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: 10659016
• 负责人: Elham Hatef-Naimi
• 金额: $ 68.45万
• 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 2025-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10659016
• 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; Community Participation; Complement; Data Analyses; Development; Disadvantaged; Disease; Disparity; Disparity population; Electronic Health Record; Ensure; Evaluation; Focus Groups; Frontline worker; Goals; Health; Health Services Research; Health system; Informatics; Information Technology; Institution; Intervention; Interview; Length; Link; Low income; Managed Care; Management Decision Support Systems; Maryland; Measures; Medical; Methods; Minority; Minority Groups; Morbidity - disease rate; Neighborhoods; Outcome; Patients; Persons; Phase; Population; Primary Care; Process; Provider; Quality of life; 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; burden of illness; clinical decision support; clinical implementation; clinical risk; cohort; community organizations; data dissemination; data quality; design; digital; ethnic minority; experience; health data; health disparity; health information technology; implementation science; improved; inner city; interoperability; large-scale database; mortality; multiple chronic conditions; participant enrollment; point of care; primary care practice; programs; randomized, clinical trials; service organization; social; social disparities; social health determinants; 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.

项目概要 实现对个人健康的全面评估和解决健康差距不仅仅是 记录临床疾病和医疗干预。我们还必须捕捉、标准化、分析和报告 在操作临床决策支持（CDS）中提供关于健康社会决定因素（SDOH）的可靠信息 电子健康记录（EHR）中内置的系统。此外，要真正对日益减少的健康产生影响， 差异，数据分析不够。在护理点，我们必须数字化地支持医疗服务之间的互动， 和社会服务。我们提出的项目通过应用以下方法解决了这一过程中的许多障碍： 信息学、社会科学、卫生服务研究、实施科学和利益相关者参与的研究。这 该项目将由一个经验丰富的跨学科调查小组进行，该小组拥有许多现有资源。 为了最大限度地发挥影响力，学术团队将得到一个特殊的合作网络的补充， 社区、业务信息技术和来自该地区和国家的利益相关者机构。我们 目标是促进将有关SDOH需求和服务的可用数字信息集成到供应商 EHR旨在改善对患有慢性病的少数群体和弱势群体的护理。 第一个目标是整合临床和非临床大型数据库（例如，EHR，社会 风险评估和邻里特征），以开发一个多层次的CDS工具，包括 综合社会风险评分作为本CDS的一部分，与马里兰州健康信息中心合作， 交流，我们还将开发一个可互操作的闭环转诊系统之间的初级保健 实践和3个社区（社会服务）组织（CBOs）。这些和所有其他发展 各阶段将建立在研究合作者在相关领域完成的大量初步工作的基础上。 第二个目标是将CDS工具纳入既定的护理管理支持 系统和工作流程，并使用随机临床试验来试验这种基于健康信息技术的干预措施 (RCT)设计在约翰霍普金斯卫生系统（JHHS）内的四个初级保健实践。的主要意图 这种基于CDS的干预将确定和评估非洲裔美国成年患者（18岁以上）的SDOH， 这是一个非常重要的问题，因为他们的收入和慢性病的沉重负担，并在必要时将他们转介给参与这一试点的社区组织。 第三个目标是评估CDS工具的可接受性（包括其风险评分和转诊 模块），并启动数据平台的传播，以支持其在JHHS中的实施 机构，马里兰州全州（CPC+）初级保健计划，并可能在全国范围内。为了实现这一目标， 我们将与临床服务提供者、社区组织以及由地方和国家一级人员组成的咨询委员会密切合作， 领导者，以及患者和一线工作人员（例如，社区卫生工作者、护理管理人员和社会 工人）。在我们咨询委员会中的几位国家领导人的帮助下，我们希望能够为 关于将SDOH和临床数据数字化整合到EHR支持的工作流程中的更广泛的国家议程。

项目成果

Application of natural language processing to identify social needs from patient medical notes: development and assessment of a scalable, performant, and rule-based model in an integrated healthcare delivery system.

• DOI: 10.1093/jamiaopen/ooad085
• 发表时间: 2023-12
• 期刊: JAMIA open
• 影响因子: 2.1

Development of a Social Risk Score in the Electronic Health Record to Identify Social Needs Among Underserved Populations: Retrospective Study.

在电子健康记录中制定社会风险评分，以确定服务不足人群的社会需求：回顾性研究。

• DOI: 10.2196/54732
• 发表时间: 2024
• 期刊: JMIR formative research
• 影响因子: 2.2
• 作者: Hatef,Elham;Chang,Hsien-Yen;Richards,ThomasM;Kitchen,Christopher;Budaraju,Janya;Foroughmand,Iman;Lasser,ElyseC;Weiner,JonathanP
• 通讯作者: Weiner,JonathanP