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Journal of the American Medical Informatics Association: JAMIA logoLink to Journal of the American Medical Informatics Association: JAMIA
. 2023 May 23;30(11):1811–1817. doi: 10.1093/jamia/ocad092

Comparison of SIREN social needs screening tools and Simplified Omaha System Terms: informing an informatics approach to social determinants of health assessments

Jeana M Holt 1,✉, Robin R Austin 2, Rivka Atadja 3, Marsha Cole 4, Theresa Noonan 5, Karen A Monsen 6
PMCID: PMC10586032  PMID: 37221701

Abstract

Objective

Numerous studies indicate that the social determinants of health (SDOH), conditions in which people work, play, and learn, account for 30%–55% of health outcomes. Many healthcare and social service organizations seek ways to collect, integrate, and address the SDOH. Informatics solutions such as standardized nursing terminologies may facilitate such goals. In this study, we compared one standardized nursing terminology, the Omaha System, in its consumer-facing form, Simplified Omaha System Terms (SOST), to social needs screening tools identified by the Social Interventions Research and Evaluation Network (SIREN).

Materials and Methods

Using standard mapping techniques, we mapped 286 items from 15 SDOH screening tools to 335 SOST challenges. The SOST assessment includes 42 concepts across 4 domains. We analyzed the mapping using descriptive statistics and data visualization techniques.

Results

Of the 286 social needs screening tools items, 282 (98.7%) mapped 429 times to 102 (30.7%) of the 335 SOST challenges from 26 concepts in all domains, most frequently from Income, Home, and Abuse. No single SIREN tool assessed all SDOH items. The 4 items not mapped were related to financial abuse and perceived quality of life.

Discussion

SOST taxonomically and comprehensively collects SDOH data compared to SIREN tools. This demonstrates the importance of implementing standardized terminologies to reduce ambiguity and ensure the shared meaning of data.

Conclusions

SOST could be used in clinical informatics solutions for interoperability and health information exchange, including SDOH. Further research is needed to examine consumer perspectives regarding SOST assessment compared to other social needs screening tools.

Keywords: Omaha System, standardized terminologies, social determinants of health, nursing informatics, holistic health

INTRODUCTION

Social determinants of health (SDOH) are conditions in which people work, play, and learn.1 SDOH are recognized as significantly impacting health inequities, accounting for 30–55% of health and healthcare outcomes.2–5 For example, unemployment has been linked with a higher risk of death for people with cardiovascular disease, higher rates of depression, and lower levels of physical activity.6 Recent national initiatives call to harness data and technology to improve healthcare quality and patient outcomes and provide a 360-degree whole-person view of the patient, including SDOH.7 SDOH instruments have proliferated since 2014 when the Institute of Medicine (IOM), now the National Academies of Medicine (NAM), developed SDOH recommendations for inclusion in the electronic health record (EHR). A critical barrier is existing tools are rarely harmonized across settings or developed using standardized language, leading to gaps in the identification of needs and referral to appropriate resources.8,9

Recent attention has been given to SDOH instrument development and testing. The University of California—San Francisco established the Social Interventions Research and Evaluation Network (SIREN) to gather and disseminate SDOH research and inform practice.10 SIREN is nationally recognized as the curator of social risk screening tools in health care settings.10 SIREN identified the challenge of numerous independently developed social risk screening tools, making it difficult for clinicians and researchers to determine which tool is most appropriate for which populations or settings and whether these tools can detect changes in social risks over time. SIREN has inventoried 15 social risk screening tools; however, the included tools are not based on any standardized nursing terminology or other clinical informatics standards. Standardized nursing terminologies, particularly the Omaha System, are known to be robust, rigorous SDOH assessments.11–15

Standardized nursing terminologies can provide a structure to collect SDOH, including a comprehensive, holistic assessment.11–13 The Omaha System is a multidisciplinary standardized terminology developed to systematically and comprehensively capture the patient/client–clinician exchange.16,17 Using the Omaha System, supporting whole-person health and capturing data across 4 health domains (Environmental, Psychosocial, Physiological, and Health-related Behaviors), including SDOH, becomes possible.11,18

Although terminology mapping studies have been published for over 3 decades,19–21 studying semantic equivalence between concepts remains important. Researchers and clinicians continue to develop tools that lack representation of standardized assessment items, which impedes data re-use, interoperability, and identification of gaps within and across terminologies, tools, and EHRs.21 Therefore, this article aims to evaluate the semantic equivalence of the 15 SIREN social needs tools and the Simplified Omaha System Terms (SOST) to understand the scope and gaps in the 15 SIREN social needs tools and the Omaha System. Semantic equivalence is the lexical, conceptual, and/or synonymity of meaning between 2 concepts.21 It is the first step in standardizing commonly used social needs tools to promote communication among researchers and clinicians and facilitates comparison across settings and studies.21 Because the SIREN social needs tools were consumer-facing, we used the Omaha System as translated into SOST.22 SOST is a rigorous taxonomic health and healthcare ontology condensed to consumer-facing language (Figure 1).22

Figure 1.

