Leveraging Technology to Improve Outcomes for Vulnerable and High-Risk Populations

The shift from fee-for-service to value-based payment has accelerated interest in the collection and analysis of data related to Social Determinants of Health (SDOH) such as stable housing, adequate food, and reliable transportation.  SDOH can be broadly applied to anything that impacts health and is defined simply as “the conditions in which people are born, live, grow, and age” (Mullangi, Pollak, Ibrahaim, 2019, pg.1). Although 83% of doctors agreed with the Institute of Medicine’s 2014 recommendation that they collect patients’ SDOH information such as sociodemographic, psychological, and behavioral information, only 20% reported that they had the time to enter that information into their electronic medical records (EMR). With new insights gained through SDOH data analysis, alternative collection methods have emerged.

Smartphones, credit card information, and social media are all modern tools that can offer healthcare providers a unique look into patients’ individual lives and the overall sociodemographic and economic settings of their patient population.


Key Takeaways

  1. Physical location is a key SDOH. Geolocation from smartphones or location sharing on social media can offer providers insight into the communities where their patients live. They can determine if their patient population has ready access to whole and fresh foods, or if they can exercise and spend time outdoors in relative safety. In a study on smoking cessation and relapse patterns, it was discovered that the patients’ location and the availability of point-of-sale tobacco warehouses were “significantly associated with lapses even when [tobacco product] cravings were low” (Mullangi, Pollak, Ibrahaim, 2019, pg. 2). While this data collection method is still in development, it is easy to see how this type of data could be used to provide patients with the tools and knowledge to help themselves succeed in their health goals.
  2. A second SDOH data point can be gained by understanding patient purchasing patterns, which can aid in the administration of care management plans. If providers have access to purchase information, it “would go a long way into understanding whether patients fill their prescriptions, purchase cigarettes, or order salads.” (Mullangi, Pollak, Ibrahaim, 2019, pg. 3). These behaviors could then be assessed and presented to the patient as a tool to demonstrate the link between healthy habits and generally better health.
  3. People are protective of their privacy, particularly when it comes to sensitive information like their health and personal data. As such, providers should take care to respect and acknowledge the concerns of their patients. One method to increase patient cooperation may be to incorporate programs that can be trusted by the target population. An initiative led by Parkland Hospital in Dallas, Texas, that sought to connect data on “patients’ usage of food pantries, homeless shelters, and other social services with their medical records, [and] found that patients were more willing to be enrolled into a digital database when asked to do so by community partners that had earned their trust rather than in the emergency room” (Mullangi, Pollak, Ibrahaim, 2019, pg.4). Providers who are interested in utilizing SDOH recording methods should work to build and maintain rapport with their patient populations to create the best environment possible for acceptance and adoption of these resources.




About Innovista

Innovista exists to help providers succeed in value-based care by developing strong relationships, delivering innovative solutions and driving exceptional performance. Strong dedication to improving patient outcomes drives Innovista to provide our physician partners with expert staffing, clinical programs, delegated services, and analytics capabilities optimized to drive effective change.


Innovista Media Contact

Laura Bingham