Crossing the Digital Divide for SDOH

By Matt Phillion

When considering social determinants of health (SDOH), we often look at core needs that impact a person’s ability to remain healthy, like food, medicine, education, and transportation. But recent surveys have found there’s also a “digital divide” that stands between patients and better care.

Data exists that can help patients achieve better healthcare, but the industry itself must ensure that this data is available, accessible, and understood. Organizations and providers often have access to some of the data in question; the key, though, is connecting healthcare stakeholders and patients to complete information that enables informed decisions, which the industry has not yet perfected.

Often, payer care management systems are built for transactions rather than coordinated care, and thus there are several places where coordination can break down, including disparate, unstructured, or undigitized data, or a lack of patient consent. If patients aren’t equipped to navigate the complexities of the healthcare system, they may struggle to get the help they need, adhere to medications, or deal with other complications that can reduce their quality of care.

All this being factored in, where can hospitals and healthcare organizations work to connect patients with this data?

Viewing behind the scenes

“When you think about traditional healthcare delivery and networks, what tends to be the case is a lot of care management coordination activities are obfuscated from the patient,” says Lynn Carroll, COO of HSBlox, the maker of a digital health platform that enables SDOH risk stratification, care coordination, and permissioned data sharing. “The patients don’t have a lot of view behind the scenes.”

Carroll explains that empowering the patient means giving them the tools, information, and education they need to take better care of their own health.

The healthcare environment can be a fragmented place, which complicates the task of keeping patients informed. It’s challenging to bring the array of players into alignment when they include community-based organizations, social service agencies, and home care providers, as well as medical professionals. Stakeholders who are part of a patient’s care team have bits and pieces of information about that patient, but they don’t have all of the information—and neither does the patient.

“If I want to bring the patient traditional care delivery systems and these neighborhood or social contracts into play, how do I orchestrate that?” asks Carroll. “That’s one of the things we’re focused on here. How do you go to the intersection of the digital and physical worlds and enable that empowerment, not only for the patient but also for the care team, and effectively manage the patient’s needs?”

The obvious places to start are areas like chronic conditions or disease management where there are many data points to parse, but the focus can be beneficial across the healthcare spectrum.

What patients don’t know about themselves

Often, patients don’t know what they don’t know—and their lack of data can have a negative impact on their outcomes. Specifically, with SDOH, they may be unaware of a local organization that offers needed assistance, such as with transportation. Other examples are behavioral approaches that can help them address chronic conditions.

“There’s a patient awareness aspect,” says Carroll. “What are the patient’s medical needs, and what are their social needs? There’s been a lot of dialogue recently about the need for social interaction, particularly for the elderly, and there are organizations focusing on this.”

These organizations do, in their own way, gather important data on their patients. It’s not tracked in the traditional healthcare sense, but it’s out there—and it has the potential to help.

“There’s structured data, the kind that ends up being in the electronic medical record,” says Carroll. “But there is also unstructured data: clinical notes and things of that nature. Trying to understand a more holistic approach to the medical and social components is a challenge, and part of that challenge is this unstructured data.”

For example, even in interacting with healthcare practitioners, items indicative of social care may be buried in the notes of a patient’s records. “How do we bring unstructured data into structured?” says Carroll.

A basic step is to bring it into the billing data so you have a more holistic record of the patient’s care. “If you need to align medical resources, you need information on what each of those resources knows and be able to communicate effectively about how these resources can be utilized,” says Carroll.

Carroll and his colleagues look at traditional and social components and apply this structured and unstructured data to achieve a holistic view. This enables organizations to stratify populations and target areas for specific interventions, like chronic disease management scenarios or indicators of acute events.

“We focus on the orchestration component,” says Carroll. “The patient becomes more integrated into the process. Our belief is that if the patient is empowered with more information, alongside these other tools, we can better orchestrate their involvement in the continuum of care.”

The impact of unstructured data

Unstructured data is an untapped goldmine of patient information. It involves touch points with the patient that are more frequent than, say, scheduled quarterly visits to a specialist. These points of contact provide an opportunity to proactively understand changes in a patient’s medical condition or social contract. “That’s a part of the secret sauce” of orchestrating better outcomes, says Carroll.

The other component is that, in contrast to traditional integrated networks like hospitals and specialty groups that rely on more sophisticated technology, the system grows less sophisticated as you move down the line of care providers—some caregivers in community organizations manage their information through things like spreadsheets or manila envelopes.

“We need more connectivity with the digital world at the street level,” says Carroll. “The hidden gems can be lifted out of that unstructured data and structured alongside traditional data.”

Optimization through data

The data analysis component is used part and parcel with more traditional health methods, explains Carroll. But the difference here is that care is targeted with data from individual experiences.

“You might have a health score, but also a social score,” says Carroll. “You might have a combined score. It helps us focus our efforts to stratify and identify the particular social needs unmet for a given patient.”

An example of one of those needs is English as a Second Language (ESL). Does the platform the patient is engaged with support the appropriate languages? If there is a caregiver at home, such as a spouse or an adult child, there might be a language barrier. ESL support becomes part of the street-level contract with the patient to ensure proper delivery of services.

“From our point of view, we want to keep the patient happy and healthy, and empower them to be able to stay at home and be healthy as much as possible,” says Carroll.

Many patient needs go beyond healthcare but are still pivotal to health: employment security, housing, food security, social interaction, and transportation, for example. The patient needs to be able to interact with the healthcare system and the outside resources the system draws upon, and there may not be readily available coordination with patients for some of these resources.

The impact on providers

With a better understanding of who is providing care in the home, how do we bring that information back into the medical world and the medical record so that practitioners can take action?

Part of the answer, Carroll notes, is collecting the information in a timely fashion. A primary care physician or specialist may not be able to be regularly in the home. More current or real-time status information is an untapped resource for these professionals.

“How often is someone participating in the continuum of contact with the patient so you can have as much up-to-date information as possible to properly digest?” says Carroll.

This goes beyond human interaction, as well. It’s possible to utilize mobile device integration, remote monitoring, and even the internet of things to provide information on a more real-time basis.

“Part of the approach is to ultimately personalize medicine,” says Carroll. “To empower patients to understand what’s available. But it’s also addressing, from a healthcare equity standpoint, where we can create more opportunity for a diverse population to participate in things like clinical trials. If we’re relying solely on a practitioner seeing the patient or a claim being generated, we’ve got a big blind spot.”

The other question is what technology is needed to make all of this happen. Fortunately, healthcare doesn’t have to reinvent the wheel. There are already examples of this kind of orchestration working in other professional settings, like the supply chain or financial services industries.

This orchestration looks at components that are event driven, have multiple stakeholders, and require a coordination of activity in real time or near real time—components that are common in these other industries that healthcare can benefit from.

“The endgame is to empower patients to be healthy and to empower their caregivers in the process,” says Carroll. “The ‘what’ for us is integrating the patient, the ‘how’ is the digital platform at the edge of the physical and digital worlds, and the ‘why’ is for patient empowerment.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at