Promoting Social Determinants of Health Services: Informatics Is the Answer

by Gulzar H. Shah, PhD, MStat, MS; Kristie Waterfield, MBA

Health Informatics Innovations and Applications highlights ways that health informatics innovations and applications are supporting stakeholders in public health practice and policy to advance their mission of improved population health. The series will also highlight innovations in health care informatics.

Informatics, That’s What’s Happening

The more I learn about the potential of information technology for advancing public health, population health, and clinical care, the more I search for a car sticker that says “Informatics is the answer.” The naysayer will perhaps also place a sticker right next to it on my car that may read “The worm in the radish doesn’t think there is anything sweeter,” a quote attributed to the famous author and playwright Sholem Aleichem, who among many other works penned the script of the movie Fiddler on the Roof. It is true that I teach informatics, do research in this field, and have friends who do the same, but in disagreement to the 2nd sticker, I will place a sticker on top of it that will say “Informatics is the answer.” Among my friends who have made informatics their bread and butter is Dr. Joshua Vest, the Director for the Center for Health Policy at Richard M. Fairbanks School of Public Health at Indiana University. At a recent professional conference, we had a chance to catch up and ask each other what’s happening. Our answer summed up to “Informatics, that’s what’s happening.” I asked Josh if he could dedicate some of his precious time to talk with me about what he has been up to for this blog.

Role of Data in Leveraging SDoH

Some of Dr. Vest’s most recent work has focused on the use of structured and unstructured data to do predictive modeling of social determinants of health services. Dr. Vest and colleagues have integrated patient clinical data with community-level data. They then built predictive models that assist in identifying patients in need for wraparound services and their utilization rates. This research has examined the impact of risk stratification on referrals for the wraparound services, and in turn, the role of wraparound services in reducing preventable hospitalizations and ED visits.

Listen to the Full Interview

Read the full transcript of this interview here

Facilitators of Spread of SDoH Services Approach

I asked Josh to elaborate on how his work in healthcare can be expanded to support public health organizations in their quest to promote population health. He explained, “[t]he entire perspective of addressing upstream factors through non-medical providers is really a Public Health perspective.” He further explained: “Globally on things like prevention and addressing inequalities and supporting more effective, proactive use of resources and dealing with challenges and risks before they manifest as ill-health or unintended and undesirable consequences. Across the board it’s a Public Health perspective.”

Infrastructural Update to Match the Changing Landscape of Care

A few developments are essential for all agencies providing the wraparound services to make diffusion of SDoH services a reality on a broader scale. First, there needs to be a broader shift in focus among healthcare systems from patient’s sickness to patient’s health. The infrastructural capacity needs to evolve accordingly in all partnering organizations with a common goal to address a patient’s upstream factors. 

Secondly, adequate informatics infrastructures must be in place for providers of the SDoH services so that practitioners can identify a patient’s overall service needs. For health interventions to be successful, building informatics capacity may be essential for systemic risk stratification and re-stratification of patients; such stratification allows screening, assessing, or leveraging the upstream factors. For the organizations collaborating on population health services, informatics can be instrumental in facilitating communications and information sharing.

Supportive Cultural Values

The organizations involved in SDoH services must have the culture and values to support the infrastructural capacity-building and the addition of wraparound services for their patients. Josh explained it eloquently: “An organization that has an interest in fostering health and making the overall health of their community better, needs communication and dedication from the community itself, and this will hopefully lead to the development of the culture within the organization. The organization also needs to view improved health as a goal of the organization and needs to add value to the need to add wraparound services for their patients.”

Related Articles in the Journal of Public Health Management and Practice:
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JPHMP Consulting Editor of Biostatistics Dr. Gulzar Shah and guest Dr. Joshua Vest discuss the role of data and other informatics components in supporting upstream wraparound services through non-medical providers to leverage SDoH. 

Dr. Gulzar Shah

Gulzar H. Shah, PhD, MStat, MS, currently serves as a Professor of Health Policy and Management and the Department Chair, Health Policy and Community Health, at the Jiann-Ping Hsu College of Public Health (JPHCOPH), Georgia Southern University. He served the JPHCOPH as an Associate Dean for Research before accepting the Department Chair position in 2017. Prior to moving into academia, Dr. Shah spent over 17 years serving in public health practice, first at the Utah State Department of Health, and subsequently at the National Association of Health Data Organizations (NAHDO) and National Association of County and City Health Officials (NACCHO). [Full bio.]



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