=Paper=
{{Paper
|id=Vol-3805/ICBO-2022_paper_0492
|storemode=property
|title=The Gaps in the Terminological Representation of the ACORN Social Determinants of Health Survey
|pdfUrl=https://ceur-ws.org/Vol-3805/ICBO-2022_paper_0492.pdf
|volume=Vol-3805
|authors=Melissa Resnick,Diane Montella,Wilmon McCray,Steven Brown,Keith Campbell,Jonathan Nebeker,Frank LeHouillier,Peter Elkin
|dblpUrl=https://dblp.org/rec/conf/icbo/ResnickMMBCNLE22
}}
==The Gaps in the Terminological Representation of the ACORN Social Determinants of Health Survey==
https://ceur-ws.org/Vol-3805/ICBO-2022_paper_0492.pdf
The Gaps in the Terminological Representation of the ACORN
Social Determinants of Health Survey
Melissa P. Resnick 1, Diane Montella 2, Wilmon McCray 1,2, Steven H. Brown 2, Keith E.
Campbell 2, Jonathan Nebeker 2, Frank LeHouillier 1 and Peter L. Elkin 1,2,3,4
1
Department of Biomedical Informatics, University at Buffalo, Buffalo, New York, USA
2
U.S. Department of Veteran Affairs, Office of Health Informatics, Washington D.C., USA
3
U.S. Department of Veteran Affairs, WNY VA, Buffalo, New York, USA
4
Faculty of Engineering, University of Southern Denmark, Odense, Denmark
Abstract
Objective: Social Determinants of Health (SDOH) greatly influence health outcomes and
healthcare utilization. Tools, such as the Assessing Circumstances & Offering Resources for
Needs (ACORN) survey, have been developed to screen for SDOH. The purpose of this study
is to determine the level of terminological representation of the ACORN survey by the Solor
terminology. Methods: Each ACORN survey question was read to determine its concepts. Next,
Solor was searched for each of the concepts and for the appropriate attributes. If no attributes
or concepts existed, they were created. Then, each question's concepts and attributes were
arranged into subject-relation-object triples. Results: Eleven unique attributes and 18 unique
concepts were created. These results demonstrate a gap in representing SDOH with
terminologies. We believe that using the Basic Formal Ontology (BFO) machinery to fill this
gap will assist in bringing together the concepts to better represent SDOH.
Keywords 1
Social Determinants of Health, ACORN Screening Tool, Solor Terminology
1. Introduction occur in various environments and settings
including: schools, places of employment,
religious centers, and neighborhoods [3].
There has been an increased interest in Social
Examples of SDOH include: (1) opportunities for
Determinants of Health (SDOH) for over two
education and employment, (2) level of income,
decades [1]. This is due to the fact that they
(3) access to housing and affordable utilities, (4)
greatly influence health outcomes and healthcare
social and community support, and (5) access to
utilization, thus, contributing to health disparities
transportation, just to name a few [5,6].
for disadvantaged individuals [2]. As noted by
Powell (2019), SDOH affect health, behavioral
health, and general quality of life [3]. 1.1. World Health Organization and
Social Determinants of Health are the SDOH
conditions in which individuals are born, grow,
live, work, and age [3,4]. These SDOH occur
The World Health Organization (WHO) has
across dimensions of functioning, such as, social,
three areas of work: (1) building the evidence for
economic, and physical dimensions [3]. They also
action; (2) promoting health in all policies and
1ICBO 2022, September 25-28, 2022, Ann Arbor, MI, USA
EMAIL: mresnick@buffalo.edu (A. 1); diane.montella@va.gov
(A. 2); wilmon.mccray@va.gov (A. 3); steven.brown@va.gov (A.
4); campbell@informatics.com (A. 5); jonathan.nebeker@va.gov
(A. 6); fdl1@buffalo.edu (A. 7) ; elkinp@buffalo.edu (A. 8)
ORCID: 0000-0001-9699-852X (A. 1); 0000-0001-9396-8798 (A.
2); 0000-0001-6103-1845 (A. 4); 0000-0001-5355-5008 (A. 6);
0000-0002-2961-1273 (A. 7); 0000-0001-9616-6811 (A. 8)
©️ 2022 Copyright for this paper by its authors. Use permitted under Creative
Commons License Attribution 4.0 International (CC BY 4.0).
