Table 1

SDH Data Tools and SDH Domains

SDH Data ToolsDescription
SDH Data Collection ToolsIncluded 14 SDH screening questions based on PRAPARE and National Academy of Medicine recommendations. Data collection modes included: data-entry flowsheets accessible by diverse clinic staff, a print version for patients to complete after which the data would be entered by CHC staff into a flowsheet, and an online portal form that patients could complete before the visit.
SDH Summary ToolsPatient’s most recent SDH data displayed (as entered in flowsheets or elsewhere in the EHR), and past SDH-related referrals.
SDH Data RostersAdded SDH-related data columns to the EHR’s panel management tools to identify patients who (1) had a pending visit (enabling e-mailing those with online portal accounts about completing SDH screening pre-appointment); (2) had a positive SDH screen and needed follow-up; or (3) were due for SDH screening.
Problem ListCreated a new SDH class of problem list diagnoses, so that users could manually categorize SDH diagnoses in the problem list.
SDH Referral ToolsBuilt as preference lists, to parallel the clinics’ processes for making clinical referrals. Worked with pilot clinics to create preference lists of local resources for addressing specific SDH needs. Used to add information about relevant resources to the patient’s after-visit summary and to identify resources that clinic staff could discuss with the patient.
SDH Domainsa
Alcohol usebEducationExposure to violence
Race/ethnicitybFinancial resource strainPhysical inactivity
Tobacco use and exposurebHousing insecuritySocial isolation
DepressionbFood insecurityStress
  • CHC = community health centers; EHR = electronic health record; PRAPARE = Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences; SDH = social determinants of health.

  • a Wording defined in Supplemental Appendix 1, available at

  • b Information on these domains is routinely documented elsewhere in the EHR so they were not included in the SDH data collection tool flowsheet. Responses, however, were pulled into the SDH summary tool.