Transcript here - Champ Software

Social Determinants and the
Omaha System:
Showing our Work & Outcomes
Karen A. Monsen, PhD, RN, FAAN
[email protected]
Part 1: Definitions
Definitions
• “The term ‘behavioral’ refers to overt actions; to underlying
psychological processes such as cognition, emotion, temperament,
and motivation; and to bio-behavioral interactions. The term ‘social’
encompasses sociocultural, socioeconomic, and socio-demographic
status; biosocial interactions; and the various levels of social context
from small groups to complex cultural systems and societal
influences” (Office of Behavioral and Social Science Research, 2010).
• Social determinants of health are the environmental context and
social conditions in which people live (World Health Organization).
• Behavioral determinants of health are not seen as simply individual
choice but rather are defined as individual responses to disease that
are shaped by social conditions that influence health. (Evans &
Stoddart, 1990)
Evans & Stoddart, 1990
Part 2: Study of EHRs
with and without the
Omaha System
Background
• Electronic health records (EHRs) are a promising new source of
population health data that may improve health outcomes.
• The contribution of social and behavioral determinants (SBDH)
of health is know, but SBDH may not be documented in EHRs.
• The Institute of Medicine (IOM) study (2014) recommended
core SBDH items that should be incorporated within EHRs.
Social Determinants Documentation
in Electronic Health Records
With and Without Standardized
Terminologies
Karen A. Monsen, PhD, RN, FAAN, [email protected]
Nicole Kapinos, BSN, RN,
Joyce M. Rudenick, MA, BSN, RN,
Kathryn Warmbold, BSN, RN
Role of standardized terminology
• National recommendations are to use standardized
terminologies in EHRs to ensure shared understanding and
interoperability
• Standardized nursing terminologies are a potential source of
SBDH data in EHRs.
Gap
• Little is known about the extent to which SBDH are currently
documented in EHRs, including how SBDH are documented,
and by whom
Purpose
• To examine documentation of social and behavioral
determinants of health in EHRs with and without standardized
nursing terminologies.
Methods
• A review of the literature yielded 107 SBDH items that were
organized by topic for analysis
• Key informant interviews were conducted regarding SBDH
items in nine EHRs (6 acute care, 3 community care);
documentation type/method; documenter role; and EHR
screen placement
Results
• 107 SBDH items were documented using free text, structured
text, and clinical terminologies in diverse screens and by
multiple clinicians, admitting personnel, and other staff.
Terminologies
• In the nine EHRs, SBDH items were documented using one of
three standardized terminologies, (N=average number of
items per terminology per EHR):
• ICD-9/10 (n=1)
• SNOMED CT (n=1)
• Omaha System (n=92)
Documentation role
• Most often, clinical terminology data were documented
by nurses or other clinical staff vs. receptionists or other
non-clinical personnel.
“Unknown” result
• Documentation ‘unknown’ differed significantly between EHRs
with and without the Omaha System [mean=26.0 (SD=8.7) vs
mean=74.5 (SD=16.5)] (p=.005).
Mapping SBDH to Omaha System
• Mapping 107 SBDH items yielded 21 problems in 4
domains
• Mapping 12 IOM-recommended SBDH items yielded 6
problems
Discussion
• Understanding and managing SBDH and all patient
information is critical for high quality health care and
improving population health.
• Nursing expertise may be leveraged in assessing and
communicating all aspects of patient health and wellbeing
using standardized terminologies.
• Software programs that are based on nursing terminologies
are much better at describing a comprehensive, holistic view
of health compared to conventional software.
Implications
• EHRs based on the Omaha System were used in community
care settings, and data needed for care in community may
differ from data needed in inpatient setting.
• The IOM approach to SBDH documentation may be expanded
by leveraging the value of existing terminologies, as advised
by the AAN policy call to action.
Conclusions
• SBDH documentation in EHRs differed vastly based on
presence of a nursing terminology.
• The Omaha System enabled a more comprehensive, holistic
assessment and documentation of interoperable SBDH data.
• Further research is needed to determine SBDH data elements
that are needed across settings, the uses of SBDH data in
practice, and to examine patient perspectives related to SBDH
assessments.