Figure 1.

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Simplified Omaha System terms domains and challenges.

The use of SOST in clinical settings aligns with the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity23 report that calls for a comprehensive whole-person health assessment, including identifying the influence of social and structural determinants. Findings also indicate that SOST, a structured consumer-facing language, captures comprehensive strengths-based SDOH from the client’s perspective. SOST has been used in a web-based application, MyStrengths+MyHealth (MSMH), and allows individuals to share whole-person health data and preferences regarding care.24 SOST maintains the rigor and structure of the Omaha System, embedded within SNOMED CT and LOINC, to allow for sharable and comparable data across settings from the client’s perspective.25,26

MATERIALS AND METHODS

Instrument

This mapping study was exempt from institutional review. We used the Omaha System as translated into SOST. The Omaha System consists of 3 interrelated standardized instruments: Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes. The Problem Classification Scheme assessment includes 42 health concepts that describe all of health and healthcare within 4 domains (Environmental, Psychosocial, Physiological, and Health-related Behaviors). Each problem has a unique set of signs and symptoms (range 2–18) for 42 problems.25 These 335 signs/symptoms (called challenges in SOST) are binary signs/symptoms for each concept (yes if selected, no if not selected).11,22,25 The SOST has been community validated and is written at the fifth-grade reading level.22

Mapping procedure

A research team of Omaha System experts (J.M.H., R.R.A., K.A.M.) and nurse informaticist graduate students (R.A., R.C., T.N.) mapped the content by comparing the term definitions of the SIREN social needs tools items to SOST. In 3 phases, we mapped the 285 SIREN items to the 335 SOST challenges. The research team consisted of graduate students and faculty (J.M.H., R.R.A., R.A., M.C., T.N., K.A.M.) all of whom were familiar with or had expertise in the Omaha System and SOST, as well as SDOH instruments. This methodological approach has been used for encoding and comparing unstructured, nontaxonomic theories and tools to a standardized language.25 Mapping unstructured, nontaxonomic tools into a standardized language facilitates the accurate documentation of clinical knowledge representation.27,28 See Supplementary Appendix SA for a description of the SIREN social needs tools.

In phase 1, the research team (J.M.H., R.R.A., R.A., M.C., T.N.) separately mapped 3 to 6 SIREN social needs tools to SOST based on term definitions. Following the initial mapping, each SIREN social needs tool was double coded by either J.M.H. or R.R.A. J.M.H. is an Omaha System expert with a focus on practice-based research. R.R.A. is an Omaha System expert whose research uses SOST to understand whole-person health from the consumer perspective.

Following methods from previous mapping studies (e.g., mapping an evidence-based low-back pain guideline to the Omaha System; mapping the Wanda Horta theory to the Omaha System), terms were classified as full, partial, no match, or multiple matches.29–31 Terms were deemed a full match when SOST and the social needs screening tool item content had the same meaning; a partial match when SOST and the social needs screening tool term had a similar but not fully the same meaning and a no match when there was no content in common between SOST and the social needs screening tool item.31 Terms were deemed to have multiple full and/or partial matches when the SIREN item mapped to multiple SOST challenges. We include mapping examples in Table 1.

Table 1.

Exemplars of mapping SIREN social needs tool items to SOST challenges

Tool Item SOST challenge
Type of match

  • Full

  • Lexical, conceptual, and/or synonymity equivalence of meaning between the SIREN item and SOST challenge

Accountable Health Communities Mold Mold (cleaning)

  • Partial

  • SIREN item is either broader and has a less specific meaning to the SOST challenge, or the SIREN item is narrower and has more specific meaning than the SOST challenge

American Academy of Family Physicians Provider (AAFP)—Short Tool Do you put off or neglect going to the doctor because of distance or transportation? Transportation barrier (connecting)

  • No

  • A concept with some degree of equivalence was not found between the SIREN item and SOST challenge

Medicare Total Health Assessment In general, would you say your quality of life is? None

  • Multiple

  • Lexical, conceptual, and/or synonymity equivalence of meaning between the SIREN item and multiple SOST challenges

Kaiser Tool More help with activities of daily living, childcare/other child-related, issues/loan repayment All challenges in personal care concept, all challenges in caretaking concept, difficulty buying necessities in income concept
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Note: Type of match definitions adapted from Ref. [21].

In phase 2, K.A.M., an Omaha System, and SDOH national and international expert reviewed all the phase 1 mapping. After KAM’s review of the mapping, the research team (J.M.H., R.R.A., K.A.M.) met to resolve differences in mapping over 6 meetings using consensus. The faculty researchers reached a 100% consensus on the mapping results, including categorizing if there were full, partial, multiple, or no matches between the SIREN social needs screening tool item and SOST. Finally, in phase 3, the authors presented the final mapping at 2 virtual international meetings of Omaha System users for further validation. The presentations presented the problem of using unharmonized tools in EHRs, purpose, methods, results, and discussion. The international participants affirmed the research team’s findings and did not suggest any revisions.

