title: "Community vital signs": incorporating geocoded social determinants into electronic records to promote patient and population health.
abstract: Social determinants of health significantly impact morbidity and mortality; however, physicians lack ready access to this information in patient care and population management. Just as traditional vital signs give providers a biometric assessment of any patient, "community vital signs" (Community VS) can provide an aggregated overview of the social and environmental factors impacting patient health. Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes. This information could also help care teams target disease prevention initiatives and other health improvement efforts for clinic panels and populations. Given the proliferation of big data, geospatial technologies, and democratization of data, the time has come to integrate Community VS into the electronic health record (EHR). Here, the authors describe (i) historical precedent for this concept, (ii) opportunities to expand upon these historical foundations, and (iii) a novel approach to EHR integration.
authors.affiliation: Robert Graham Center for Policy Studies in Primary Care, Washington, DC, USA.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Bazemore
authors.affiliation: OCHIN, Inc., Portland, OR, USA Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Erika K
authors.initials: EK
authors.lastname: Cottrell
authors.affiliation: OCHIN, Inc., Portland, OR, USA Kaiser Permanente NW, Center for Health Research, Portland, OR, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Gold
authors.affiliation: Robert Wood Johnson Foundation Clinical Scholars Program®, Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Lauren S
authors.initials: LS
authors.lastname: Hughes
authors.affiliation: American Board of Family Medicine, Washington, DC, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Phillips
authors.affiliation: Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA angierh@ohsu.edu.
authors.forename: Heather
authors.initials: H
authors.lastname: Angier
authors.affiliation: Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Burdick
authors.affiliation: HealthLandscape, American Academy of Family Physicians, Cincinnati, OH, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Carrozza
authors.affiliation: OCHIN, Inc., Portland, OR, USA Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: DeVoe
mesh_terms: D057286:Electronic Health Records; D062306:Geography, Medical; D006801:Humans; D012111:Residence Characteristics; D064890:Social Determinants of Health; D012959:Socioeconomic Factors
keywords: electronic health records; residence characteristics; social determinants of health; socioeconomic factors