Acknowledgments
• This informatics-policy project was completed by University of
Minnesota School of Nursing Doctor of Nursing Practice
students and faculty at the request of the Minnesota eHealth
Initiative – Minnesota Department of Health, and the
University of Minnesota Center for Nursing Informatics.
Part 3: Harmonizing
IOM-recommended
instruments and the
Omaha System
IOM Recommendations
IOM-Recommended Concepts
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Financial resource strain
Stress
Depression
Physical activity
Tobacco use and exposure
Alcohol use
Social connections and social isolation
Intimate partner violence
Race/ethnicity
Educational attainment
Neighborhood and community
compositional characteristics
IOM-Recommended Measures
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Overall financial resource strain (1 Q)
Stress Elo et al. 2003 1 Q
PHQ 2
Exercise Vital Signs (2 Q)
NHIS (2 Q)
AUDIT-C (3 Q)
NHANES III (4 Q)
HARK (4 Q)
U S census (2 Q)
Educational attainment (2 Q)
Residential address
Census tract-median income
Financial Resource Strain
• How hard is it for you to pay for the very basics like food,
housing, medical care, and heating? Would you say it is…
• Very hard
• Somewhat hard
• Not hard at all
Kahn, J. R., and L. I. Pearlin. 2006. Financial strain over the life course and health
among older adults. Journal of Health and Social Behavior 47(1):17–31.
Financial Resource Strain
scoring/ Income s/sx
• The answer is then scored on a scale of 1 (very hard) to 3 (not
at all)
• The Financial Resource Strain question is equivalent to one or
more sign/symptoms of the Income problem (Martin, 2005)
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low/no income (very hard or somewhat hard)
uninsured medical expenses
difficulty with money management
able to buy only necessities (somewhat hard)
difficulty buying necessities (very hard)
Kahn, J. R., and L. I. Pearlin. 2006. Financial strain over the life course and health
among older adults. Journal of Health and Social Behavior 47(1):17–31.
Stress
• Stress means a situation in which a person feels tense,
restless, nervous, or anxious, or is unable to sleep at night
because his/her mind is troubled all the time. Do you feel this
kind of stress these days?
• Not at all, A little bit, Somewhat, Quite a bit. Very much
Elo, A.-L., A. Leppänen, and A. Jahkola. 2003. Validity of a single-item measure of
stress symptoms. Scandinavian Journal of Work, Environment & Health 29(6):444–451
Stress Scoring/
Mental health s/sx
• The response is recorded on a five-point Likert scale ranging
from 1— indicating not at all, 2—a little bit, 3—somewhat, 4—
quite a bit, to 5— indicating very much. This single question
shows content validity as well as concurrent criterion validity.
The single question converged with items on psychological
symptoms and sleep disturbances and with validated
measures of well-being.
• A score of greater than one is equivalent to the “difficulty
managing stress” sign/symptom of the Mental health problem
(Martin, 2005)
Elo, A.-L., A. Leppänen, and A. Jahkola. 2003. Validity of a single-item measure of
stress symptoms. Scandinavian Journal of Work, Environment & Health 29(6):444–451
PHQ-2
(Patient Health Questionnaire-2)
Over the past 2 weeks, how often have you been bothered by any
of the following problems:
1. Little interest or pleasure in doing things
• Not at all (0), Several days (1), More than half the days (2), Nearly
every day (3)
2. Feeling down, depressed or hopeless
• Not at all (0), Several days (1), More than half the days (2), Nearly
every day (3)
Kroenke, K., R. L. Spitzer, and J. B. W. Williams. 2003. The Patient Health Questionnaire-2:
Validity of a two-item depression screener. Medical Care 41(11):1284–1292.
PHQ-2 Scoring/
Mental health s/sx
• A PHQ-2 score is the sum of points for the answers to the two
questions, and ranges from 0-6. The clinical cutoff of 3 for yes or no
risk for depression is a common diagnostic metric that can be
approximated by the PHQ-2
(http://www.cqaimh.org/pdf/tool_phq2.pdf)
• The PHQ-2 questions are equivalent to one or more sign/symptoms
of the Mental health problem (Martin, 2005)
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sadness/hopelessness/decreased self-esteem (Q2)
apprehension/undefined fear
loss of interest/involvement in activities/self-care (Q1)
narrowed to scattered attention/focus
flat affect
irritable/agitated/aggressive
purposeless/compulsive activity
difficulty managing stress
difficulty managing anger
somatic complaints/fatigue …
Kroenke, K., R. L. Spitzer, and J. B. W. Williams. 2003. The Patient Health Questionnaire-2:
Validity of a two-item depression screener. Medical Care 41(11):1284–1292.
