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Evelyn Gallego
CEO & Founder

As the EMI team closes out 2019, I want to reflect on what a phenomenal year this has been for all things related to social determinants of health (SDOH).

EMI as bridge to SDOH future

Addressing whole-person care as part of the clinical care model is becoming a top priority for stakeholders across the health ecosystem.  Investments in mobile clinics, housing supports, and food and transportation benefits consistently demonstrate an impact on overall well-being while reducing health care-related costs.  The outcomes of these interventions, coupled with the growing number of “calls to action” for health systems to play a more prominent role in reducing patient social risk, underscore the importance of designing and implementing SDOH-related programs, policies, and supporting technologies.

Yet we remain behind the curve. Current technical barriers to integrating SDOH data into the health care system fall into four key areas:

  1. Data Definitions. There is no agreement on terms and definitions for SDOH concepts regardless if they are captured in clinical or community-based settings. This lack of shared knowledge across sectors makes data less meaningful and useful, and ultimately promotes siloed work processes.
  2. Coding Gaps. For SDOH data to have shared meaning across sectors and thereby be ‘interoperable’ it needs to be represented using publicly available value sets and coding vocabularies. Existing coding gaps and overlaps inhibit the ability to document specific SDOH activities in clinical settings.
  3. Disparate Data Collection in Electronic Health Records (EHRs)Many health systems using certified EHRs are collecting some SDOH data but do so inconsistently and with variation. Most EHRs support screening activities but remain limited in how they use or integrate with community referral platforms.
  4. Misaligned Guidance and Incentives. Current SDOH innovations at scale are bolstered by new value-based payment models and accountable care organizations (ACOs) focused on enhanced data and analytics. However, state and local health systems remain dependent on federal financing to effectively navigate and coordinate fragmented and complex SDOH programs.

A critical first step in addressing these data gaps is achieving consensus on the relative data definitions regardless of the data capture system: enter the Gravity Project.

What is the Gravity Project?

Initiated by the Social Interventions Research and Evaluation Network (SIREN), with funding from the Robert Wood Johnson Foundation and in partnership with EMI Advisors LLC, the Gravity Project is a multi-stakeholder public collaborative of 800+ participants focused on developing, testing, and validating standardized SDOH data for use in patient care, care coordination between health and human services sectors, population health management, public health, value-based payment, and clinical research.

The Gravity Project is a direct response to multi-stakeholder recommendations and calls to action around creating national standards for representing SDOH data in EHRs. The eventual standards need to be able to support both:

Why do We Need Data Standards for SDOH? 

SDOH by definition are the conditions in which people are born, live, work, and age. SDOH encompasses all the elements needed for whole-person care. It is well documented that taking these conditions into account is critical to improving both primary prevention and the treatment of acute and chronic illnesses.

The recent National Academy of Sciences report on integrating social care into health care delivery acknowledges that the current shift to value-based payment models provides the necessary incentive for the health care sector to move beyond acute care delivery. This shift requires systems to incorporate and use standardized data sources beyond what is available in electronic health records (EHRs).

Health systems need to capture standardized SDOH data to:

  • Promote data collection and improve data usage. Coded data facilitates clinical and administrative decision making and quality improvement.
  • Facilitate the sharing of data across organizations. For data interoperability across and in between health care and social services systems, data needs to be accessed, shared, and exchanged using consensus-based and open standards.
  • Facilitate payment for social risk and social needs data collection and intervention activities. Coded data is used to design payment models, process claims for reimbursement, and monitor resource utilization.

Laying the Foundation

As the Gravity Project works to define and test coded data elements for key SDOH domains and create open application programming interfaces (APIs) using the HL7 Fast Health Interoperability Resource (FHIR), we are setting the groundwork needed to facilitate social care integration in health systems.

The foundation is laid but there is still much work to do. All health care and social service stakeholders—from clinical providers, community-based providers, EHR vendors, referral platforms, government organizations, research entities, and digital platforms—are encouraged to join Gravity and help us design the digital infrastructure of the future.

It takes a village.

To learn more about the Gravity Project, contact

To learn how EMI Advisors can support your digital health strategy, contact


Evelyn Gallego

Evelyn Gallego, MBA, MPH, CPHIMS
CEO & Founder, EMI Advisors LLC

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