Applying CAMEO and Ground-view to Identifying Social Determinants of Health (SDH) via our drag & drop interoperable software solution.


According to the World Health Organization - The social determinants of health (SDH) are the conditions, in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. 

According to a Study performed by Michigan State University SDH - There is widespread interest in the role of local social determinants of health at the local level. Federal, state, and local government agencies, academic institutions, and community organizations are increasingly recognizing the need to understand and address the socioeconomic contexts within which people work and play in order to improve their health and welfare. There is renewed emphasis on implementing interventions aimed at improving socioenvironmental conditions. 

It is critical that decisions regarding how to improve health and eliminate health disparities are integrated into the larger picture of community characteristics that promote or endanger health.

This Data Set Directory of Social Determinants of Health at the Local Level is a response to those needs. The directory contains an extensive list of existing data sets that can be used to address these determinants. The data sets are organized according to 12 dimensions, or broad categories, of the social environment. Each dimension is subdivided into various components.   EHN will focusing on 9 dimensions for Phase I of the initiative.   EHN only wants to utilize data that is readily available in CAMEO or Groundview for Phase I.    The data below will be measured against mortality rates by region or nationally.  

Dimensions of the Social Environment

  • Economy  
    • What is the median and per capita income?
    • What is the mean hourly wage?
    • What is the cost of living? 
  • Employment  
    • What is the employment rate?
    • What is the unemployment rate?
  • Education  
    • What is the graduation rate?
      • Educational attainment among persons aged ≥25 years
      • Number of diploma recipients; number of other high school completers
      • High school graduation rates.
    • What is the dropout rate?
      • Percent of persons aged 16-19 years not enrolled, not high school graduates
      • Dropout rates for grades 7-12 and 9-12
      • High school dropout rates
    • What is the literacy rate? 
      • Reading assessment results?  
  • Political  
  • Environmental 
    • Environmental Hazards
      • Chemicals - Total pounds of chemical waste released by industry, by chemical?
      • Heavy Metals - Total pounds of selected heavy metals released by industry?
      • Pesticides - Total pounds of pesticide chemicals?
      • Climate - Maximum and minimum temperatures?
      • Noise - Percent of households reporting noise to be a problem or bothersome?
    • Land Use
      • Public recreational space/number of parks – 
        • Expenditures on natural resources, parks, and recreation?
      • Waste disposal/dumping/sanitation services – 
        • Pounds of waste managed?
      • Percent of households reporting major trash, litter, or junk on streets near their home?
      • Reporting neighborhood litter/deterioration to be a problem or bothersome; and reporting poor city or county services in neighborhood?
      • Curbside recycling programs 
        • Pounds of waste transferred to recycling?
    • What is the water quality 
      • Number of violations per year for federally regulated drinking water contaminants?
      • Total pounds of surface water chemicals discharged by industry, by chemical?
  • Housing  
    • Rental vs. owner occupied. 
      • Percent of occupied housing units that are owner occupied?
    • Homelessness
      • What is the percentage of homeless population?
    • Value
      • Median sales price of existing homes?
    • Age of Home
      • What is the median age of housing units?
      • What is the percent of housing units vacant?



  • Medical  
    • Primary Care 
      • Number of providers - Total number of nonfederal MD/DOs in primary care, family practice, general practice, internal medicine, ob/gyn, and pediatric primary care practice?
      • Provider training/competence/ certification 1. Nonfederal physicians in primary care who are foreign medical graduates and who are board certified; hospital associated medical staff who are board certified ?
      • Medicaid/Medicare reimbursement levels 1. Medicaid reimbursement rates for various medical services, including preventive care visits, immunization, critical care, emergency care, and surgery?
      • Age, sex, race, illness, and price adjusted reimbursements for noncapitated Medicare per enrollee?
    • Number of Specialty Care?
    • Number of Emergency Services? 
    • Number of Home Health Care Services? 
    • Number of Mental Health Care? 
    • Number of Long-Term Care? 
    • Number of Oral Health Care? 
    • Access to/Utilization of Care?
      • Insurance coverage 1. Percent of persons aged 0-64 years who are uninsured, have job-based insurance, have no usual care source, and who delayed or went without needed care?
      • Race/ethnicity staff-to-population ratios 1. Race/ethnicity staff-to-population ratios for primary care family practice, general practice, pediatric practice, internal medicine, ob/gyn, and medical and surgical subspecialties?
      • Provision of care in total and indigent care 1. Number of short-term general hospital admissions and emergency hospital outpatient visits?
      • Costs of care 1. Average cost of routine MD visit, hospital room?
      • Consumer expenditures on health care?
      • Rates of ambulatory care sensitive hospitalizations 1. Rates of ambulatory care sensitive hospitalizations per 1,000 Medicare enrollees?


