RISK FACTORS AND DETERMINANTS

1. Risk Factors and the
Social Determinants of Health
A Current State Assessment
SemanticConsulting
Tim Blake
Managing Director, Semantic Consulting
tim@semanticconsulting.com.au
@timblake1978

2. Contents
• Risk factors in current GP
desktop systems
• What are the social
determinants of health?
• Why do we want to collect this
information?
• Getting a head start on data
standardisation

3. Risk factors in current GP desktop systems
Risk factors include:
• Observations
• Family history
• Smoking status
• Alcohol consumption
Lack of data consistency,
structure, coding and data
quality are significantly
impeding secondary use of
risk factor data.

4. QI PIP Measures
1. Proportion of patients with diabetes with a current
HbA1c result
2. Proportion of patients with a smoking status
3. Proportion of patients with a weight classification
4. Proportion of patients aged 65 and over who
were immunised against influenza
5. Proportion of patients with diabetes who were
immunised against influenza
6. Proportion of patients with COPD who were
immunised against influenza
7. Proportion of patients with an alcohol
consumption status
8. Proportion of patients with the necessary risk
factors assessed to enable CVD
assessment
9. Proportion of female patients with an up-to-date
cervical screening
10. Proportion of patients with diabetes with a blood
pressure result.
The Improvement Measures are:

5. What are the social determinants of health?

6. What are the social determinants of health? (continued)
• Income and social status
• Employment and working conditions
• Education and literacy
• Childhood experiences
• Physical environments
• Social supports and coping skills
• Healthy behaviours
• Access to health services
• Biology and genetic endowment
• Gender
• Culture
• Race / Racism
Determinants of health are the broad range of personal, social, economic and environmental factors that
determine individual and population health. The main determinants of health include:

8. Why do we want to collect this information?
• A growing recognition that we need to consider
social determinants in designing and prescribing
health interventions, with (in some instances)
bespoke intervention based on various factors
• Greater co-design of care with patients
• Improved predictive models for patient risk
• Track health outcomes and improve
measurement of healthcare value
• To support social care through social prescribing

9. Why do we want to collect this information?
Considerations:
• Over-collection of data
• Care plans are key!
• Much of this information is deeply personal – can
any other model than patient owned data work?
• Legitimate concerns about privacy
• Need for better / standardised ”informed
consent” processes
• The politicisation of social care
• Co-use of systems introduces new human
factors issues – visual feedback, not just
language

10. Getting a head start on data standardisation
• LOINC
• The Gravity Project (US) – working on a FHIR IG
for SDoH
References:
• Integrating Data On Social Determinants Of
Health Into Electronic Health Records
• 5 Ways to Ethically Use Social Determinants of
Health Data
• Incorporating Social Determinants of Health in
Electronic Health Records: Qualitative Study of
Current Practices Among Top Vendors
The project will focus on food security; housing stability and quality; and
transportation access. It will examine and augment coding standards in each
domain that can be used to capture three core healthcare activities:
• Screening: This refers to activities where SDOH data from individual patients
are initially captured, either through a self-administered, provider-administered,
or health plan-administered questionnaire.
• Assessment/Diagnosis: These include activities where providers and health
plans analyze the data obtained through screening to determine a patient’s
social risks and needs.
• Treatment/Interventions: These refer to actions undertaken by providers and
health plans to help address identified social needs. These activities include
referrals, case management, care planning, counseling and education, and
provision of services and orders.
This project will not focus on evaluating, testing or harmonizing existing social
risk screening tools