Exercise Vital Sign
• 1. On average, how many days per week do you engage in
moderate to strenuous exercise (like walking fast, running,
jogging, dancing, swimming, biking, or other activities that
cause a light or heavy sweat)?
• 2. On average, how many minutes do you engage in exercise
at this level?
Coleman. 2012. Initial validation of an exercise “vital sign” in electronic medical
records. Medicine Science in Sports Exercise 44(11):2071–2076.
Exercise Vital Sign Scoring/
Physical activity s/sx
• The first question has a categorical response option set (0–7
days), and the second question is recorded in blocks of 10
minutes, from 0–150 or greater. The two numbers are
multiplied to display minutes per week of moderate-vigorous
activity, which can also be converted into the three category
clinically useful variable: inactive, insufficiently active, or
sufficiently active.
• The EVS scoring is equivalent to one or more sign/symptoms
of the Physical activity problem (Martin, 2005)
• sedentary life style (inactive)
• inadequate/inconsistent exercise routine (insufficiently active)
• inappropriate type/amount of exercise for age/physical condition
Coleman. 2012. Initial validation of an exercise “vital sign” in electronic medical
records. Medicine Science in Sports Exercise 44(11):2071–2076.
NHIS/Tobacco use and exposure
• 1. Have you smoked at least 100 cigarettes in your entire life?
• Yes, No, Refused, Do not know, and if yes:
• 2. Do you NOW smoke cigarettes every day, some days or not
at all?
• Every day, Some days, Not at all, Refused, Do not know
Adsit, R., and M. C. Fiore. 2013. Assessing tobacco use. The national landscape August
2013. Madison: University of Wisconsin School of Medicine and Public Health Center for
Tobacco Research and Intervention.
NHIS Scoring/Substance use s/sx
• A “current every day smoker” or “current some day smoker” has smoked at least
100 cigarettes and still regularly smokes every day or periodically, yet
consistently. A “former smoker” has smoked at least 100 cigarettes but does not
currently smoke. A “never smoker” has not smoked 100 cigarettes. “Smoker,
current status unknown” is known to have smoked at least 100 cigarettes, but
whether they currently still smoke is unknown
• The NHIS scoring of current every day smoker or current some day smoker are
equivalent to a sign/symptoms of the Substance problem (Martin, 2005)
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abuses over-the-counter/prescription medications
uses “street”-recreational drugs
abuses alcohol
smokes/uses tobacco products (NHIS current every day or current some day
smoker)
difficulty performing normal routines
reflex disturbances
behavior change
exposure to cigarette/cigar smoke
buys/sells illegal substances
Adsit, R., and M. C. Fiore. 2013. Assessing tobacco use. The national landscape August
2013. Madison: University of Wisconsin School of Medicine and Public Health Center for
Tobacco Research and Intervention.
AUDIT C/Alcohol use
• 1. How often do you have a drink containing alcohol? a. Never
b. Monthly or less c. 2–4 times a month d. 2–3 times a week e.
4 or more times a week
• 2. How many standard drinks containing alcohol do you have
on a typical day? a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 to 9 e. 10 or
more
• 3. How often do you have six or more drinks on one occasion?
a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or
almost daily
Babor, T. F., J. C. Higgins-Biddle, J. B. Saunders, and M. G. Monteiro. 2001. AUDIT: The alcohol use
disorders identification test. Guidelines for use in primary care. Geneva, Switzerland: World Health
Organization, Department of Mental Health and Substance Dependence.