CEUR Workshop Proceedings (CEUR-WS.org)
CEUR
ceur-ws.org
Workshop ISSN 1613-0073
Proceedings
intersectoral action capacities; and (3) special economic stability; (2) education; (3) social and
initiative for action on social determinants of community context; (4) health and health care;
health for advancing health equity [7]. The area of and (5) neighborhood and built environment [13].
"special initiative for action on social Each of these five areas encompasses key issues
determinants of health for advancing health in SDOH as follows: (1) economic stability:
equity" is most applicable to our work and will be employment, food insecurity, housing instability,
discussed in more detail. According to WHO, the poverty; (2) education: early childhood education
goal of this initiative is: "to ensure that health and development, enrollment in higher education,
equity is integrated into the development of social high school graduation, language and literacy; (3)
and economic policies, including its gender social and community context: civic participation,
dimensions, to improve the social determinants of discrimination, incarceration, social cohesion; (4)
health for at least 20 million disadvantaged people health and health care: access to health care,
in at least 12 countries" [8]. To begin working access to primary care, health literacy; and (5)
toward this goal, WHO appointed the neighborhood and built environment: access to
Commission on Social Determinants of Health foods that support healthy eating patterns, crime
(CSDH) [9,10]. and violence, environmental conditions, quality of
The CSDH set out to identify how the structure housing [13]. This framework was used starting in
of societies are affecting population health, and 2010 to establish new SDOH objectives, and to
what governments and public health can do to identify the existing Healthy People objectives
change it [9,10]. Through their work, the CSDH existing at that time that were relevant to SDOH
determined that the circumstances in which [13]. Healthy People 2030 (released in 2020)
people live are shaped by the distribution of added a fifth overarching goal, and expanded the
money, power and resources at global, national wording of the goal addressing social
and local levels [11]. Keeping this in mind, they determinants of health to: “Create social,
provided three key strategic directions for policy physical, and economic environments that
work in SDOH: (1) the need for strategies to promote attaining the full potential for health and
address context; (2) intersectoral action; and (3) well-being for all” [14]. Downstream, the Healthy
social participation and empowerment [10]. Thus, People SDOH objectives and the activities to
health outcomes cannot be achieved by merely achieve them will aid in identifying important
acting in the health sector alone; actions in other resources and to enact public health policy at
sectors are critical as well [11]. federal, state and local levels [13], and it is notable
that the fifth overarching goal newly added with
1.2. Healthy People and SDOH the release of Healthy People 2030 seeks to
engage leaders and other key people who can
design and promote “policies that improve the
In 1979, Healthy People began as the Surgeon health and well-being of all” [14].
General's report on Disease Prevention and Health
Promotion [12]. This was followed in 1980 by the
first set of national 10-year objectives [12]. Since 2. Screening Tools for SDOH
that time, successive objectives of Healthy People
2000 (released in 1990) and Healthy People 2010 Various tools can be used to screen individuals
(released in 2000) have identified emerging for SDOH. These include, but are not limited to:
public health priorities, which have been aligned WellRx [15]; Protocol for Responding to and
with health promotion strategies [12]. The Assessing Patient Assets, Risks, and Experiences
objectives of Healthy People 2020 were (PRAPARE) [16]; and Assessing Circumstances
broadened to include the influence of social & Offering Resources for Needs (ACORN) [17].
environment on health outcomes [12]. The ACORN survey is a relatively new tool for
Four overarching goals were recommended by measuring SDOH. As such, little is known about
Healthy People 2020 [12]. One of the four goals the terminological representation of the questions
is to: "create social and physical environments in this survey. The aim of this research study is to
that promote good health for all" [12,13]. To meet begin to represent the questions of the ACORN
this goal, Healthy People 2020 began by survey using the Solor terminology. First, we turn
developing a framework specifically for social to the ACORN screening tool.
determinants of health [13]. This framework
consists of five determinants or key areas: (1)
2.1. The ACORN Screening Tool employment, and (5) education [16]. In addition,
PREPARE includes: (1) social and emotional
health; (2) being insured or uninsured; (3)
One tool for measuring SDOH is the
clothing needs; and (4) income, just to name a few
Accessing Circumstances & Offering Resources
[16].