  • Governmental
  • Public Health- EHN Pathways 
  • Psychosocial  


  • Behavioral 
    • Tobacco Use
      • Smoking rates 1. Rate of ever smoking; number of cigarettes smoked per day; current smoking rates among adults? 
      • Current smoking rates among children in grades 6-8 and 9-12?
      • Cessation programs Directory of local smoking cessation programs?
      • Smoking prevention - Tobacco control funding?
      • Workplace/public space smoking restriction laws- Workplace smoking policies?
      • Cost/accessibility of cigarettes 1. Cigarette tax-  Average local price of cigarettes?
    • Physical Activity
      • Physical activity levels 1. Type, frequency, and duration of physical activity?
      • Physical education requirements in schools - Expenditures on natural resources, parks, and recreation?
      • Public and private recreational facilities?
      • Television viewing patterns? 
    • Diet/Obesity
      • Fresh fruit and vegetable consumption 1. Food intake history
      • High-fat, high-sugar food consumption 1. Food intake history
      • Food quality/availability 1. 
        • Number of supermarkets, convenience stores? 
        • Percent of food sales that are supermarket sales?
        • Progressive Grocers Market Scope?
        • Percent of households reporting unsatisfactory shopping in their neighborhood?
      • Number of fast food establishments - Number of fast food restaurant?
      • School nutrition - Regulation of subcontracting to vendors?
        • Nutrition education    
    • Alcohol and Illicit Drug Use Transport
      • Number of beer, wine, and liquor stores?
      • Drug and alcohol treatment services - Number of hospitals with outpatient alcohol/drug abuse services; number of alcohol/chemical dependency treatment beds?
      • Syringe laws/exchange programs - Law allowing sterile syringe exchange?
    • Violence
      • Availability - Presence of firearms in home/vehicle?
      • Exposure to violence - Rates of violent crime?
      • Perception of neighborhood safety?
      • Percent of households perceiving neighborhood crime as a problem or bothersome?
      • Police protection


  • Transport
  • Vehicles A. Numbers of vehicles 
    • 1. Vehicles available per household -  Types of vehicles 
    • Numbers of automobiles, buses, trucks, and trailers registered ...
  • Public Transportation 
    • Availability/density/efficiency  
    • Percent of households reporting unsatisfactory or no public transportation in their neighborhood
  • Types of public transportation available 
    • Percent of workers aged >16 years using various means of transportation to work
  • Cohesiveness/integration 
    • Percent of trips taken by car, by transit, on foot, and by bicycle


Use Cases series 1-4 will focus on identification of Providers, Facilities, and Patients 

Use Case Series 1 – NPI DB Validate, Standardize, Normalize

  • Validate Address in DB via Universal Address Module
  • Identify Duplicates 
  • Geocode and Store
  • Be able to Update NPI with EHN acting as source
  • Build Hierarchy in Data based on known relationships (Names->DBA->Places to Faces)  

Objective- Quantify a specific population in a particular geographic area (zip code), then identify number of Providers in the region segmented by taxonomy.   Result would possibly yield not enough Cardiologists in Prince George’s County zip code 20706.


Use Case Series 2 – Data in ADT MSH Header, Sending Facility to NPI

  • Retrieve and match NPI if available
  • Identify single representation of the provider
  • Identify facility address

Report: List of facilities in a region based on data in the ADT feed.  Match the sending facility to NPI or NPI’s in the Spectrum MDM and leverage location intelligence to visually map Providers facilities.   

Input – 

  • Patient Name 
    • Time Stamp of message sending and receiving facility 


Use Case Series 3 – Patient Visit Segment (PV1)

  • Match sending facility to NPI
  • Match referring, consulting, or attending Physician to NPI
  • If NPI is available verify number

Report 1 – List of Physicians. Match the referring, consulting, or attending Physician to NPI or NPI’s in the Spectrum MDM and leverage location intelligence to visually map the specific Providers.   

Report 2 – Group and provide a list of known Facilities and Providers based on data available in the ADT feed.     Use location intelligence or graph to visually represent the provider and facility results.

Input – 

  • Patient Name
    • Time Stamp of message sending and receiving Provider 


Use Case Series 4 – Patient Identification segment (PID) – Identify possible solutions for data enrichment


Report 1 – Provide a full patient list.  Use location intelligence to map all patients.

Report 2- Group and provide a list of Patients to their Providers, present data in a graph .  

Report 3 –Provide a percentage of total volume of patients seen by each provider.  Graph the results.

