SDOH Guidance And Technical Support

Gravity SDOH Interoperability Pilots Are Underway

Under American Medical Association (AMA) sponsorship, Elimu Informatics has worked closely with HL7 since 2019 on the largest national SDoH standards project, the Gravity Project. Elimu has also contributed to the development of core use cases, the Gravity SDOH implementation Guide and the Gravity Pilots Implementation program.  

Since its inception in 2017, the Gravity Project has grown in membership and national recognition and has progressed to the implementation phase with the support of the Civitas Networks for Health. Civitas is a non-profit organization that specializes in convening key national stakeholders such as state Health Information Exchanges (HIEs), Regional Health Improvement Collaboratives (RHICs), and government agencies to facilitate standards-based solutions development and adoption. Elimu is proud to contribute our expertise in terminology standards and integration to offer tailored adoption guidance. For example, we are working with the New York eHealth Collaborative SHIN-NY program to assist with incorporation of Gravity FHIR standards into their data lake design and data capture workflows using standard screen instruments such as the CMS AHC HRSN forms, interoperable messaging and data access FHIR APIs.  

Many states are currently applying for CMS 1115 Waiver funding in order to develop similar programs that support appropriate services provision, patient coverage and eligibility through the robust capture of interoperable SDOH data. We expect to see these programs continue to grow over the next few years and look forward to assisting with design, implementation and deployment guidance. 

Elimu, in collaboration with Civitas, provides professional guidance in several of the following domains to support practical and tailored adoption of the Gravity standards:

SDOH Screening And Assessments

It all begins here, with the screening and assessments for SDOH related health concerns such as food insecurity, homelessness, financial insecurity, domestic abuse and much more. The Gravity Project has identified a set of nationally available screening instruments that have been standardized to support capture of the key data that can drive the provision of services, coverage and eligibility determinations, and downstream plans of care.  New instruments are constantly being added to the Gravity set using a systematic evidence-based approach that ultimately results in the use of national terminology standards key to supporting interoperable messaging, reporting and decision support.  

Elimu provides assistance with adoption, implementation, and FHIR representation of these screening instruments in several ways: 

• Mapping or transformation of existing screening or assessment forms into the Gravity FHIR formats (Questionnaire, QuestionnaireResponse and Observation Screening Response).
• Persistence of the FHIR formats into standards compliant databases for use in reporting and interoperable messaging.
• Tailored options for assistance with translation of customized forms that already exist at the state or regional levels into these FHIR formats so that they can be used for regulatory reporting purposes.

SDOH Health Concerns and Needs Identification  

Health concerns are commonly identified through screening and assessment instruments. Elimu can provide solutions that can enable the efficient identification of social risks from these instruments using the Gravity standards:

• Automated identification of positive SDOH findings that can lead to provider documentation of SDOH health concerns on the patient problem list (e.g., ICD10CM Z Codes)
• Identify positive screening results that can drive the need for further comprehensive assessments (e.g., by referral to CBOs for assessment and provision of services)
• The Gravity standard defines FHIR solutions that can translate data collected via screening instruments into suspected health concerns or observations that can in turn be validated by a provider.
• Elimu can, if needed, provide software plug-in solutions on our FHIR Sapphire® platform that can implement decision support suggesting positive findings or health concerns derived from FHIR versions of screening and assessment instruments (Quesionnaire Response or Observation Screening Response). Sapphire® SMART-on-FHIR applications can be plug-ins into an EMR or run as stand-alone web applications depending on the needs and implementation environment.  Sapphire® makes it possible to build practical workflows enriched with clinical decision support insights that can incorporate both clinical and SDOH data.

Referrals to Community Based Organizations 

Elimu can provide guidance, design and software solutions that support creation of referrals to Community Based Organizations (CBOs) to address identified health concerns such as food insecurity or homelessness:

• We can assist with the creation and sending of appropriate referrals to CBOs either directly or using SCNs. Social Care Networks ( SCNs) are online platforms that connect people who need social care services with organizations that can provide them. These platforms typically allow users to search for services by location and type of need. For example, an older adult looking for help with transportation might use a social care network to find a local program that provides rides.
• We can assist with the closed loop referral workflow which allows the provider to receive confirmation of acceptance of the referral, details of services provided, plans, goals, and outcomes of provided services. These activities and workflows are all supported by the Gravity standard but require tailoring depending on the implementers’ capabilities , existing systems and resources. 
• Elimu can develop and deploy software solutions if needed on our flexible Sapphire® digital health platform which enables integration with FHIR-enabled systems (such as EHRs) as well as traditional non-FHIR platforms. For example, a Sapphire® workflow application that manages transmission of referrals from an EHR and receipt of status updates from CBOs or SCNs can be easily developed and deployed on our Sapphire® platform.

SDOH Focused Data Lakes 

Frequently, states may opt to develop data lakes that store SDOH data in standardized format to support regulatory reporting, analytics, coverage/eligibility and shared care planning. The design and deployment of data lakes at the state level involves several key activities where Elimu can aid:

• Data lake design incorporating Gravity SDOH standards
• Assistance with defining data flow from the various upstream sources into the data lake
• Assistance with standardizing (normalizing) disparate data sources into intermediate and/or FHIR based standards (the needs can vary based on state and regional requirements)

Access to SDOH Data Using Interoperable Standards

• Defining APIs that would provide access to data stored in the data lake for a breadth of consumers such as regulatory entities, payers, providers, SCNs , CBOs, analysts, HIEs.
• Elimu can also provide as needed Sapphire® plug-ins or standalone applications that  provide views of data stored in statewide data lakes. These views can incorporate valuable decision support insights such as trends and predictive outcomes at the patient level

Analytics and Reporting

The Gravity IG was designed to facilitate the collection of SDOH data in a standardized way that can enable referral workflows across multiple systems, more accurate reporting, and interoperable decision support. Elimu can assist with:

• Guidance on how to use these standards optimally for regulatory reporting. 
• Guidance with respect to outcomes analysis leveraging the relationships between health concerns, services provided and outcomes observations
• Defining standards based quality measures that leverage the Gravity FHIR constructs that may be persisted in repositories such as statewide data lakes

Decision Support for Optimal Management and Referrals

In addition to quality reporting and analytics, point of care decision support enabled by the Gravity SDOH IG can be very valuable in determining what types of services are needed based on positive findings in screeners, eligibility/coverage data and past outcomes analysis of services that may (or may not) have been effective. Elimu can assist with:

• Decision support rules design
• Workflow integration of decision support opportunities in the referral process
• Sapphire® applications that can incorporate provision of evidence based guidance based on these factors