Transforming Health Outcomes: 
The Power of Integrating Social Care Technology with Electronic Health Records

Introduction

In 2014, the Institute of Medicine (IOM) recommended specific social drivers of health (SDOH) data be documented in electronic health records (EHRs), underscoring a broader shift in how healthcare systems approach patient care.

EHRs have revolutionized the way providers manage and access clinical information by providing a digital repository of patient health data, yet they often lack the ability to natively capture social factors that significantly impact a patient’s health.
However, the ongoing effort to bridge the gap between medical and non-medical factors — from both a technological and clinical perspective — speaks to the larger transformation in healthcare today. Beyond the improvements in workflow efficiency, integrating SDOH data into EHRs enables the healthcare industry to create a more scalable, patient-centered system of care.
This holistic approach could not only redefine how health outcomes are improved at both individual and community levels, but in shaping the future of integrated, value-based care.

The Role of EHRs and Social Care Technology Today

Source: Becker’s Hospital Review

As of 2021, 96% of all non-federal acute care hospitals and nearly 4 in 5 office-based physicians had implemented a certified EHR system.

At the same time, SDOH screening and referral technology has been on the rise, which is designed to help securely identify, capture, and address the non-medical aspects of a patient’s health, such as housing stability, transportation needs, food stability, and more. Studies have shown that SDOH accounts for up to 80% of a person’s health outcomes, emphasizing the importance of addressing these factors to improve holistic health.

By integrating SDOH information directly into EHRs, providers can seamlessly create a comprehensive, 360-degree view of their patients with speed, efficiency, and accuracy.

This visibility empowers providers to:

• Create more personalized care plans to address holistic needs;
• Capture information that helps direct targeted interventions; and
• Send closed-loop referrals to track patient journeys and health outcomes for more informed care insights;
• Improve population health at scale

The Building Blocks of EHR Integration

EHR integration is the process of connecting an EHR system, such as Epic, with other healthcare tools to securely exchange information, supporting patient-centered workflows and data access at the point of care. EHR integration enables authorized healthcare professionals to quickly and securely access comprehensive medical records for the patients they serve, regardless of where the information was initially recorded.

A Closer Look at Integration and Interoperability

Both integration and interoperability are essential components of comprehensive patient care, and a well-rounded interoperability strategy must include robust system integrations.

Integration is the foundational step that translates information between systems. For example, the Unite Us Platform can be seamlessly integrated into an EHR, enabling healthcare providers to conduct SDOH screenings and manage referrals directly from their familiar EHR interface. This minimizes manual data entry and the need to toggle between systems.

Interoperability builds on integration so that data is not only transferred but also usable where and when needed, whether for a clinician’s workflow at the point of care or for data-driven population health strategies. Interoperability also involves real-time data exchange, which is critical for timely decision-making.  For example, the Unite Us Platform enables clinicians to view the social care referral history for the patients they serve within the EHR, presented as if it were native to the EHR.

Unite Us Integrated App – Easily send secure, electronic social care referrals to community partners by embedding the Unite Us Platform within Epic.

The Role of Technology

To achieve true interoperability, systems must adhere to common data standards so that data from one system can be understood and utilized by another. Recent federal policy advancements, driven by ONC and the 21st Century Cures Act, emphasize the use of SMART on FHIR standards and APIs:

• FHIR (Fast Healthcare Interoperability Resources): A framework for defining and exchanging standardized healthcare data. FHIR defines discrete elements for data standardization and exchange through FHIR bundles and APIs.
• SMART (Substitutable Medical Applications Reusable Technologies): Builds on FHIR to help define the standards for apps within EHRs.
• API (Application Programming Interface): A set of rules or protocols that enable software systems to communicate and exchange information in a structured way. APIs are the backbone of both integration and interoperability.

At Unite Us, we leverage APIs, SMART on FHIR and other HL7 protocols to give our partners the ability to connect data or unlock functions from the Unite Us Platform directly within their system of record. This allows users to:

• Automatically send information (like an SDOH screening) that is created in their source system (like an EHR or case management system) to Unite Us;
• Receive an automated list of resource recommendations for a patient’s social needs in the EHR, which can be shared with the patient through an After-Visit Summary or through a patient portal;
• See social care referral status and history directly in their source system (such as an EHR or case management system); and
• Leverage social care data beyond the point of care to inform population health strategies.

By combining these elements, Unite Us puts necessary information at healthcare providers’ fingertips. In this way, integration and interoperability not only enhance the speed and accuracy of care delivery but also empower clinicians to make more informed decisions. They can ask different and more relevant questions about a patient’s social drivers of health, leading to proactive and personalized care plans.

