Piloting a Clinical Decision Support Tool to Identify Patients With Social Needs and Provide Navigation Services and Referral to Community-Based Organizations: Protocol for a Randomized Controlled Trial.

Background: Social needs and social determinants of health (SDOH) significantly outrank medical care when considering the impact on a person's length and quality of life, resulting in poor health outcomes and worsening life expectancy. Integrating social needs and SDOH data along with clinical risk information within operational clinical decision support (CDS) systems built into electronic health records (EHRs) is an effective approach to addressing health-related social needs. To achieve this goal, applied research is needed to develop EHR-integrated CDS tools and closed-loop referral systems and implement and test them in the digital and clinical workflows at health care systems and collaborating community-based organizations (CBOs).

Association of buprenorphine retention and subsequent adverse outcomes following non-fatal overdose: An analysis using statewide linked Maryland databases.

Introduction: Patients receiving buprenorphine after a non-fatal overdose have lower risk of future nonfatal or fatal overdose, but less is known about the relationship between buprenorphine retention and the risk of adverse outcomes in the post-overdose year.

Objective: To examine the relationship between the total number of months with an active buprenorphine prescription (retention) and the odds of an adverse outcome within the 12 months following an index non-fatal overdose.

Materials And Methods: We studied a cohort of people with an index non-fatal opioid overdose in Maryland between July 2016 and December 2020 and at least one filled buprenorphine prescription in the 12-month post-overdose observation period.

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

Background: Patients with unmet social needs and social determinants of health (SDOH) challenges continue to face a disproportionate risk of increased prevalence of disease, health care use, higher health care costs, and worse outcomes. Some existing predictive models have used the available data on social needs and SDOH challenges to predict health-related social needs or the need for various social service referrals. Despite these one-off efforts, the work to date suggests that many technical and organizational challenges must be surmounted before SDOH-integrated solutions can be implemented on an ongoing, wide-scale basis within most US-based health care organizations.

Prevalence of lifestyle-related behavioral information in claims data in the U.S.

Objective: Given their association with varying health risks, lifestyle-related behaviors are essential to consider in population-level disease prevention. Health insurance claims are a key source of information for population health analytics, but the availability of lifestyle information within claims data is unknown. Our goal was to assess the availability and prevalence of data items that describe lifestyle behaviors across several domains within a large U.

Trends and Patterns of Social History Data Collection Within an Electronic Health Record.

There is increased acceptance that social and behavioral determinants of health (SBDH) impact health outcomes, but electronic health records (EHRs) are not always set up to capture the full range of SBDH variables in a systematic manner. The purpose of this study was to explore rates and trends of social history (SH) data collection-1 element of SBDH-in a structured portion of an EHR within a large academic integrated delivery system. EHR data for individuals with at least 1 visit in 2017 were included in this study.

Outcomes of In-Person and Telehealth Ambulatory Encounters During COVID-19 Within a Large Commercially Insured Cohort.

Importance: Since the start of the COVID-19 pandemic, few studies have assessed the association of telehealth with outcomes of care, including patterns of health care use after the initial encounter.

Objective: To assess the association of telehealth and in-person visits with outcomes of care during the COVID-19 pandemic.

Design, Setting, And Participants: This cohort study assessed continuously enrolled members in private health plans of the Blue Cross and Blue Shield Association from July 1, 2019, to December 31, 2020.

Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study.

Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes.

Patient perceptions of safety in primary care: a qualitative study to inform care.

Patients' perspectives on patient safety have rarely been incorporated into quality initiatives in primary care. Our objective was to understand the patient perspective on patient safety in patient-centered medical homes (PCMHs). We conducted 12 patient focus groups/interviews in nine sites with 65 patients at a geographically diverse sample of National Committee on Quality Assurance Level 3 recognized PCMHs across three states.

Social and Behavioral Variables in the Electronic Health Record: A Path Forward to Increase Data Quality and Utility.

Purpose: Social and behavioral determinants of health (SBDH) are important factors that affect the health of individuals but are not routinely captured in a structured and systematic manner in electronic health records (EHRs). The purpose of this study is to generate recommendations for systematic implementation of SBDH data collection in EHRs through (1) reviewing SBDH conceptual and theoretical frameworks and (2) eliciting stakeholder perspectives on barriers to and facilitators of using SBDH information in the EHR and priorities for data collection.

