Using patient level social determinants of health data within electronic health records to provide integrated people-centred health services: scoping review

Background: Integrated people-centred health services (IPCHS) are an evolving concept which focus on putting people and communities, not diseases, at the centre of health systems.(1) As part of creating an enabling environment to deliver IPCHS, the World Health Organization recommends strengthening information systems, but social determinants of health (SDoH) data are often missing from patient records.(2)

 

In England, national policy (10-year National Health Service Plan and population health management) is advocating the single patient electronic health record, where health, social care and SDoH data are individually linked at a neighbourhood level to support the delivery of integrated people-centred health services.(3)

This review aimed to map and synthesise the evidence on the use of linked or integrated health and social care records at point of care, and factors associated with the integration of data across health and social care settings, to provide IPCHS to patients with multiple or complex needs attending primary, secondary or community care settings.

 

Approach: We conducted a scoping review searching titles and abstracts in CINAHL, MEDLINE (Ovid), Global Health, APA PsycInfo and Health Management Information Consortium (HMIC) databases between January 2014 – September 2025, with no geographical limit. Grey literature was also searched. All study types and methods were included.

The findings were analysed and mapped to a modified framework for integrating SDoH data into healthcare systems(4) and reported following PRISMA-ScR guidelines.

 

Results: Four thousand six hundred and forty-five studies were identified, and three hundred and forty-nine full texts screened. Eight studies were included, all primary research from high income countries, with a mix of qualitative and quantitative research methodologies. One paper presented case studies implementing tools to integrate SDoH data into health records. Most studies were conducted in single primary care settings. Study populations included clinicians, administrative staff and social service providers.

Patient populations were those on low income and/or without health insurance. SDoH data included in health records were food insecurity, housing instability, social isolation, financial insecurity, interpersonal safety and physical inactivity.

 

Four themes were identified: desirable functionalities of an integrated system for social determinants of health; co-design to integrate or parallel systems into existing workflows; co-design and local feedback to tailor collected data to local population groups; and training considerations associated with an integrated system.

Mapping the findings onto the modified framework showed a lack of evidence regarding integration of external databases and registries outside of healthcare settings with patient records. There is also a lack of evidence regarding the impact of integrating this data on clinical decision making and patient outcomes.

 

Implications:Integrating care records across health and social care ultimately seeks to improve patient care by using data in real time consultations to facilitate equitable and person-centred services. Whilst integration requires greater data collaboration between agencies and community partners, there is currently a lack of evidence about the best way to achieve this. Further research is required to identify best practice for live data integration of SDoH data across systems to support the delivery of ICPHS.

 

References 1.Khatri RB, Wolka E, Nigatu F, Zewdie A, Erku D, Endalamaw A, Assefa Y. People-centred primary health care: a scoping review. BMC primary care. 2023 Nov 9;24(1):236.

2.Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

3.10 Year Health Plan for England: fit for the future [Internet]. NHS England. 2025. Available from: https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future

4.DeVoe JE, Bazemore AW, Cottrell EK, Likumahuwa-Ackman S, Grandmont J, Spach N, et al. Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice. Annals of family medicine. 2016;14(2):104-8.