for Needs (ACORN) survey. In 2020, a 13-
question survey to screen for SDOH was
developed by the Veterans Health Administration 3. Representing the Screening Tools
(VHA) for use with Veterans [17,18]. This survey
uses one question from the WellRx tool, one The use of these various screening tools for
question from the PRAPARE tool and five social determinants of health produces a wealth of
questions from other sources. The remaining six data. These data are a valuable source of health
questions were developed by the VHA. Veteran- information, but currently are not fully utilized by
specific topics on the ACORN survey include: (1) many clinicians [20]. In fact, knowing that a
needing information about educational benefits patient has trouble finding transportation, has a
for Veterans, and (2) setting up a video visit with potentially unsafe relationship with someone
a member of the VA care team [17]. Topics not close, is currently unemployed, or various other
specific to Veterans and not from other sources SDOH would assist healthcare providers to design
include: (1) legal issues, (2) feeling lonely or treatment plans to best help the patient [20].
isolated, (3) having access to and being able to use Watkins and colleagues (2020) point out the need
a smartphone or a computer, and (4) having access for standardized SDOH for care delivery
to reliable and affordable Internet [17]. supported by electronic health records: "these
SDOH must be gathered, represented, and stored
2.2. WellRx Screening Tool in a standardized way before they can be
leveraged by informatics tools designed for health
providers" [20]. Terminologies, such as the
In 2014, there was no widely available
Systematized Nomenclature of Medicine Clinical
structured method intended or tested for
Terms (SNOMED CT), Logical Observation
healthcare providers to identify and capture
Identifiers Names and Codes (LOINC), and
SDOH in the outpatient primary care medicine
RxNorm can be used to represent these SDOH
setting [15]. WellRx, an 11-question screening
screening tools and their resulting data.
tool for SDOH, was developed and piloted at the
Arons and colleagues (2018) performed
University of New Mexico for this purpose [15].
preliminary work to determine how well concepts
The questions encompass such topics as: (1) food
from six SDOH tools were covered in SNOMED
insecurity, (2) access to housing, (3) affordability
CT, LOINC, ICD-10, and CPT [6]. These SDOH
of utilities, (4) transportation, (5) employment, (6)
tools included: (1) the NAM's 2014
education, and (7) safety [15].
Recommended Social and Behavioral Domains
and Measures report; (2) the PRAPARE survey;
2.3. The PRAPARE Screening Tool (3) the Accountable Health Communities (AHC)
survey; (4) the Health Leads questionnaire; (5) the
The Protocol for Responding to and Assessing SEEK tool; and (6) the WE CARE survey [6].
Patient Assets, Risks, and Experiences They noted that although a large number of
(PRAPARE) survey is a 21-question screening concepts from these SDOH tools are covered by
tool for SDOH [19]. In 2013, the National standardized vocabularies, there exist some gaps
Association of Community Health Centers [6]. Not surprisingly, Arons and colleagues
(NACHC) and partners launched a project to (2018) demonstrated that the Education,
develop and implement a national standardized Employment, Housing, Safety, and Social
patient social determinants of health risk Connections/Isolation domains had particularly
assessment protocol, PRAPARE [16]. With its high numbers of codes, as these are well covered
implementation in 2016, PRAPARE provided a in SNOMED CT and LOINC [6]. However,
way to assess SDOH and to expedite actions at the domains such as child care, clothing,
individual, community, and health system levels incarceration, immigration/migration, and
[16]. PRAPARE covers most of the same topics Veteran status were found to be lacking codes [6].
as WellRx namely: (1) food security, (2) access to The ACORN survey was created two years
housing and utilities, (3) transportation, (4) after Arons and colleagues published their work.
Thus, ACORN could not be included in their 4. Methods
analysis. In addition, RxNorm was not included as
one of the terminologies in their analysis. It is also
The Assessing Circumstances & Offering
possible that additional terms were added to any
Resources for Needs (ACORN) survey was
or all of the terminologies contained within the
obtained [18]. Each survey question was read to
Solor terminology within the ensuing years.
discern all terms.
