IHMI will use definitions of Functional Status, Health State, Patient Goals, and Social Determinants of Health to build consensus in healthcare about how we represent critical information that is often missing from an individual’s health record. Functional Status, Health State, Patient Goals, and Social Determinants of Health, paint a more complete picture of the patient that provides a better understanding of the factors that contribute to improved outcomes. We will incorporate this information in the integrated health model to promote consistent representation of health data.

Michael,
I agree with your explanation of how AMA will use these definitions. I also think that incorporating the SDOH will render the clinical information more valuable. A report from healthpeople.gov highlights this notion. healthypeople.gov/2020/topics-...-

Definitions are somewhat vague or too general.
For example, functional status is very important but it really should be correlated to perceived exertion (RPE) or other measure of stress.
From a scientific point of view status of functional movements is a very complex issue. In sports one might measure 1RM for a specific movement but we know this provides a very limited picture as things like velocity-specific strength, power, acceleration, power-range, strength endurance, strength recovery, etc. are all important indicators of the movement.
So for normal functional movements the issues might be much deeper. One example is neurodegenerative disorders. They might manifest early as movement abnormalities that a subject might notice and complain about but the physician can't diagnose anything. Yet, six months later as things get progressively worse MS might be diagnosed.
The point is that deeper and more objective functional movement metrics clearly will provide a better understanding of movement and - maybe (lots of studies needed here) - pick up early neuromuscular or - some - neurodegenerative diseases.

Thanks for proposing these definitions! It is especially great to see that physical, psychological, social and spiritual domains listed under functional capacity. It is also great to see roles included under functional status. The concepts of “live, learn, work, and play” in SDOH are critical to health and well-being.

It is fantastic to see the IHM include ADLs and IADLs in the context of performance. This really is critical information that is not captured by structured data.
Many of the members of the American Occupational Therapy Association (AOTA) focus on ADL and IADL performance on a daily basis, so AOTA has spent considerable effort in identifying and defining the two concepts.
The definition of ADL and IADL is a great start; however, the list included in the definition following “They include” is limited on both. I would recommend either (1) changing the language to “ADLs [IADLs] include, but are not limited to” or (2) expand the list.

In additional to the activities listed in the ADL definition, we would include: feeding (in addition to eating), personal device care, sexual activity, and personal hygiene and grooming.

We would also strongly encourage the IHM to consider the term mobility or functional mobility instead of walking. There is a significant portion of the population who uses wheeled or other mobility devices in lieu of walking for a variety of reasons.

In additional to the activities listed in the IADL definition, we include: Care of others, children, and pets; communication management; driving and community mobility; health management; home management; religious and spiritual activities; safety and emergency maintenance; and shopping.

Finally, I really appreciate the discussion in the document examining the health goal from the perspectives of providers and persons or patients. But, I have a question about health outcomes. Could a health outcome be achieved from the person’s perspective? The examples provided all align with the clinical or practitioner view. If so, I would encourage IHM to consider adding another example under “Health Outcome – Examples” that captures an outcome related to a “patient set goal”. For discussion:
- Ability to prepare a meal for his/her family (compensating for pain)
- Safely drove self to a recent appointment
- Attended 2 school events with children
- Ability to dress self with no assistance
- Returned to 5 day work week
I am really excited to continue to follow this project. Thank you for soliciting input on this really critical topic!

Great point, Jeremy. A Health Outcome may be impacted by health system interventions, or events outside the four walls of medicine. Adding a Health Outcome example that results from a patient-set goal is a good reminder that an individual’s goals and environment are core to understanding their health.

Your feedback is much appreciated, and we’ll bring it back to the team.

First, let me congratulate the AMA for their groundbreaking work to integrate social determinants of health (SDOH) into physician workflow. Earlier this week AMA issued a solid report on SDOH to educate its membership; and then the House of Delegates approved policies calling for standardized assessment templates to be embedded into the EHR.

There are a lot of instruments and approaches to measuring SDOH. At Watson Health we use a two stage screening process in our population health solutions: area insights will automatically flag a patient who lives in an economically deprived neighborhood for additional screening with a validated instrument.

For place-based assessments, I really like the Area Deprivation Index (ADI). It is a validated index of 17 census measures that is readily available for every zipcode in the US and is strongly correlated with morbidity mortality and hospital readmissions. For patient-reported social determinants there are a lot of assessment instruments. The CMS 10 question Accountable Health Communities Screening Tool is a good one. Community Health Centers use “Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences” (PRAPARE). Many similar tools have been developed by care systems and are based on a comprehensive report by the National Academy of Medicine (then IOM) in 2014.

Thanks Dr. Kassler for sharing about the Area Deprivation Index (ADI), as it is a tool we can certainly use for Therapy.Coach to target service delivery to the geographies with high rate of hospital readmissions.

In addition to running Therapy on Demand, LLC since 2015, our team has recently established the Therapy on Demand Foundation (nonprofit) out of Delaware to help target services like ours to those who need it most. Throughout our products and services we are embedding assessments that are norm'ed, validated, and demonstrate ecological validity.

We are excited to hear about the AMA's SDOH report, and look forward to continuing the conversation about assessing community health, and applying that data in useful ways.

Just as many practices have moved to apply quick depression (PHQ-2/PHQ-9) or alcohol use (CAGE) screening tools; that same strategy can be used for SDoH. It could just be a few brief questions filled out in the waiting room, or asked by the medical assistant rooming the patient.

During the clinical encounter, SDH information is valuable because it provides a layer of knowledge about patients' lives that is not captured in lab results, vital signs, imaging studies, observations and reasons for visit. At the very least, this knowledge can help guide patient-provider conversations and providers' recommendations in a way that fosters patient engagement through personally relevant dialogue (e.g., "My doctor really understands what I'm going through!") and care recommendations (e.g., prescribe low cost generics for patients with low income and offer them samples if available). And when deleterious SDH factors exist, screens for stress/anxiety, depression and other behavioral health conditions could be a priority, as well as referrals to community resources. These kind of things could be of value to the patient even when the underlying causes of the SDH do not change.

Here is a great paper on how 6 healthcare organizations developed screening tools for identifying their patients' social determinants: ncbi.nlm.nih.gov/pubmed/289909...

It's helpful to know the SDH data capture challenges faced by implementers. It's also important to the best ways to use those screening data to foster patient engagement, satisfaction and good clinical outcomes through referrals to community resource and hand-offs to care team members (e.g., behavioral health specialists). Solid research that shows how best to map SDH data to specific interventions that help attain these kinds of positive results would enable the develop of useful decision-support algorithms when a patient's health and well-being are adversely impacted by SDH factors.

Not only should patients' health goals be considered, but I believe it would be beneficial to determine how and why they may diverge from other established health goals. When such divergence if found, there ought to be a discussion with the patient as to ways to agree.