AUDIT C Scoring/
Substance use s/sx
• The questions are scored on a scale of 0 to 12: a = 0 points, b = 1 point, c
= 2 points, d = 3 points, and e = 4 points. A score greater than 4 for men
or 3 for women is considered to be heavy or hazardous drinking
• The EVS scoring is equivalent to one or more sign/symptoms of the
Substance problem (Martin, 2005)
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abuses over-the-counter/prescription medications
uses “street”-recreational drugs
abuses alcohol (AUDIT C score of greater than 4 for men or 3 for women)
smokes/uses tobacco products
difficulty performing normal routines
reflex disturbances
behavior change
exposure to cigarette/cigar smoke
buys/sells illegal substances
Babor, T. F., J. C. Higgins-Biddle, J. B. Saunders, and M. G. Monteiro. 2001. AUDIT: The alcohol use
disorders identification test. Guidelines for use in primary care. Geneva, Switzerland: World Health
Organization, Department of Mental Health and Substance Dependence.
NHANES III – Social Networks
and Social Isolation
0. Marital status –
• Scoring 1 point for being married or living together with someone in a partnership at the
time of questioning;
1. In a typical week, how many times do you talk on the telephone with family, friends, or
neighbors?
2. How often do you get together with friends or relatives?
• Scoring 1 point for averaging three or more social interactions per week (assessed with
questions one and two, above);
3. How often do you attend church or religious services?
• Scoring 1 point for reporting attending church or other religious services more than four
times per year (assessed with question three, above)
4. How often do you attend meetings of the clubs or organizations you belong to?
• Scoring 1 point for reporting that they belong to a club or organization(assess with question
four, above).
Pantell, M., D. Rehkopf, D. Jutte, S. L. Syme, J. Balmes, and N. Adler. 2013. Social isolation:
A predictor of mortality comparable to traditional clinical risk factors. American Journal
of Public Health 103(11):2056–2062.
NHANES III Scoring/Social Contact
• A score of 0 represents the highest level of social isolation and
a score of 4 represents the lowest level of social isolation
• The NHANES III questions are equivalent to one or more
sign/symptoms of the Social contact problem (Martin, 2005)
• limited social contact (positive for yes answers to Q1 or Q2)
• uses health care provider for social contact
• minimal outside stimulation/leisure time activities (positive for
yes answers to Q3 or Q4)
Pantell, M., D. Rehkopf, D. Jutte, S. L. Syme, J. Balmes, and N. Adler. 2013. Social isolation:
A predictor of mortality comparable to traditional clinical risk factors. American Journal
of Public Health 103(11):2056–2062.
HARK
• H HUMILIATION
Within the last year, have you been humiliated or emotionally
abused in other ways by your partner or your ex-partner?
• A AFRAID
Within the last year, have you been afraid of your partner or expartner?
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RAPE
Within the last year, have you been raped or forced to have any
kind of sexual activity by your partner or ex-partner?
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KICK
Within the last year, have you been kicked, hit, slapped or
otherwise physically hurt by your partner or ex-partner?
Sohal, H., Eldridge, S., & Feder, G. (2007). The sensitivity and specificity of four
questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in
general practice. BMC Family Practice, 8, 49. http://doi.org/10.1186/1471-2296-8-49
HARK Scoring/Abuse s/sx
• There is an 83% probability that a woman with a HARK score greater
than or equal to 1 has experienced IPV in the past year (positive
predictive value); and she is 16 times more likely to have been
affected by IPV in the last year than someone with a HARK score of 0
(likelihood ratio of a positive result)
• The HARK questions are equivalent to one or more sign/symptoms
of the Abuse problem (Martin, 2005)
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harsh/excessive discipline
welts/bruises/burns/ injuries (K)
questionable explanation of injury
attacked verbally (H)
fearful/hypervigilant behavior (A)
violent environment
consistent negative messages (H)
assaulted sexually (R)
Sohal, H., Eldridge, S., & Feder, G. (2007). The sensitivity and specificity of four
questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in
general practice. BMC Family Practice, 8, 49. http://doi.org/10.1186/1471-2296-8-49
Residential address
Geocoded residential address information enables capture of a
wide variety of exposures
• Compositional characteristics of the neighborhood
• Contextual characteristics
• hazards and resources
• physical and social environment
Diez-Roux, A. V., and C. Mair. 2010. Neighborhoods and health. Annals of the New York
Academy of Sciences 1186(1):125–145.
