Panelists at the annual meeting of the Office of the National Coordinator for Health Information Technology discussed efforts to holistically treat low-income or chronic care populations by taking social determinants of health into consideration.

Christopher Forrest, MD, professor of pediatrics at the Children’s Hospital of Philadelphia and a member of the Institute of Medicine (IOM), explained his work with the IOM of identifying a set of domains and measures for capturing social and behavioral factors in electronic health records (EHRs).

Gathering this information can be critically important to understanding the population healthcare systems serve, explained Jeffrey Caballero, MPH, executive director of the Association of Asian Pacific Community Health Organizations. Some of the facilities his organization represents have large percentages of patients who cannot speak or engage in English very well. He explained that 70% of patients seen at these facilities are at or below 100% of the federal poverty line.

Robert Zarr, MD, MPH, FAAP, pediatrician with Unity Clinic and leader of Parks Rx, Stacy Lindau, MD, MAPP, with the Community Rx program, and Joseph Flesh, co-founder of Purple Binder, all explained how they use health information technology (IT) to improve outcomes among underserved communities.

Dr Zarr has been prescribing parks to children. He mapped all the parks in Washington, DC, and linked it to the EHR and found that doing so actually made the child more active by 22 minutes per week.

“We have 1 good study that says prescribing nature in a clinical setting by a physician embedded by an EHR affects change,” he said.

Dr Lindau has used health IT to link health information platforms with databases of community resources that may be of use to the community she serves in the south side of Chicago.

“The ACA has created, for the first time, a reason for health systems to address social determinants,” Mr Flesh said.

His company works with health systems and local governments to connect patients with the community services that can help improve their care, like food pantries, community health clinics, churches that provide items to people in need, places that give out free eye glasses, etc.

However, the next step is to gather health outcomes data, he said, and Purple Binder is already running randomized controlled trials to determine the impact on health outcomes of connecting people to community resources.