Therefore, the recent creation of the ACORN
Next, Solor was searched for each of the
survey and the possibility of newly added SDOH-
identified ACORN terms. For those ACORN
related terms to SNOMED CT, LOINC and
terms for which concepts were found to be present
RxNorm (Solor terminologies) provided the
in Solor, the codes and names were noted. If the
impetus for this research.
needed concept was not present in Solor, a "new"
concept was created.
3.1. The Solor Terminology In the final step, Solor was searched for
appropriate attributes in order to form subject-
Solor [21] is an integrated terminology system attribute-object triples. If no appropriate attributes
created in collaboration with the U.S. Dept. of existed, they were created.
Veterans Affairs (VA) that combines SNOMED
CT (representing diseases, findings, and 5. Results
procedures), LOINC (representing laboratory test
results), and RxNorm (representing medications)
A total of 52 terms relating specifically to
[22]. Solor has two fundamental building blocks:
social determinants of health were identified from
concepts with their synonyms, and semantics
the ACORN survey questions. During the
[22]. In this case, a concept is a medically-related
encoding process, 12 unique attributes were used:
idea, such as heart attack, while a semantic is data
1 unapproved SNOMED CT attribute and 11
that provides contextual meaning to the concepts
newly created attributes (see Table 1).
[22,23]. Like SNOMED CT, Solor is built on a
logic model [22]. Most of the concepts are shared
Table 1
by Solor and SNOMED CT and are arranged into
12 Unique Attributes Utilized
hierarchies using "is_a" relationships [22].
Therefore, the modeling is based on SNOMED Unapproved Created
CT, LOINC, and RxNorm. SNOMED CT Attribute Attribute
As an integrated terminology system, Solor without (unapproved
provides many advantages. For instance, this attribute)
single consistent method of encoding clinical data experienced_by
can allow this data to flow among clinical has_access_to
documentation, decision support applications, and has_behavior
order entry at the point of care [22]. Solor can also has_desire
support research, quality measurement, and other has_frequency
secondary uses [22].
has_lived_as
At the current time, the Solor terminology is
has_lived_in
used in three different contexts. As noted by
Resnick and colleagues (2021) it is used in a has_lived_with
research setting [22]. Solor also provides Clinical has_need_for
Decision Support (CDS) modeling at the VA. In has_truth_value
the third context, Solor is part of the Sentinel scheduled_for
initiative at the Food and Drug Administration
(FDA). Sentinel is the FDAs national electronic
system which allows researchers to monitor the A total of 34 unique concepts were used from
safety of FDA-regulated medical products, such the Solor terminologies. Of these, 20 were from
as drugs, vaccines, biologics, and medical devices SNOMED CT; 14 were from LOINC; and 0 were
[24]. The Sentinel Initiative leverages from RxNorm.
organizational partnerships in informatics, data As seen in Table 2, 18 unique new SDOH
science (using natural language processing and concepts were created.
machine learning) and other areas [24].
Table 2 The encoding of the ACORN survey questions
18 Unique Concepts Created revealed three issues: (1) the need to create new
Concept Created concepts; (2) concepts from more than one
terminology that represent any one question; and
Affordable internet at home
(3) lack of appropriate attributes or relations. In
Apartment/House/ Room (no government one of the cases, however, it appeared that
subsidy) SNOMED CT attributes could be used. For
Apartment/House/Room (with government example, it seemed possible to utilize
subsidy) "inheres_in" to create the triple: 267076002
As a part of household feeling lonely (finding) "inheres_in" 116154003
Cell phone patient (person). However, this is not possible, as
Friend SNOMED CT dictates that the domain of
Help getting food this week "inheres_in" needs to be an observable entity, not
Help learning to use computer a finding [25]. Thus, a new attribute
Help learning to use smartphone "experienced_by" was created.
Information about Veterans educational Almost all of the attributes were created (see
benefits Table 1). This is most likely due to the fact that
I don't want internet access at home the relations or attributes for social determinants
Information about Veterans educational of health are not well represented in SNOMED
resources CT, and thus, Solor. The lack of appropriate
attributes demonstrates a gap in the representation
Reliable internet at home
of relations between the SDOH concepts.
