Imagine your doctor's computer system could see not just your blood pressure numbers, but also whether you're having trouble affording food, finding stable housing, or getting to appointments. A new study tested whether giving doctors this kind of 'social risk' information could help them manage chronic conditions better. In a large network of primary care clinics, six were given special tools in their electronic health records. These tools alerted doctors when a patient was overdue for a screening about life challenges like food or housing insecurity. For patients with uncontrolled high blood pressure or diabetes—or who frequently missed appointments—the tools offered additional support. Over 12 months, blood pressure control improved in all clinics, but it improved significantly more in the clinics that had the social risk alerts. Control of blood sugar for diabetes, however, didn't show a difference. The clinics with the special tools were also much more likely to screen for and document these social risks. While different clinics used the tools in different ways, the overall finding is clear: when doctors have a better picture of the life challenges their patients face, they might be better equipped to help them manage conditions like high blood pressure.
EHR social risk tools boost BP control, screening in primary care RCTCould tracking patients' life struggles help doctors control high blood pressure? A new study suggests yes
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This cluster randomized controlled trial evaluated whether electronic health record (EHR)-integrated social clinical decision support (SCDS) tools improved blood pressure (BP) and hemoglobin A1c (HbA1c) control, and increased social risk-informed care and documentation in community-based primary care clinics. The pragmatic trial was conducted in a large primary care network, with 6 clinics randomized to receive the SCDS tools embedded in the EHR and 44 clinics serving as controls. The tools supported clinic-wide workflows and targeted decision support. A screening alert was triggered for adult patients lacking up-to-date social risk screening. Additional tool components were activated for patients with uncontrolled hypertension or diabetes, or with a diagnosis of either condition combined with a visit no-show rate of at least 50%. The primary outcomes were BP and HbA1c control, with secondary outcomes including social risk screening and documentation. Generalized linear mixed models accounted for patient clustering. Over 12 months, blood pressure control improved in both arms, with significantly greater improvement observed in the intervention clinics. Control of HbA1c showed no significant differences between groups. Intervention clinics had significantly greater odds of social risk screening and documentation. Use of individual SCDS tool components varied widely across the clinics. The study concluded that access to EHR-integrated SCDS tools was associated with increased documentation of social risks and greater improvements in BP control.
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