Rishi Manchanda

Social and Behavioral Domains in
Electronic Health Records
Rishi Manchanda MD MPH
Veronica had a chronic headache.
She sought relief in numerous
healthcare encounters
Rishi Manchanda. The Upstream Doctors:
Medical Innovators Track Sickness to Its Source.
TED Books. June 6th, 2013
But Veronica
was still sick.
Good Care?
Veronica then presented to a clinic that
asked her routine questions about housingrelated risk factors, identified her problem
and developed a treatment plan.
Photo taken with permission
Rishi Manchanda.
The Upstream Doctors:
Medical Innovators Track Sickness to Its Source.
TED Books. June 6th, 2013
and her home
got better.
Propietary/ Confidential
Better Care
Robert Wood Johnson Foundation
“Health Care’s Blind Side” December 2011
Propietary/ Confidential
We mobilize and equip frontline
providers with tools and training
to improve care and the social
determinants of health
Social & Behavioral Domains in
• Foundational vs Flexible Domains
– Income Insecurity
– Housing Insecurity
– Food Insecurity
• Capability
• Design changes
Foundational + Flexible Approach
All EHRs
Frame properly
to avoid stigma
“Every person faces different stresses
that can affect their health.
We ask everyone about these issues
because we may be able to help.”
Health Literacy
“How confident are you filling out medical
forms by yourself?”
• Accurate in detecting limited and
limited/marginal health literacy skills.
Wallace L. S., Rogers E. S., Roskos S. E., Holiday D. B., Weiss B. D. Screening items to identify
patients with limited health literacy skills. Journal of General Internal Medicine.
Income Insecurity
• “Do you ever have difficulty making ends
meet at the end of the month?”
– Sensitivity 98%, Specificity 64% for those living
below the poverty line.
– Inadequate income
– Low financial literacy
Brcic, Vanessa, Caroline Eberdt, and Janusz Kaczorowski (2011), “Development of a Tool to
Identify Poverty in a Family Practice Setting: A Pilot Study,” International Journal of Family
Medicine, vol. 2011.
Housing Insecurity
• “In the past 2 months, have you been living in
stable housing that you own, rent, or stay in as
part of a household?”
• “Are you worried or concerned that in the next
2 months you may NOT have stable housing
that you own, rent, or stay in as part of a
Homelessness Clinical Reminder, US Department of Veterans Affairs, National Center on
Homelessness Among Veterans, 2012.
Contact Ann Elizabeth Montgomery /[email protected]
Food Insecurity
Limited or uncertain availability of nutritionally adequate and safe foods
or limited or uncertain ability to acquire acceptable foods in socially
acceptable ways.
Within the last 12 months,
• “Were you ever worried about whether your food would
run out before you got money to buy more?
• “Did you find that the food that you bought just didn't last
and you didn't have money to get more?”
• “Have you had difficulty affording to eat a balanced
“The effectiveness of a short form of the household food security scale,” by S.J. Blumberg, K.
Bialostosky, W.L. Hamilton, and R.R. Briefel (published by the American Journal of Public Health,
Homeless Patient- Aligned Care Team
(HPACT) at Greater Los Angeles VA
• In a VA-funded demonstration project in Los Angeles,
we created a clinic for homeless Veterans by adapting
and integrating approaches including
– Social Determinants of Health,
– Community Oriented Primary Care (COPC) and
– Ambulatory Intensive Caring Unit (AICU)
• Target population: Homeless Veterans with complex
social and medical needs and high utilization of
emergency and inpatient services.
Integrating upstream and downstream
operational models for chronic care
HPACT at Greater Los Angeles VA
Among 101 homeless, high utilizer patients
We also observed improvements in 'vertical' and 'horizontal
' integration
among health, housing and social service sectors.
Considerations in integrating Social Screening in EHRs
Evaluate Patient Capability
• The capability framework was created to evaluate
individual well-being and its social context.
• Capability is defined as the extent to which people have
the opportunity to live the kind of life they value.
• A capability perspective implies, e.g., that poverty
should not be defined primarily by income but by scarce
opportunity to pursue valued activities and goals.
Ferrer and Carrasco. Capability and Clinical Success. ANNALS OF FAMILY MEDICINE
Meaningful Use
must address patient capability
1. What are person’s values and goals with respect to this
health issue?
2. What resources are locally available? Is there
opportunity to access them? How convenient are they?
What is the price?
3. What personal, family, or community factors help or
hinder using those resources?
Ferrer and Carrasco. Capability and Clinical Success. ANNALS OF FAMILY MEDICINE
Design Considerations to address
Social & Behavioral Domains
• Most EHRs are not care management tools.
– Without these tools, clinics cannot act on, and
therefore, will be less likely to ask about the social and
environmental determinants of health
• Clinics require support to make design changes
to current practice workflows
– Finding, referring and linking with community resources
remains a common design challenge
– Without design changes, providers will, at best, simply
follow the letter, not the spirit, of Meaningful Use vis-àvis social domains.
• Workforce requires training & support AND to be held
accountable by their systems to ask and act on
The HealthBegins
‘Community Health Detailing’ Model:
Building a community-powered
“Yelp for Health” to support system design change in clinics
A better workforce model
for the healthcare system
By 2020,
Populationlevel Impact
Upstreamists ensure that their
healthcare systems systematically:
-Ask about where patients live, work, eat,
and play using EHRs and other tools
-Address upstream problems at patient,
clinic, and population levels
-Build bridges with upstream actors (i.e.
those who work where health happens)
using a data-driven approach to system
design and a unique blend of skills.
With tools and training, clinicians
and care delivery systems can
better address social factors
Provider confidence to address
housing & other social needs
A better standard of care is possible
Photo taken with permission
Propietary/ Confidential
Rishi Manchanda MD MPH
[email protected]
The Upstream Doctors is available on Kindle, Nook, or from
the iBookstore. It can be purchased for US$1.99 each.

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