Exposures and Neighborhood/
workplace safety s/sx
• Geocoded residential addresses may be used as indicators of area
socioeconomic composition that serve as a proxy for a variety of
features of neighborhood environments (including both physical and
social features) that may be etiologically relevant to many different
health-related processes
• Signs/symptoms of the Neighborhood/workplace safety problem
provide data on hazardous neighborhood characteristics (Martin,
2005)
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high crime rate
high pollution level
uncontrolled/dangerous/infected animals
inadequate/unsafe play/exercise areas
inadequate space/resources to foster health
threats/reports of violence
physical hazards
vehicle/traffic hazards
chemical hazards
radiological hazards
Resources and Communication
with community resources s/sx
• Geocoded residential addresses may be used as indicators of area
socioeconomic composition that serve as a proxy for a variety of
features of neighborhood environments (including both physical and
social features) that may be etiologically relevant to many different
health-related processes
• Signs/symptoms of the Communication with community resources
problem provide data on accessing resources (Martin, 2005)
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unfamiliar with options/procedures for obtaining services
difficulty understanding roles/regulations of service providers
unable to communicate concerns to provider
dissatisfaction with services
inadequate/unavailable resources
language barrier
cultural barrier
educational barrier
transportation barrier
limited access to care/services/goods
unable to use/has inadequate communication devices/equipment
Race/ethnicity
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American Indian or Alaskan Native
Asian or Pacific Islander
Black, not of Hispanic origin
Hispanic
White
OMB (Office of Management and Budget). 2003. Revisions to the standards for the
classification of federal data on race and ethnicity. http://www.whitehouse.gov/omb/
fedreg_1997standards (accessed July 16, 2014).
Experience of social disadvantage
• The reason for including race/ethnicity is that racism (social
disadvantage) impacts health
• Race/ethnicity demographics are important for population health
research because groups can be defined and compared
• The experience of racism may be captured and quantified in diverse
signs/symptoms (examples suggested for four problems)
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Income: low/no income
Abuse: attacked verbally
Abuse: fearful/hypervigilant behavior
Abuse: violent environment
Abuse: consistent negative messages
Grief: difficulty coping with grief responses
Grief: difficulty expressing grief responses
Spirituality: expresses spiritual concerns
Spirituality: disrupted spiritual rituals
Spirituality: disrupted spiritual trust
Williams, D. R., R. Lavizzo-Mourey, and R. C. Warren. 1994. The concept of race and health
status in America. Public Health Reports 109(1):26–41.
Educational attainment
MacArthur Research Network on SES & Health. 2008. Sociodemographic questionnaire.
http://www.macses.ucsf.edu/research/socialenviron/sociodemographic.php
Educational attainment
What is the highest degree you earned? Check one.
High school diploma
GED
Vocational certificate (post high school or GED)
Association degree (junior college)
Bachelor’s degree
Master’s degree
Doctorate
MacArthur Research Network on SES & Health. 2008. Sociodemographic questionnaire.
http://www.macses.ucsf.edu/research/socialenviron/sociodemographic.php
Experience of educational attainment
• Education is a well-established determinant of health that also
relates to socioeconomic status (SES)
• The experience of lack of education and/or low SES may be
captured and quantified in diverse signs/symptoms (examples
suggested for the Communication with community resources
problem) (Martin, 2005)
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unfamiliar with options/procedures for obtaining services
language barrier
cultural barrier
educational barrier
transportation barrier
limited access to care/services/goods
unable to use/has inadequate communication
devices/equipment
IOM Recommendations
IOM-Recommended Concepts
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Race/ethnicity
Educational attainment
Financial resource strain
Stress
Depression
Physical activity
Tobacco use and exposure
Alcohol use
Social connections and social
isolation
• Intimate partner violence
• Neighborhood and community
compositional characteristics
Omaha System Problems
• Communication with
community resources
• Income
• Mental health
• Physical activity
• Substance use