Rented housing A second issue involves the representation of
Runs out of phone minutes the concepts for each question. Many of the
Smartphone questions are represented by concepts from two
Steady place to stay different Solor terminologies: SNOMED CT, and
Worry about housing in near future LOINC (see Appendix A). This, in turn, also
contributed to the difficulty in finding appropriate
attributes or relations to form the triples from
In Appendix A, two of the ACORN survey these concepts. In other instances, the concepts
questions with their triples are shown. As shown do, indeed, exist in the same Solor terminology
in column 2, the subject of the triples are (see Appendix A). However, as shown in
represented by concepts from SNOMED CT or Appendix A, it is still necessary to use a created
LOINC. The same is true for the object of the attribute in order to form the triples.
triples, as seen in column 4. For these two survey Finally, it was necessary to create some new
questions, none of the created concepts, and three concepts (see Table 2). In viewing these concepts,
of the 11 created attributes were used to form the it appears that they represent housing, utilities and
triples. education. Once again, this demonstrates that
there is a gap in the coverage of social
determinants of health by the Solor terminologies:
6. Discussion SNOMED CT, LOINC, and RxNorm.
Before moving on, a brief note must be made
Among the contributions of this work are the about the lack of RxNorm concepts. This is not
triples. These triples can be leveraged with at least necessarily a function of a gap in coverage.
two informatics tools: (1) Natural Language Rather, it is most likely due to the content of the
Processing (NLP) tools, and (2) Clinical Decision questions. In fact, none of the questions ask about
Support tools. In the case of NLP, the triples specific medications, thus, obviating the need for
provide increased accuracy in tagging the concepts from this Solor terminology.
unstructured text, which can influence other There are at least two solutions to the
activities downstream. Triples also allow for the previously discussed issues. First, the created
triggering of CDS rules, which in turn, can attributes and concepts could be submitted for
improve the care given to patients. Hence, it is for inclusion in SNOMED CT, which would also be
these reasons that the triples are created while included in Solor. Second, the Basic Formal
encoding the ACORN survey. Ontology (BFO) could be used to represent the
created attributes and concepts. Once this has
been accomplished, the remaining concepts from Question six (6) of the ACORN survey reads:
the different terminologies for each question How often do you feel lonely or isolated from
could be brought together using the BFO those around you? a. Often b. Sometimes c. Never
representations of the newly created attributes. By [17]. Concepts for this question were found in
using the BFO machinery in this way, we would SNOMED CT, and are as follows: (1) 116154003
be able to fill in the gaps created by lack of patient (person); (2) 267076002 feeling lonely
appropriate SNOMED CT or Solor attributes. (finding); and (3) 307048004 feeling isolated
The BFO is a realism-based, formal and (finding). For the reason previously discussed, the
domain-neutral upper level ontology that is attribute “inheres_in” could not be used. Thus,
designed to represent, at a very high level of since other appropriate attributes to express the
generality, the types of entities in the world and triples were not found, two new attributess were
the relations that exist between them [26]. Since it created: “experienced_by”, and “has_frequency”.
is intended to provide only the most basic building This allowed us to form such triples as: (1)
blocks for constructing domain-specific 267076002 feeling lonely (finding)
ontologies, it is very small [26]. In addition, it “experienced_by” 116154003 patient (person);
provides a starting point for the logical and (2) 267076002 feeling lonely (finding)
descriptions of the types of entities in a specific “has_frequency” LA10044-8 often. Using the
domain [26]. Thus, an advantage of utilizing the BFO framework would allow us to express these
BFO is that the domain ontologies are, to a degree, triples without forming new concepts and
interoperable [26]. attributes.
