• Pavela G Bambekova, Winston Liaw, Robert L Phillips, and Andrew Bazemore.
• From Long School of Medicine, University of Texas Health San Antonio, San Antonio (PGB); Department of Health Systems and Population Health Sciences, University of Houston College of Medicine (WL); American Board of Family Medicine, Lexington, KY (RLP, AB). Bambekova@livemail.uthscsa.edu.
• J Am Board Fam Med. 2020 May 1; 33 (3): 463-467.

AbstractClinicians are concerned about their patients' social determinants of health (SDH); yet, they are unsure how to effectively gather patient-level SDH data and intervene without adding to current administrative burdens. Designed properly, clinical registries offer solutions to integrate neighborhood SDH data with clinical data from electronic health records, enabling the understanding of community factors to guide patient care. Federal and state interest in adjusting reimbursements based on SDH further underscores the need for strategies that integrate SDH and clinical data. The Population Health Assessment Engine (PHATE) exemplifies a registry-based SDH data integration solution that adjusts payments, contributes to public health surveillance, organizes care around hot spots (gaps in quality or uncontrolled disease), assesses patient risk, and connects with community organizations. PHATE also permits residency training to meet community health competency milestones by incorporating the PHATE curriculum. These functions enhance value, and their utility in education and care delivery would benefit from further investigation.© Copyright 2020 by the American Board of Family Medicine.

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