Health Care Companies, Federal Agencies to Solve Interoperable Data Sharing on Social Determinants

A group of health care organizations is developing interoperable systems for sharing information on social determinants of health across care settings.

The Sync for Social Needs Coalition seeks to standardize the types of data that providers collect from patient screenings for social determinants and develop ways to integrate that information into electronic medical records (EMR) with interoperability among settings.

The project’s participants include the health care tech company WellSky, SCAN Health Plan, Sanford Health System, Rush University System for Health, Tufts Medicine, HL7 International, Riverside Health System, BayCare, Geisinger, and the U.S. Veterans Health Administration.


The coalition’s aims are likely achievable using existing technology, but what has been missing until this point was the concerted will among private and government stakeholders to make it happen, according to WellSky CEO Bill Miller.

“The first thing that any of these efforts require is willpower. Most of the things that have to happen from a technology and interoperability standpoint are well within our bounds and relatively easy to do,” Miller told Hospice News. “Historically, what has always tripped us up in data sharing concepts across health care is just provincialism around data. With the White House, and certainly this coalition, putting their firepower on things like hunger, it starts to solve a little bit for the whole willpower thing.”

A self-described optimist, Miller said that this level of interoperability could “be a reality in relatively short order.” 


Social determinants are non-medical needs that can have a significant impact on the trajectory of patients’ health, such as nutrition, transportation, social or caregiver support, and housing, among others. Social and economic factors like these drive about 55% of individuals’ health outcomes, according to the Better Medicare Alliance.

For example, 2016 research found that close to 3.6 million people in the United States did not receive necessary medical care as a result of transportation barriers, contributing to an annual $150 million in preventable spending, according to the American Hospital Association.

Food insecurity is a similar example. Not only are malnourished patients more likely to be hospitalized, but the cost of those stays is nearly twice as high as those for patients who have sufficient access to quality food, according to the Agency for Healthcare Research and Quality (AHRQ).

“We know that food insecurity is always going to be a major unwinder of great clinical care — meaning all the great clinical care in the world can get unwound if someone doesn’t have sufficient nutrition,” Miller said. “Because then your metabolism doesn’t work, then your meds don’t work, and you don’t have any energy. It’s a vicious circle, not taking care of the social needs.”

Health care providers, payers, and other stakeholders are increasingly paying more attention to both social determinants and palliative care, including Medicare and Medicaid. The need to address social determinants has been cited as an impetus for the push toward value-based reimbursement.

Case in point, the U.S. Centers for Medicare & Medicaid Services (CMS) as of 2020 allows Medicare Advantage plans to cover supplemental non-medical benefits, including transportation and food services and some home modifications, among others.

While offering these benefits is optional for MA plans, a rising number are embracing them. As of 2021, 67% of individual plans offered support related to meals, as well as 69% of special needs plans, according to the Kaiser Family Foundation.

In addition, about 38% of individual plans covered transportation benefits. Among special needs plans the proportion was 87%.

Coalition member WellSky will develop a pilot program to integrate screening tools for specific social needs into EMRs.

In addition, standards-development agencies such as the National Quality Forum and the National Committee for Quality Assurance to The Joint Commission will help the coalition scale this approach across more standards-based tools.

“This really important if you intend to take care of not only yourself or your family, but we as a nation to take care of our population — Medicaid, Medicare, or otherwise. Focusing on and coordinating social health data is extraordinarily instrumental,” Miller told Hospice News. “This is a big key that unlocks whole-person health.”

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