• Social contact
• Abuse
• Neighborhood/workplace
safety
Harmonization of s/sx and measures
• IOM-recommended documentation: 6 problems, 17 s/sx
• Demographics (race/ethnicity and educational attainment)
• Geocoded residential address
Problem
Income
Income
Income
Social contact
Social contact
Mental health
Mental health
Mental health
Abuse
Abuse
Abuse
Abuse
Abuse
Physical activity
Physical activity
Substance use
Substance use
Sign/symptom
able to buy only necessities
low/no income
difficulty buying necessities
limited social contact
minimal outside stimulation/leisure time activities
loss of interest/involvement in activities/self-care
sadness/hopelessness/decreased self-esteem
difficulty managing stress
attacked verbally
consistent negative messages
fearful/hypervigilant behavior
assaulted sexually
welts/bruises/burns/ injuries
sedentary life style
inadequate/inconsistent exercise routine
smokes/uses tobacco products
abuses alcohol
SBDH Measure
General resource strain (+ for somewhat hard)
General resource strain (+ for very hard or somewhat hard)
General resource strain (+ for very hard)
NHANES III (+ for yes answers to Q1 or Q2)
NHANES III (+ for yes answers to Q3 or Q4)
PHQ-2 (+ for Question 1)
PHQ-2 (+ for Question 2)
Single item measure of stress symptoms (+ for score of >1)
HARK (+ for "H")
HARK (+ for "H")
HARK (+ for "A")
HARK (+ for "R")
HARK (+ for "K")
Exercise vital sign (+ for inactive)
Exercise vital sign (+ for insufficiently active)
NHIS (+ for current every day or current some day smoker)
AUDIT C (+ for score of greater than 4 for men or 3 for women)
Comprehensive Omaha System
SBDH Assessment (65 s/sx)
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Income
Neighborhood/workplace safety
Communication with community resources
Social contact
Mental health
Abuse
Physical activity
Substance use
Part 4:
Care Plans and KBS
Existing tools can provide extensive SBDH decision support
and data
KBS: Baseline population assessment
Outcomes of SBDH interventions
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Income
Neighborhood/workplace safety
Communication with community resources
Social contact
Mental health
Abuse
Physical activity
Substance use
SBDH Guidelines
• May be mapped to Omaha System Intervention Scheme
• Existing guidelines for identified problems available at
omahasystemguidelines.org
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Statewide Health Improvement Program
Family Home Visiting
Community Dwelling Elders
Community Asthma Care Plan
• Prioritize new care plans for development
• Healthy People 2020
Reporting
• Frequencies of population s/sx
• Most frequent interventions for SBDH
• KBS reports for SBDH problems
Challenges
• Limited assessment
• The Omaha System consists of 42 problems
• 18 in the Physiological Domain
• 24 SBDH (Environmental, Psychosocial, Health-related Behaviors)
• 8 problem subset of SBDH problems does not capture the true
impact of SBDH
• Additional documentation burden
• programs may not assess s/sx and KBS for all 8 SBDH problems
• Reporting to decision makers
• need to ‘translate’ harmonization of IOM-recommended
measures to Omaha System terms
References
• American Academy of Nursing (2014). Electronic Health Records: Opportunities for "Putting
Health in the Electronic Health Record" — Presented by the Informatics & Technology,
Bioethics, Military/Veterans, LGBTQ, and Building Healthcare System Excellence Expert
Panels. Washington DC, October 17, 2014.
• Evans, R.G. and Stoddart, G.L. 1990, Producing Health, Consuming Health Care, Social
Science and Medicine 31:1347-1363
• Graves, J.R., & Corcoran, S. (1988). Design of nursing information systems: Conceptual and
practice elements. Journal of Professional Nursing, 4, 168-177.
• Institute of Medicine (IOM). (2014a). Capturing social and behavioral domains in electronic
health records: Phase 1. Washington, DC: The National Academies Press.
• Institute of Medicine (IOM). (2014b). Capturing social and behavioral domains and
measures in electronic health records: Phase 2. Washington, DC: The National Academies
Press.
• Office of Behavioral and Social Science Research. 2010. Behavioral and social sciences
research (BSSR) definition. Bethesda, MD: National Institutes of Health, Office of Behavioral
and Social Sciences Research.
http://obssr.od.nih.gov/about_obssr/BSSR_CC/BSSR_definition/definition.aspx#bfr
• United States Federal Register (2012). CMS Final Rule, Meaningful Use State 2. Vol 77,
Number 171.Available at: https://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/201221050.pdf
• World Health Organization. What are social determinants of health?
http://www.who.int/social_determinants/sdh_definition/en/