Physicians should collect more information about patients' behavior and social environment in their electronic health records, according to an Institute of Medicine panel.
The IOM subcommittee recommends in a new report that federal health information technology policymakers promote the addition of eight new social and behavioral-health domains to clinicians' EHR workflows, which the panel says would improve clinical research as well as individual and population healthcare delivery.
The 317-page report, Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2, recommends that providers use their EHRs to capture patients' census tract information (to estimate their median income and for geo-coded mapping), as well as information about their financial resource strain and levels of physical activity and stress. The IOM panel also recommended that EHRs and their users gather information about patients' educational status; whether they are experiencing depression; their social connections and sense of social isolation; and whether or not they're subjected to violence by a partner in an intimate relationship.
“The inclusion and use of such data in an EHR should foster better clinical care of individual patients and of populations, and enable more informative research on the determinants of health and the effectiveness of treatments,” the IOM subcommittee report said. Its members looked at “what social and behavioral information should be included in EHRs and identifying obstacles to the inclusion of such information and ways to overcome those obstacles.”
The widespread capture of data in these eight categories, or “domains,” could be achieved by adding them to the requirements of the federal government's EHR incentive payment program, the IOM committee recommended.
The recommendations will be submitted to the CMS and the Office of the National Coordinator for Health Information Technology at HHS for their consideration as they develop requirements for Stage 3 of the EHR incentive program, according to Dr. William Stead, co-chairman of the 13-member IOM subcommittee that released the report. Stead is a professor of medicine and biomedical informatics at Vanderbilt University.
The CMS writes the rules on what providers must do to become “meaningful users” of EHRs, qualify for incentive payments and avoid Medicare penalties under the program created by the American Recovery and Reinvestment Act of 2009. The ONC sets the EHR testing and certification requirements vendors must meet so providers using their systems can meet their meaningful-use requirements.
Some of the panel's recommended requirements—information gathering about patients' use of alcohol and tobacco; their residential addresses; and their race and ethnicity—are already routinely being collected by clinicians and kept in EHRs, according to panel co-chair Nancy Adler, director of the Center for Health and Community at the University of California at San Francisco.
For the remaining social and behavioral health “domains” covered by additional data-gathering recommendations, the committee tried to come up with a “parsimonious” list, with related questions and measures, according to Stead. Indeed, the number of domains and measures were cut roughly in half compared with those in a Phase 1 report from the subcommittee released in April.
In making its new recommendations on what should be asked, gathered and shared, the panel considered what effect using the data gathered from each area to be measured might have on evaluating the health of the individual or a population and its potential in research.
The panel considered the feasibility of gathering the information, its sensitivity and whether it was available from any other source, or best gathered into an EHR.
None of the new recommendations should pose significant technical difficulties for vendors, Stead said. The greater challenge is for providers, particularly since it's expected that some of the information—particularly with more technologically advanced provider organizations and patients—could be gathered from patients using patient portals or mobile devices, he said.
“Practices will need to consider workflow design,” Stead said, including how and what information is shared with other healthcare and social services providers. “Who it's going to be shared with and why is essential to maintain trust,” he said. That may require two-way consent from patients to share their information between providers and outside agencies, he added, but the “benefits of addressing these concerns outweigh the problems collecting it.”
Whether there will be room for even this IOM subcommittee's short list of new Stage 3 requirements remains to be seen. Last month, a pair of ONC advisory committees recommended that the feds cut Stage 3 requirements to a minimum to enable providers to focus on achieving interoperability of their existing health IT systems while converting to a proposed, new health IT exchange architecture built on Internet-based principles.
ONC advisors are expected to hear a presentation from IOM subcommittee member Dr. George Hripcsak at a Nov. 20 meeting of the advanced health models and meaningful use work group of the Health IT Policy Committee. Hripcsak is a chairman of biomedical informatics at Columbia University and director of medical informatics services at New York-Presbyterian Hospital/Columbia Campus, in New York.
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