Development, Piloting and Dissemination of an Integrated Clinical and Social Multi-level Decision Support Platform to Address Social Determinants of Health Among Minority Populations in Baltimore City

开发、试点和传播综合临床和社会多层次决策支持平台，以解决巴尔的摩市少数民族人口健康的社会决定因素

• 批准号: 10454106
• 负责人: Elham Hatef-Naimi
• 金额: $ 68.72万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-07-20 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10454106
• 关键词: Address; Adult; African American; African American population; Algorithms; Baltimore; Caring; Case Manager; Characteristics; Chronic; Chronic Disease; Cities; Clinical; Clinical Data; Clinical Decision Support Systems; Clinical Services; Clinical Trials Design; Clinical effectiveness; Collaborations; Communities; Community Health Aides; Complement; Data Analyses; Development; Disadvantaged; Disease; Electronic Health Record; Enrollment; Ensure; Evaluation; Focus Groups; Frontline worker; Goals; Group Interviews; Health; Health Services Research; Health system; Informatics; Information Technology; Institution; Intervention; Length; Link; Low income; Management Decision Support Systems; Maryland; Measures; Medical; Methods; Minority; Minority Groups; Morbidity - disease rate; Neighborhoods; Outcome; Patients; Persons; Phase; Population; Primary Health Care; Process; Provider; Quality of life; Randomized Clinical Trials; Recommendation; Reduce health disparities; Reporting; Research; Research Personnel; Resources; Risk; Risk Assessment; Services; Site; Social Sciences; Social Work; Social Workers; Standardization; Support System; System; Technology Assessment; Testing; Work; arm; base; burden of illness; clinical decision support; clinical implementation; clinical risk; cohort; data dissemination; data quality; design; digital; disadvantaged population; ethnic minority; experience; health data; health disparity; health information technology; implementation science; improved; inner city; interoperability; large-scale database; mortality; multiple chronic conditions; point of care; programs; service organization; social; social disadvantage; social health determinants; social integration; standard of care; support tools; system architecture; tool; treatment arm; work-study

 PROJECT SUMMARY Achieving a comprehensive assessment of a person's health and addressing health disparities goes beyond just documenting clinical diseases and medical interventions. We must also capture, standardize, analyze, and report reliable information on Social Determinants of Health (SDOH) within operational Clinical Decision Support (CDS) systems that are built-into electronic health records (EHRs). Moreover, to truly have an impact on decreasing health disparities, data analysis is not enough. At the point of care, we must digitally support interactions between medical and social services. Our proposed project addresses many of the hurdles in this process through the application of informatics, social science, health services research, implementation science, and stakeholder engaged research. This project will be undertaken by an experienced interdisciplinary team of investigators with many pre-existing resources. To maximize impact, the academic team will be complemented by an exceptional network of collaborating community, operational information technology, and stakeholder agencies from both the region and nationally. Our goal is to facilitate the integration of available digital information regarding SDOH needs and services into provider EHRs with the intent of improving care for minority and disadvantaged populations with chronic diseases. The first aim will be to integrate both clinical and non-clinical large-scale databases (e.g., EHRs, social risk assessments, and neighborhood characteristics) in order to develop a multi-level CDS tool inclusive of a comprehensive social risk score. As part of this CDS, in collaboration with the Maryland Health Information Exchange, we will also develop an interoperable closed loop referral system between primary care practices and 3 community based (social service) organizations (CBOs). These and all other development phases will build on extensive preliminary work the study collaborators have completed in related domains. The second aim will be to integrate the CDS tool into the established care management support system and workflow and to pilot this Health IT-based intervention using a randomized clinical trial (RCT) design at four primary care practices within the Johns Hopkins Health System (JHHS). The main intent of this CDS-based intervention will be to identify and assess SDOH of African-American adult patients (18+) with low incomes and a high burden of chronic illness, and as needed to refer them to the CBOs participating in this pilot. The third aim will be to assess the acceptability of the CDS tool (including its risk score and referral module) and to initiate dissemination of the data platform in support of its implementation across the JHHS institution, the Maryland statewide (CPC+) primary care program, and potentially nationally. To accomplish this aim, we will collaborate closely with clinical providers, CBOs, and an advisory board made up of the local and national leaders, as well as patients and frontline workers (e.g., community health workers, care managers, and social workers). With the help of several national leaders on our advisory board, we expect to substantially contribute to the broader national agenda regarding the digital integration of SDOH and clinical data into EHR-supported workflows.

项目总结