Input –

  • Provider Information Patient List (name, home address, sex, age)


Use Series 5 and 6 will focus on Payor’s

Use case Series 5 Guarantor Segment (GT1)

  • Identify the Guarantor
  • Match patients to Guarantor
  • Build data model based on relationships

Use Case Series 6 Insurance Segment (IN1)

  • Uniquely identify the Policy
  • Link patient to Policy
  • Identify Insurance Company (Payor)
  • Note for future (Validate Address and Geocode)


Report – Produce a list of all known insurance companies based on data in ADT feed.  Map the list. 

Input – 

  • Zip Code (return % of usage of each ins. Company Medicaid, Medicare, Uninsured, Commercial)


Use Case 7, 8, and 9 will focus identifying conditions based on diagnosis, labs, and events 

Use Case Series 7 Diagnosis Segment (DG1)

  • Load ICD 9 and 10 into DB
  • Link Patient to Diagnosis
  • Location Intelligence 
  • Perform Query based on Diagnosis

Report 1 – Percentage breakdown in a list / graph of the population’s chronic condition ( Ex. 60% Diabetes, 20% Hypertension, 10% COPD, 10% Asthma)

Report 2 – Percentage of population having multiple chronic conditions and what those conditions are.

Report 3 – List of patients tied to their conditions

Report 4 – Map patient’s chronic condition(s) using location intelligence to patient map from PID segment.  

Input – 

  • Zip Code and Diagnosis (return % of population with specified condition)


Use Case Series 8 Observation Segment (OBX1)

  • Identify most common labs, frequently ordered labs
  • Identify LOINC Codes for labs
  • Upload LOINC Codes to DB
  • Link Patients to Labs
  • Location Intelligence
  • Perform Query based on Lab results 

Report 1 – Produce a list of patients tied to their associated labs.

Report 2 – Produce a list of patients 18–75 years of age with diabetes (type 1 or type 2) who had lab result HbA1c >9.0%.



  • Patient demographics and diagnosis (HBA1c >9.0%) 

Specific Population Health Result – The graphic will show Patient and location, provider and location, diagnosis, lab, provide an alert of patients with poor HBA1c >9.0% for outreach.  

Apendix 2( provides CQM Adult Recommended Core Measures

2Measure NQF 0059

Measure: Diabetes: HbA1c Poor Control

Measure Description: The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had HbA1c >9.0%.

Numerator Calculation: The numerator for this measurement is calculated based on the following: 

1.     The number of patients in the denominator that have had an HbA1c >9.0%. This should be documented using the following SMARText code in the Summary Interventions field or the encounter Plan field using "PQRIdmA1c": 3046F.

Denominator Calculation: The denominator for this measurement is calculated based on the following: 

1.     The number of patients that were between 18 and 74 years of age by the start of reporting period and have at least one face-to-face encounter with the provider during the reporting period;

2.     And have a diagnosis of Diabetes (recorded by using one of the ICD9 / 10 codes in DB) must be recorded in the patient's Summary Active Problems field OR encounter Assessment field:


Use Case Series 9 Event Segment (EVN)

  • Identify Patient readmissions based on events 
    • Admit
    • Readmission
    • Discharge 

Report 1- Calculate hospital readmission based on EVN segment data using the formula below:

Definition of Readmissions A readmission is a subsequent hospital admission in the same or a different hospital within 30 days following an original admission (or index stay). The discharge date for the index stay must occur between January and November to allow a 30-day follow-up period for all index stays. 

This approach captures an index stay with a discharge date in November and a readmission in December. The 30-day readmission rate is defined as: 


Number of stays with at least one subsequent hospital stay within 30 days / the total number of hospital stays between January and November (for demo shorten length 60 / 90 day)

*Note for demonstration report # of readmissions per month from multiple facilities for specified time period.

That is, when a patient is discharged from the hospital (the index stay), they are followed for 30 days in the data. If any readmission to the same or a different hospital occurs during this 30-day time period, the index stay is counted as having a readmission. No more than one readmission is counted within the 30-day period since the outcome measure assessed here is "percentage of admissions with a readmission." When there was more than one readmission in the 30-day period, the data reported reflect the characteristics and costs of the first readmission.


Report 2 – Produce a report detailing specific diagnosis tied to a readmission.  

Input – 

  • Patient name (output is readmissions and history)

Allergy Section

  • Allergies LOINC and ICD 9/10 Codes Upload


  • Patient name (out put list of allergies)

Eclipse Pathway’s DB – Provide PB with DB Structure and sample data

  • Initial Adult Checklist
  • Smoking
  • Medical Home
  • Follow Up