Social determinants of health (SDoH) largely shape the health and well-being of individuals, create health inequities and drive a large fraction of avoidable adverse health outcomes and healthcare costs for these individuals. However there remains significant gaps around best practices for SDoH screening, effective integration and use of Health Information Technology, and connection of those with needs to supportive services through efficient and sustainable solutions. Our overall objective is to design, develop and pilot the prototype of a novel electronic-health record (EHR)-enabled standards-based mobile health information technology to enable earlier, detailed, and continuous identification of SDoH barriers among individuals with cancer; prioritize actionable social needs; incorporate the collected and prioritized SDoH data into the clinical workflow; and facilitate the connection of the individuals to the most relevant and needed community-based organizations and social supportive services to reduce the burden of disease for patients, their families, their physicians and clinical practices. Our technical objectives are (1): Design and prototype a tool that enables the convenient, secure and user-friendly collection of comprehensive data on SDoH from patients via mobile health technology and makes it available as discrete fields within an EHR to drive customized decisions for patients. (2): Integrate the SDoH data with an intelligent community referral system that will serve as a “connector” to match patient needs to social support services and community-based organizations. (3): Perform pilot usability testing of the SDoH data collection and connector tool in a clinical environment to assess usability by patients and clinic staff.
