US Core Implementation Guide
4.2.0 - CI Build

US Core Implementation Guide, published by HL7 International - Cross-Group Projects. This is not an authorized publication; it is the continuous build for version 4.2.0). This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

SDOH Guidance

This US Core Social Determinant of Health (SDOH) Guidance Page has been added in response to United States Core Data for Interoperability (USCDI) V2 updates that the Office of the National Coordinator (ONC) published by the Office of the National Coordinator (ONC) in July of 2021. The new data elements include:

  • SDOH Assessments
  • SDOH Goals
  • SDOH Interventions
  • SDOH Problems/Health Concerns

This page documents how the US Core Profile can be use to represent these elements.

Purpose and Intent

The intent of adding these SDOH data elements to US Core is to be able to use US Core Profiles along with a defined set of FHIR RESTful interactions to represent and access SDOH patient data. This is in contrast to the SDOH Clinical Care HL7 Implementation Guide. This guide was developed by the Gravity Project and documents the orchestration of SDOH data capture and related interventions and how it is represented using FHIR. US Core Profile span across use cases and thus less constrained, but they form backbone for the SDOH Clinical Care Profiles. Many of the additions to US Core Profiles to meet the SDOH data element requirements are based on the efforts by the Gravity led project. In the following sections the interrelation between the SDOH elements is summarized and how each element is represented in US Core documented.

SDOH Activities

The figure below shows how the SDOH elements are inter-related:

  • SDOH Assessment: SDOH Assessments represent the recording of SDOH assessment screening tools and other questionnaires as well as individual clinical observations. These assessments are represented by the US Core Social History Assessment Observation Profile and US Core Screening Response Observation Profile
  • SDOH Problems/Health Concerns: Identifying a Social Determinants of Health-related condition (for example, homelessness) is represented by the US Core Condition Profile.
  • SDOH Interventions: Services offered to a patient to address identified Social Determinants of Health problems/health concerns (for example, referral to transportation support programs) are represented by the US Core ServiceRequest Profile. In addition, the US Core Procedure Profile can be used to record a completed service or intervention.
  • SDOH Goals: Identifying and defining a future desired condition or change in condition related to an SDOH risk (for example, Has adequate quality meals and snacks) is represented by US Core Goal Profile
SDOH Activities
sdoh_assessment.svg

SDOH Terminology in US Core

Category Codes

The LOINC “grouping” code: LG41762-2 “Social Determinants Of Health” is used to categorize SDOH for Assessments, Problem, and Service Requests. This concept enables API consumers to be able to separate out SDOH data when accessing patient information. Alternatively, clients may find it more efficient to query based on a specific codeor set of codes (for example, Condition.code) or request all of a patient’s resources for a particular type and filter by code(s) to access items of interest.

Codes for Problems/HealthConcerns, Goals, Service Requests, and Procedures

For the SDOH Clinical Care HL7 Implementation Guide, the Gravity project has defined the following value sets across specific social risk factor domains for problems/health concerns, goals, procedures, and service requests:

US Core uses broadly defined value sets that contain concepts that are used across many use cases including SDOH. The Figure below illustrates how the Gravity value sets are grouped for use in the US Core Condition Profile and how the grouped valueset is compatible with the US Core Problem code valueset. When recording SDOH data US Core Profiles, servers SHOULD use the SDOH value sets listed above.

Example of SDOH Grouping Value set in US Core Condition Code Value Set
sdoh_condition.svg

Assessment Codes

Assessment Screenings can represent a structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. The assessment scale responses are represented in US Core with US Core Screening Response Observation Profile. The US Core Social History Assessment Observation Profile is for simple observations made by an individual during the course of care about a patient’s social history status. These Observation can contribute to the identification of SDOH Problems and can be the reason for SDOH Service Requests or Procedures.

US Core has developed US Core Common SDOH Assessments ValueSet - commonly asked social questions as identified by FindHelp.org, a social service assistance tool. This is not intend to replicate the complexities and robustness of the FHIR Questionnaire and QuestionnaireResponse resources developed for SDOH assessment screening tools and other questionnaires. The Gravity Project is working on a more comprehensive set of codes to meet these challenges (this guide may leverage that work in the future).

Searching for SDOH Patient Data

Below is a simple example of FHIR RESTful search transaction to access a patient’s SDOH assessment data.

  • Observation type = Observation
  • Patient’s FHIR_id = “example”
  • Observation category = “LG41762-2”

Request

Request url using GET

GET http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient/example&category=LG41762-2

Request Headers

User-Agent: python-requests/2.25.1
Accept-Encoding: gzip, deflate
Accept: application/fhir+json
Connection: keep-alive
Content-Type: application/fhir+json

Response

200 OK

Response Headers

Connection: keep-alive
Content-Location: http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=LG41762-2
Content-Type: application/fhir+json;charset=utf-8
Content-Length: 4112
Date: Sun, 21 Nov 2021 03:15:18 GMT

Response Body

{
  "resourceType": "Bundle",
  "id": "158f4b97-5b3a-4363-81da-19d454a6df30",
  "meta": {
    "versionId": "1",
    "lastUpdated": "2021-11-20T22:15:18.726-05:00"
  },
  "type": "searchset",
  "total": 1,
  "link": [
    {
      "relation": "self",
      "url": "http://wildfhir4.aegis.net/fhir4-0-1/Observation?patient=Patient%2Fexample&category=LG41762-2"
    }
  ],
  "entry": [
    {
      "fullUrl": "http://wildfhir4.aegis.net/fhir4-0-1/Observation/hunger-question-example",
      "resource": {
        "resourceType": "Observation",
        "id": "hunger-question-example",
        "meta": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-name",
              "valueString": "Hunger Question Example"
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/instance-description",
              "valueMarkdown": "This is a Hunger Question Example for the *US Core Screening Response Observation Profile*."
            }
          ],
          "versionId": "1",
          "lastUpdated": "2021-11-20T22:13:54.070-05:00",
          "profile": [
            "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-screening-response"
          ]
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>meta</b>:       \n      </p><p><b>status</b>: FINAL      \n      </p><p><b>category</b>: SocialDeterminantsOfHealth         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'LG41762-2' = 'LG41762-2', given as 'SocialDeterminantsOfHealth'})</span>, Survey         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'survey' = 'Survey', given as 'Survey'})</span></p><p><b>code</b>: Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '88122-7' = 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]', given as 'Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]'})</span></p><p><b>subject</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>effective</b>: Nov 12, 2021 8:59:15 PM      \n      </p><p><b>performer</b>:         \n        <a href=\"Patient/example\">Patient/example</a></p><p><b>value</b>: Often true         \n        <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code 'LA28397-0' = 'Often true', given as 'Often true'})</span></p><p><b>derivedFrom</b>: Hunger Vital Signs Questionnaire      \n      </p></div>"
        },
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://loinc.org",
                "code": "LG41762-2",
                "display": "SocialDeterminantsOfHealth"
              }
            ]
          },
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                "code": "survey",
                "display": "Survey"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "88122-7",
              "display": "Within the past 12 months we worried whether our food would run out before we got money to buy more [U.S. FSS]"
            }
          ]
        },
        "subject": {
          "reference": "Patient/example"
        },
        "effectiveDateTime": "2021-11-12T17:59:15-08:00",
        "performer": [
          {
            "reference": "Patient/example"
          }
        ],
        "valueCodeableConcept": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "LA28397-0",
              "display": "Often true"
            }
          ]
        },
        "derivedFrom": [
          {
            "display": "Hunger Vital Signs Questionnaire"
          }
        ]
      },
      "search": {
        "mode": "match",
        "score": 1
      }
    }
  ]
}