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Standardizing Social Determinants of Health Data to Transform Equity

November 30, 2023

In the complex world of health care, data standardization is a pivotal yet often underappreciated aspect of delivering equitable care. Gravity Project is working diligently to develop consensus-based data standards to improve how we use and share information on social determinants of health (SDOH). 

Through Civitas Networks for Health and Gravity Project’s partnership, with generous support from the Robert Wood Johnson Foundation, both organizations have been working diligently to implement Gravity’s SDOH data standards at various pilot sites around the country. Through this work, we had the chance to sit down with Asha Immanuelle, a former Gravity Project team member whose roots are in perinatal nursing, to understand more about how she ventured beyond the immediacy of bedside care to make a significant impact in the broader health care ecosystem. When signing on with the Gravity team her mission was clear: to encode the nuances of SDOH data into a language that community organizations and health systems can universally understand and act upon.

Through this conversation, we gained a deeper understanding of how the Gravity SDOH data standard instruments can be used in various community health settings. Let’s learn more about Asha’s work to support our partnership. 

Asha’s Journey to Population Health Management

After serving as a nurse for a number of years in a traditional hospital setting, a turning point in Asha’s career was spurred by a stark realization of the direct link between health care biases, unmet health-related social needs, and patient harm. Determined to address these foundational issues, Asha pursued advanced education in population health management and became a prominent voice in the online health community:

“I started to share more about my public health education experience on Twitter and quickly found a group of like-minded people who cared about the same things I did,” said Asha. “It was through this that I found synergy with Sarah DeSilvey, the Terminology Director for Gravity Project. Next thing I knew, I was working with their team.”

It turns out that Asha’s alignment with the Gravity Project was serendipitous. Her involvement evolved from a community member to a central figure shaping the future of health data standardization and her work focused on the immense task of evaluating, selecting, and encoding numerous screening tools with Logical Observation Identifiers Names and Codes (LOINC), which are crucial for documenting and exchanging SDOH data.

Encoding the Language of Social Determinants of Health

The efforts of Asha and her team revolved around a singular goal: to create a seamless conduit for SDOH information across health care platforms. 

This task, though technical in nature, carries profound implications for patient care. By meticulously reviewing and mapping out 135 screening instruments, they crafted a vital reference for community health workers and health care providers to identify and act on the social factors that significantly influence patient health outcomes.

The instruments that Asha and her team helped encode are more than mere data points; they represent a step towards a future where all aspects of a person’s environment are considered in their care plan. Today, the Gravity Project and Civitas-led Pilot Sites actively utilize this database to effectively choose tools suited to their specific needs, a process Asha hopes will become industry standard with all tools encoded in LOINC.

The pilot sites are leading the charge in applying the standards developed by the Gravity Project. In the diverse landscapes of the University of Colorado, Pima County in partnership with an anonymous local tribe, the state of New York, and the connected communities MyHealthAccess Network serves in Oklahoma, these standards are not just theoretical—they’re the blueprint for transformative practices. Each of these pilot sites brings its unique patient demographics and social complexities, necessitating tailored use of the Gravity Project’s tools to accurately document and code social determinants of health data. With neutral convening support from Civitas and technical support from Gravity, these pilot sites are ensuring that precise encoding takes place regardless of the health care delivery setting – be it a tribal community where traditional practices intertwine with modern medicine, or an urban hospital facing a mosaic of socioeconomic challenges, each patient’s social needs are identified and addressed within a unified system. 

This practical application of standardized SDOH coding is a testament to how the strategic groundwork laid by Asha and her team is fueling a nationwide shift towards comprehensive, culturally sensitive, and equitable health care.

Recognizing the Challenge of Effective Communication for Complex Tools

Despite the progress made through the detailed mapping of screening tools, Asha’s experience at a LOINC conference underscored a pivotal challenge: the need for Gravity Project’s work to be communicated more effectively. The tools and resources are there, but the message needs simplification. Asha advocates for clearer messaging to accelerate the adoption of these standardized tools, thus unveiling and addressing hidden social needs at scale.

Effective communication about these tools is vital in cultivating a shared understanding and operational language among clinicians, policymakers, community health workers, and patients. Simplifying the complexity of these instruments into digestible, actionable knowledge enables diverse users to recognize the power of a common toolkit. It’s not just about having standardized resources; it’s about ensuring everyone, from the policy architect to the patient advocate, grasps their role in this standardized ecosystem. 

By speaking the same language and using the same precise tools, the entire health community can collectively identify, understand, and address the social determinants impacting health outcomes, leading to a more synchronized, effective, and equitable health care system for all.

Beyond Standardization: Advancing Health Equity

Today, Asha works at NCQA, a Civitas Networks for Health member, where her projects align closely with the objectives of Gravity, especially in the construction of state-level community health worker programs. These programs, utilizing the standardized screening tools Asha helped encode, are essential in bridging the trust gap between patients and the traditional health care system.

Asha Immanuelle’s contributions mark a significant stride forward in the journey toward comprehensive health equity. Her pioneering efforts in standardizing SDOH data are vital for creating an equitable health care framework that recognizes and responds to the unique circumstances of each individual. Civitas celebrates this synergy, understanding that such transformative tools, particularly when made freely accessible by the Gravity Project, are the cornerstones of future health innovations. 

In this shared vision, we continue to advocate for the widespread adoption of these instruments, confident that they are not just technical resources but instruments of change, ensuring every person receives the personalized and dignified care they deserve.

To learn more about Civitas’ partnership with Gravity Project, visit our website.

With generous support from the Robert Wood Johnson Foundation (RWJF), Civitas Networks for Health has partnered with the Gravity Project® leadership, Health Level Seven® (HL7®), and various Civitas members to facilitate the dissemination and implementation of Gravity Project standards through Q4 2023. Our efforts involve engaging with national, regional, and local community partners to gain insights from and provide support for the Gravity pilot’s work stream. 

Support for this project was provided by RWJF. The views expressed here do not necessarily reflect the views of the Foundation.