In summary, a robust interoperability strategy that includes system integrations is essential for bridging the gaps between different healthcare platforms. Unite Us’ approach demonstrates how these technical advancements can work together to provide a holistic view of patient care, ultimately improving health outcomes and community well-being.

Solving Common Barriers to EHR Integration

Despite the industry’s widespread acceptance of EHRs as a healthcare standard and shift towards more holistic care models, barriers still persist when it comes to SDOH data integration.

Data Privacy and Security

Protecting the privacy and security of sensitive health information is critical to supporting EHR integration, with both patients and healthcare providers highly focused on safeguarding personal health data.

Complexity

Technical challenges include maintaining data consistency, mapping fields between systems, and addressing compatibility issues. The complexity of these tasks can often lead to extended implementation timelines and unexpected costs.

Training and Adoption

Implementing comprehensive training programs is essential for healthcare and social care workers. Training tools should be designed to familiarize users with the integrated system’s features and functionalities, enabling them to efficiently navigate and use the system.

5 Benefits of EHR Integration

Five Benefits of EHR Integration

1. Support a more holistic approach to patient care by equipping providers with the comprehensive insights they need to appropriately assess and address both clinical and social needs. Integrated data can be used to create more personalized care plans that address whole-person health needs.
   1. a. Unite Us enables providers serving a shared client to maintain a single, unified, longitudinal patient record—preventing duplicate records and allowing providers to easily understand social needs at the point of care without having to toggle between different systems.
2. Improve population health by facilitating a more cohesive and scalable approach to managing a patient’s health. Providers can better identify patients with immediate social needs, address gaps in care, and with the right platform, track patient outcomes throughout their entire care journey, leading to improved patient insights and better health outcomes.
3. Enhance collaboration and decision support by fostering improved communication and collaboration between providers, community-based organizations (CBOs), government agencies, health plans, community health workers, and other key stakeholders. The Unite Us Platform automatically recommends programs and services that are the best fit for patients based on their screening results, providing decision support for clinicians and facilitating stronger communication across the patient journey.

With features like Unite Us’ chat functionality, stakeholders can communicate in real-time, sending updates and inquiries about patient journeys. From April 2023 to May 2024, over 66,700 messages have been sent by nearly 8,000 users across more than 4,100 organizations.
*Source: Unite Us Platform data

1. Reduce administrative burden by streamlining workflows, automating data transfers, and centralizing key patient information. Not only does this save valuable time and effort, enabling providers to focus more on patient care, but it also helps increase accuracy of patient data by mitigating the potential for manual errors.
2. Reduce hospital readmissions by understanding and addressing social factors that impact a patient’s ability to manage their health, and implementing targeted interventions accordingly. For example, if a patient’s screening reveals difficulties in accessing follow-up care or medication, healthcare teams can proactively connect them with community resources to mitigate these issues. This kind of proactive approach helps patients manage their health more effectively outside of a clinical setting, reducing the likelihood of readmission and improving long-term outcomes.

Improving Population Health With EHR and Social Care Integration

By integrating SDOH data into EHRs, providers can identify patterns and trends at scale across communities that may not be immediately evident when considering individual medical data alone. Understanding both medical and social drivers of health allows health systems to collaborate with other stakeholders, such as government agencies, health plans, and CBOs, to develop targeted interventions that address the root causes of these disparities. These interventions could look like connecting patients to community resources or advocating for policy changes that promote better health outcomes.

Overall, EHR and SDOH data integration support a holistic approach to healthcare. This empowers organizations across the care continuum to address population health challenges at a systemic level. By recognizing and responding to SDOH efficiently, proactively, and at scale, providers can reduce healthcare costs and better manage public health outcomes.

Building the Future of Health and Social Care with Unite Us

Unite Us is strongly committed to providing the building blocks for successful EHR integration and interoperability with other systems. To drive the future of health and social care forward, we also collaborate with leading organizations, including the Gravity Project and HIMSS Social Determinants of Health Task Force, to better define data standards and best practices in the social care industry.

The future of social care and EHR integrations holds tremendous potential to revolutionize healthcare delivery. By fostering seamless interoperability and standardizing data exchange, we can create a more cohesive and comprehensive approach to patient care. As we continue to advance these systems in collaboration with industry leaders and stakeholders, we are paving the way for a more connected, efficient, and patient-centered healthcare landscape.