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 information in and produced by the ACORN survey. 1. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the 7. Conclusion causes of the causes. Public Health Rep. 2014;129 Suppl 2:19–31. In conclusion, social determinants of health are not well represented by the Solor 2. 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In: Munn K, Smith B, editors. Applied Ontology: An Introduction [Internet]. Walter de Gruyter; 2008. p. 83–109. Available from: https://philpapers.org/rec/SMINDF 30. Hicks A, Hanna J, Welch D, Brochhausen M, Hogan WR. The ontology of medically related social entities: recent developments. J Biomed Semantics. 2016;7:47. 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)