A part of this research involves representing Using the BFO framework, “feeling lonely”
relations with the BFO. BFO has three basic would be a quality universal of which instances
relations: (1) those between two universals (as inhere in human beings. At every temporal region
within the ontology itself); (2) those between a t at which there exists an instance x of “feeling
universal and a particular; and (3) those between lonely”, there must exist a human being y in which
two particulars [27]. Relations between a x inheres. Temporal region t has two temporal-
particular and a universal are used in cases where parts: temporal region t1 and temporal region t2.
the ontology is applied to a portion of reality, as Here, t1 is composed of temporal intervals such
in the annotation of medical records for a group of that during these intervals there exists an instance
patients [27]. Relations between two particulars of feeling lonely that inheres in a human being.
are used when asserting that Mary's leg is a part Next, t2 is composed of temporal intervals such
of Mary [27]. that if at least one instance of feeling lonely exists
Relations between universals have been during the interval, none of these instances inhere
further categorized as: (1) foundational relations, in a human being. The temporal-part of t2 in
(2) spatial relations, (3) temporal relations, and (4) which none inheres in a human being represents
participation relations [27]. These have been "a human being never feels lonely. In the case of
formed into the relation Ontology, which has been a human being "feeling lonely often" t1 is larger
used in many of the ontologies of the OBO than t2. The representation for "a human being
Foundry [27,28]. This provides interoperability sometimes feeling lonely" is similar, except that
between many of the OBO Foundry ontologies t1 is smaller than t2. A similar representation can
[27]. be used for "feeling isolated".
Currently, we are beginning to investigate how Another ontology that may be helpful in our
the BFO can be used to represent the concepts and research is the Ontology of Medically Related
relations that we have created and identified. One Social Entities (OMRSE). The OMRSE is built
of the challenges is that terminologies such as upon the BFO, thus, conforming to the best
SNOMED CT and LOINC are concept-based practices of the OBO Foundry [30]. The OMRSE
[29], while BFO is realism-based [26,27]. As was originally developed to represent
such, many of the terms representing the questions demographic data, but additionally includes
of the ACORN survey, along with the created representations for organizations, roles, facilities,
terms and attributes, might not fit into the BFO demographic data, enrollment in insurance plans,
framework. However, by expressing the identified and data about socio-economic indicators [30].
terms and created terms and attributes in a Currently, of particular interest are
realism-based way, it is believed that they can representations for "healthcare facilities",
then be represented by the BFO framework. An "households" and "housing units". The OMRSE is
example is discussed below. designed to bridge the gap between BFO and more
specific domain ontologies, as well as providing of Health Informatics and Knowledge Based
various classes for reuse in other ontologies [30]. Systems.
As we move forward in our research, ontologies
such as the OMRSE will assist in representing the 10. References
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Appendix A
Two ACORN Questions with Encodings and Triples
ACORN Subject Attribute Object
Survey Question (SNOMED / LOINC) (NEW [from Table1]) (SNOMED / LOINC)
(6) How often do [SNOMED] 267076002 feeling lonely (finding) "experienced_by" [SNOMED] 116154003 patient (person)
you feel lonely or [SNOMED ]307048004 feeling isolated (finding) "experienced_by" [SNOMED] 116154003 patient (person)
isolated from those [SNOMED] 267076002 feeling lonely (finding) "has_frequency" [LOINC] LA10044-8 often
around you? [SNOMED] 267076002 feeling lonely (finding) "has_frequency" [LOINC] LA10082-8 sometimes
a. Often [SNOMED] 267076002 feeling lonely (finding) "has_frequency" [LOINC] LA6270-8 never
b. Sometimes [SNOMED] 307048004 feeling isolated (finding) "has_frequency" [LOINC] LA10044-8 often
c. Never [SNOMED] 307048004 feeling isolated (finding) "has_frequency" [LOINC] LA10082-8 sometimes
[SNOMED] 307048004 feeling isolated (finding) "has_frequency" [LOINC] LA6270-8 never
(7) How often does [SNOMED] 3030701001 person in the family "has_behavior" [LOINC] 95619-3 hurts, insults, threatens, and
anyone close to you (person) screams (hits)
physically hurt you
or threaten you with [SNOMED] 394863008 non-family member (person) "has_behavior" [LOINC] 95619-3 hurts, insults, threatens, and
harm? screams (hits)
a. Often
b. Sometimes [LOINC] 95619-3 hurts, insults, threatens, and "has_frequency" [LOINC] LA10044-8 often
c. Never screams (hits)
[LOINC] 95619-3 hurts, insults, threatens, and "has_frequency" [LOINC] LA10082-8 sometimes
screams (hits)
[LOINC] 95619-3 hurts, insults, threatens, and "has_frequency" [LOINC] LA6270-8 never
screams (hits)