ArticleApplied clinical informatics2023
Social and Health Information Platform: Piloting a Standards-Based, Digital Platform Linking Social Determinants of Health Data into Clinical Workflows for Community-Wide Use.
Article in Applied clinical informatics, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
9 citing papers in PubMed.
- Social Medicine Approaches to Community-Integrated Diabetes Care: A Narrative Review of Clinic-Based Triaging and Closed-Loop Referral Interventions.Journal of general internal medicine · 2026Review
- Co-designing an Outpatient Clinical Decision Support Prototype for Managing Social Risks in Patients Living with Dementia.Applied clinical informatics · 2026Article
- Social Worker and Community Health Worker Collaboration in Addressing Social Needs.Pediatrics · 2025Article
- Extracting Social Determinants of Health from Dental Clinical Notes.Applied clinical informatics · 2025Article
- Data linkage multiplies research insights across diverse healthcare sectors.Communications medicine · 2025Review
- Enhancing Referrals to the Supplemental Nutrition Assistance Program through Clinical Integration of a Standards-Based Decision Support System.Applied clinical informatics · 2025Article
- Predicting Provider Workload Using Predicted Patient Risk Score and Social Determinants of Health in Primary Care Setting.Applied clinical informatics · 2024Article
- EHR-Based Social Needs Screening and Referral in Primary Care: Clinician and Staff Perspectives on Practices, Barriers, and Benefits.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Clinician Awareness of Patient-Reported Health-Related Social Needs: There's Room for Improvement.Journal of primary care & community healthArticle
Corrections and comments
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Authors and funding
11 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundSocial determinants of health (SDoH)a are increasingly recognized as a main contributor to clinical health outcomes, but the technologies and workflows within clinics make it difficult for health care providers to address SDoH needs during routine clinical visits.
objectivesOur objectives were to pilot a digital platform that matches, links, and visualizes patient-level information and community-level deidentified data from across sectors; establish a technical infrastructure that is scalable, generalizable, and interoperable with new datasets or technologies; employ user-centered codesign principles to refine the platform's visualizations, dashboards, and alerts with community health workers, clinicians, and clinic administrators.
methodsWe used privacy-preserving record linkage (PPRL) tools to ensure that all identifiable patient data were encrypted, only matched and displayed with consent, and never accessed or stored by the data intermediary. We used limited data sets (LDS) to share nonidentifiable patient data with the data intermediary through a health information exchange (HIE) to take advantage of existing partner agreements, technical infrastructure, and community clinical data.
resultsThe platform was successfully piloted in two Federally Qualified Health Clinics by 26 clinic staff. SDoH and demographic data from findhelp were successfully linked, matched, and displayed with clinical and demographic data from the HIE, Connxus. Pilot users tested the platform using real-patient data, guiding the refinement of the social and health information platform's visualizations and alerts. Users emphasized the importance of visuals and alerts that gave quick insights into individual patient SDoH needs, survey responses, and clinic-level trends in SDoH service referrals.
conclusionThis pilot shows the importance of PPRL, LDS, and HIE-based data intermediaries in sharing data across sectors and service providers for scalable patient-level care coordination and community-level insights. Clinic staff are integral in designing, developing, and adopting health technologies that will enhance their ability to address SDoH needs within existing workflows without adding undue burdens or additional stress.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.