Development, Piloting and Dissemination of an Integrated Clinical and Social Multi-level Decision Support Platform to Address Social Determinants of Health Among Minority Populations in Baltimore City

开发、试点和传播综合临床和社会多层次决策支持平台，以解决巴尔的摩市少数民族人口健康的社会决定因素

• 批准号: 10454106
• 负责人: Elham Hatef-Naimi
• 金额: $ 68.72万
• 依托单位: JOHNS HOPKINS UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-07-20 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10454106
• 关键词: Address; Adult; African American; African American population; Algorithms; Baltimore; Caring; Case Manager; Characteristics; Chronic; Chronic Disease; Cities; Clinical; Clinical Data; Clinical Decision Support Systems; Clinical Services; Clinical Trials Design; Clinical effectiveness; Collaborations; Communities; Community Health Aides; Complement; Data Analyses; Development; Disadvantaged; Disease; Electronic Health Record; Enrollment; Ensure; Evaluation; Focus Groups; Frontline worker; Goals; Group Interviews; Health; Health Services Research; Health system; Informatics; Information Technology; Institution; Intervention; Length; Link; Low income; Management Decision Support Systems; Maryland; Measures; Medical; Methods; Minority; Minority Groups; Morbidity - disease rate; Neighborhoods; Outcome; Patients; Persons; Phase; Population; Primary Health Care; Process; Provider; Quality of life; Randomized Clinical Trials; Recommendation; Reduce health disparities; Reporting; Research; Research Personnel; Resources; Risk; Risk Assessment; Services; Site; Social Sciences; Social Work; Social Workers; Standardization; Support System; System; Technology Assessment; Testing; Work; arm; base; burden of illness; clinical decision support; clinical implementation; clinical risk; cohort; data dissemination; data quality; design; digital; disadvantaged population; ethnic minority; experience; health data; health disparity; health information technology; implementation science; improved; inner city; interoperability; large-scale database; mortality; multiple chronic conditions; point of care; programs; service organization; social; social disadvantage; social health determinants; social integration; standard of care; support tools; system architecture; tool; treatment arm; work-study

 PROJECT SUMMARY Achieving a comprehensive assessment of a person's health and addressing health disparities goes beyond just documenting clinical diseases and medical interventions. We must also capture, standardize, analyze, and report reliable information on Social Determinants of Health (SDOH) within operational Clinical Decision Support (CDS) systems that are built-into electronic health records (EHRs). Moreover, to truly have an impact on decreasing health disparities, data analysis is not enough. At the point of care, we must digitally support interactions between medical and social services. Our proposed project addresses many of the hurdles in this process through the application of informatics, social science, health services research, implementation science, and stakeholder engaged research. This project will be undertaken by an experienced interdisciplinary team of investigators with many pre-existing resources. To maximize impact, the academic team will be complemented by an exceptional network of collaborating community, operational information technology, and stakeholder agencies from both the region and nationally. Our goal is to facilitate the integration of available digital information regarding SDOH needs and services into provider EHRs with the intent of improving care for minority and disadvantaged populations with chronic diseases. The first aim will be to integrate both clinical and non-clinical large-scale databases (e.g., EHRs, social risk assessments, and neighborhood characteristics) in order to develop a multi-level CDS tool inclusive of a comprehensive social risk score. As part of this CDS, in collaboration with the Maryland Health Information Exchange, we will also develop an interoperable closed loop referral system between primary care practices and 3 community based (social service) organizations (CBOs). These and all other development phases will build on extensive preliminary work the study collaborators have completed in related domains. The second aim will be to integrate the CDS tool into the established care management support system and workflow and to pilot this Health IT-based intervention using a randomized clinical trial (RCT) design at four primary care practices within the Johns Hopkins Health System (JHHS). The main intent of this CDS-based intervention will be to identify and assess SDOH of African-American adult patients (18+) with low incomes and a high burden of chronic illness, and as needed to refer them to the CBOs participating in this pilot. The third aim will be to assess the acceptability of the CDS tool (including its risk score and referral module) and to initiate dissemination of the data platform in support of its implementation across the JHHS institution, the Maryland statewide (CPC+) primary care program, and potentially nationally. To accomplish this aim, we will collaborate closely with clinical providers, CBOs, and an advisory board made up of the local and national leaders, as well as patients and frontline workers (e.g., community health workers, care managers, and social workers). With the help of several national leaders on our advisory board, we expect to substantially contribute to the broader national agenda regarding the digital integration of SDOH and clinical data into EHR-supported workflows.

❖ 项目概要 实现对个人健康的全面评估并解决健康差异不仅仅是 我们还必须记录临床疾病和医疗干预措施。 临床决策支持 (CDS) 中有关健康社会决定因素 (SDOH) 的可靠信息 此外，内置电子健康记录（EHR）的系统能够真正对健康状况下降产生影响。 在护理方面，数据分析还不够，我们必须以数字方式支持医疗之间的互动。 我们提出的项目通过应用解决了这一过程中的许多障碍。 信息学、社会科学、卫生服务研究、实施科学和利益相关者参与的研究。 该项目将由经验丰富的跨学科研究团队负责，该团队拥有许多现有资源。 为了最大限度地发挥影响力，学术团队将得到一个特殊的合作网络的补充 来自该地区和全国的社区、运营信息技术和利益相关者机构。 目标是促进将有关 SDOH 需求和服务的可用数字信息集成到提供商中 电子病历的目的是改善对患有慢性病的少数群体和弱势群体的护理。 第一个目标是整合临床和非临床大型数据库（例如 EHR、社会数据库） 风险评估和邻里特征），以开发包含以下内容的多级 CDS 工具： 作为本 CDS 的一部分，与马里兰州健康信息局合作。 交流中，我们还将开发初级保健之间可互操作的闭环转诊系统 实践和 3 个社区（社会服务）组织 (CBO)。 各个阶段将建立在研究合作者在相关领域完成的广泛初步工作的基础上。 第二个目标是将 CDS 工具整合到现有的护理管理支持中 系统和工作流程，并使用随机临床试验来试点这种基于健康信息技术的干预措施 （RCT）在约翰霍普金斯大学卫生系统（JHHS）内的四个初级保健实践中进行设计。 这项基于 CDS 的干预措施将识别和评估低度非裔美国成年患者（18 岁以上）的 SDOH 收入和慢性病的高负担，并根据需要将其转介给参与该试点的 CBO。 第三个目标是评估 CDS 工具的可接受性（包括其风险评分和推荐） 模块）并启动数据平台的传播以支持其在 JHHS 的实施 为了实现这一目标，马里兰联邦 (CPC+) 初级保健计划，以及可能在全国范围内实施的计划。 我们将与临床提供者、社区组织以及由地方和国家组成的咨询委员会密切合作 领导者以及患者和一线工作人员（例如社区卫生工作者、护理管理者和社会工作者） 在我们顾问委员会的几位国家领导人的帮助下，我们期望为这一目标做出重大贡献。 关于将 SDOH 和临床数据数字集成到 EHR 支持的工作流程中的更广泛的国家议程。