in different ways, which can include alcoholism and drug addiction in the family (Z63.72)
 
  1. This data is reflective of an untapped real-time ability to connect actual health issues with SDoH so that healthcare systems can prepare more for future disasters going forward.

  2. Traditionally, only physical manifestations of disaster have been acknowledged. But there currently exists the opportunity to link the additional layers of SDoH. If the patient’s psychological effects are also identified in the chart, it can be of great use as well. For example, in the past if patient presented to the ER after sustaining a laceration as a result disaster, the link would be made; however, the link to the SDoH is less clear when patients present to the ER for non-cardiac chest pain or shortness of breath, which may be a result of anxiety. Statisticians may find meaningful inference from the SDoH. 

Now, during hurricane season and its aftermath, would be a very critical time in data capture that can help allocate healthcare resources more appropriately going forward.
Diane Iverson, RN, BSN, BS, ACM, CCM

Diane Iverson, RN, BSN, BS, ACM, CCM, is an emergency room (ER) case manager at a major university hospital in Baltimore. Previously, Iverson was a clinical documentation integrity specialist (CDIS) at Johns Hopkins Hospital.

Iverson began her healthcare career as a computer programmer, which led to her becoming a bedside nurse, including roles as an agency/travel nurse. Currently, her interest is at the intersection of clinical documentation and case management, with the goal of improving data to more accurately reflect the patient population she serves. As a result, Iverson has been advocating for a revision to the coding guidelines to include documentation from registered nurses (RNs) and social workers for the social determinants of health codes Z55-Z65.

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