Method: The authors reviewed SBDH frameworks to identify key social and behavioral variables and conducted focus groups and interviews with 17 clinicians and researchers at Johns Hopkins Health System between March and May 2018.

Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients.

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective.

Methods: We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes.

The Association Between Neighborhood Socioeconomic and Housing Characteristics with Hospitalization: Results of a National Study of Veterans.

Background: Social determinants of health (SDOH) have an inextricable impact on health. If remained unaddressed, poor SDOH can contribute to increased health care utilization and costs. We aimed to determine if geographically derived neighborhood level SDOH had an impact on hospitalization rates of patients receiving care at the Veterans Health Administration's (VHA) primary care clinics.

Integrating social and behavioral determinants of health into patient care and population health at Veterans Health Administration: a conceptual framework and an assessment of available individual and population level data sources and evidence-based measurements.

The premise of this project was that social and behavioral determinants of health (SBDH) affect the use of healthcare services and outcomes for patients in an integrated healthcare system such as the Veterans Health Administration (VHA), and thus individual patient level socio-behavioral factors in addition to the neighborhood characteristics and geographically linked factors could add information beyond medical factors mostly considered in clinical decision making, patient care, and population health. To help VHA better address SBDH risk factors for the veterans it cares for within its primary care clinics, we proposed a conceptual and analytic framework, a set of evidence-based measures, and their data source. The framework and recommended SBDH metrics can provide a road map for other primary care-centric healthcare organizations wishing to use health analytic tools to better understand how SBDH affect health outcomes.

The Impact of Social Determinants of Health on Hospitalization in the Veterans Health Administration.

Introduction: This study aims to assess the effect of individual and geographic-level social determinants of health on risk of hospitalization in the Veterans Health Administration primary care clinics known as the Patient Aligned Care Team.

Methods: For a population of Veterans enrolled in the primary care clinics, the study team extracted patient-level characteristics and healthcare utilization records from 2015 Veterans Health Administration electronic health record data. They also collected census data on social determinants of health factors for all U.

Defining and Assessing Geriatric Risk Factors and Associated Health Care Utilization Among Older Adults Using Claims and Electronic Health Records.

Background: Using electronic health records (EHRs), in addition to claims, to systematically identify patients with factors associated with adverse outcomes (geriatric risk) among older adults can prove beneficial for population health management and clinical service delivery.

Objective: To define and compare geriatric risk factors derivable from claims, structured EHRs, and unstructured EHRs, and estimate the relationship between geriatric risk factors and health care utilization.

Research Design: We performed a retrospective cohort study of patients enrolled in a Medicare Advantage plan from 2011 to 2013 using both administrative claims and EHRs.

A State-wide Health IT Infrastructure for Population Health: Building a Community-wide Electronic Platform for Maryland's All-Payer Global Budget.

Maryland Department of Health (MDH) has been preparing for alignment of its population health initiatives with Maryland's unique All-Payer hospital global budget program. In order to operationalize population health initiatives, it is required to identify a starter set of measures addressing community level health interventions and to collect interoperable data for those measures. The broad adoption of electronic health records (EHRs) with ongoing data collection on almost all patients in the state, combined with hospital participation in health information exchange (HIE) initiatives, provides an unprecedented opportunity for near real-time assessment of the health of the communities.

A Population Health Measurement Framework: Evidence-Based Metrics for Assessing Community-Level Population Health in the Global Budget Context.

Population health is one of the pillars of the Triple Aim to improve US health care. The authors developed a framework for population health measurement and a proposed set of measures for further exploration to guide the population health efforts in Maryland. The authors searched peer-reviewed, expert-authored literature and current public health measures.

A proposed national research and development agenda for population health informatics: summary recommendations from a national expert workshop.

Objective: The Johns Hopkins Center for Population Health IT hosted a 1-day symposium sponsored by the National Library of Medicine to help develop a national research and development (R&D) agenda for the emerging field of population health informatics (PopHI).

Material And Methods: The symposium provided a venue for national experts to brainstorm, identify, discuss, and prioritize the top challenges and opportunities in the PopHI field, as well as R&D areas to address these.

Results: This manuscript summarizes the findings of the PopHI symposium.