Descriptive statistics were used to analyze the mapping by domain, concept, and item. Microsoft Excel was used to create Heat Maps to evaluate associations between SOST and SIREN items. The rows and columns were sorted by frequency, and conditional formatting was applied to detect patterns in the data.32

RESULTS

Of the 286 SIREN social needs screening tool items, 282 (98.7%) mapped 429 times to 102 (30.7%) of the 335 SOST challenges. Of the 429 full or partial matches, 315 (80.7%) were full matches, and 83 (19.3%) were partial. On average, each SIREN social needs screening tools item was mapped 1.5 times to SOST challenge(s). For example, The Access Health Spartanburg social needs tool item, Have you applied for or do you receive food stamps (SNAP) benefits? was mapped to the SOST challenges of Hard to buy the things I need; Not enough income; and hard to get food or cook food to eat.

The 102 SOST challenges that did map were from 26 concepts in all domains, most frequently My Living [4/4 concepts (100%), 206/429 challenges (48.0%)], followed by My Mind & My Networks [8/12 concepts (75%), 142/429 challenges (33.1%)], My Self-care [6/8 concepts (88%), 61/429 challenges (14.2%)]; and My Body [8/18 concepts (39%), 20/429 challenges (4.7%)]. The number of items by tool ranged from 11 (NC Medicaid; mapped to 13 challenges) to 29 (Kaiser; mapped to 76 challenges). The remaining (233, 69.6%) SOST challenges did not map with any SIREN tool items. For example, hard to start or keep relationships (My Mind & Networks; relationships); cannot get birth control (My Self-care; family planning); and hard to breathe (My Body; breathing).

The most frequently mapped SIREN social needs screening tool items to SOST challenges were from 7 SOST concepts: Income, Home, Abuse, Nutrition, Connecting, Socialization, and Substance use. The most frequent challenges were for 7 SOST concepts, Income mapped 101 times [eg, not enough income (n = 47, 15.4%), hard to buy the things I need (n = 36, 11.8%), too many healthcare bills (n = 11, 3.6%)]; Home mapped 72 times [eg, no place to live or sleep (n = 31, 10.2%), no heat or cooling (n = 15, 4.9%)]; Abuse mapped 50 times [eg, verbal abuse (n = 17, 5.6%), violent home (n = 13, 4.3%)]; Nutrition mapped 22 times [eg, hard to get food or cook food to eat (n = 18, 6.9%)]; Connecting mapped 42 times [transportation barriers (n = 16, 5.2%)]; Socializing [limited social time (n = 15, 4.9%)]; and Substance use [use alcohol too much (n = 12, 3.9%)]. Four of the 286 items (1.3%) were not mapped to SOST challenges; 3 were perceived quality-of-life items,33 and 1 was financial abuse.34 See Supplementary Appendix SB for the complete mapping results (Figure 2).

Figure 2.

Figure 2.

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SIREN social needs tool items mapped to SOST challenges. Note: Figure 2 displays the full and partial matches of SIREN social needs screening tools to simplified Omaha System terms (SOST). The number in each cell represents the frequency of items within each tool that mapped to SOST, for example, the Arlington tool had 5 matches to the income SOST concept. AAFP: American Academy of Family Physicians; BMC Thrive: Boston Medical Center Thrive; Kaiser YCLS: Kaiser Your Current Life Situation; Medicare THA: Medicare Total Health Assessment; MLP: Medical-Legal partnerships; NAM Domains: National Academies of Medicine Domains; NC Medicaid: North Carolina Medicaid; PRAPARE: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.

DISCUSSION

This terminology study mapped SIREN social needs screening tool items to SOST challenges. Over 98% of the SIREN social needs screening tool items mapped to SOST challenges. This mapping analysis revealed the comprehensiveness of the SOST assessment to capture social and behavioral determinants of health data and the value of consumer-facing standardized terminology as a structured approach to examining diverse instruments.

The comprehensiveness of SOST provides a whole-person perspective that better informs clinical care compared to any of the SIREN social needs screening tools. While most SIREN needs screening tool items mapped to SOST challenges, nearly two-thirds of the SOST did not map to any SIREN social needs screening tools. Most SOST challenges absent in the SIREN social needs screening tools were from the My Body and Self-care domains. Although researchers and clinicians developed the SIREN social needs screening tools to survey social needs, these tools lack the ability for consumers to share holistic data with their clinicians. For example, thinking, the ability to process information,19 is missing from the SIREN social needs screening tools. With an aging population, understanding if a person is experiencing early signs of Alzheimer’s disease is vital to providing early interventions and resources. The thinking concept in SOST has several signs and symptoms that, when endorsed by the consumer, may signal a decline in cognition (eg, hard to remember recent things; hard to recall people, places, time; hard to figure out the right thing to do) and warrant further investigation by clinicians.

SOST comprehensively captures all of health and health care, including SDOH. Given that less complete screening tools may leave the clinician with an incomplete understanding of the patient’s health goals and preferences. In turn, clinicians may prioritize social risks and interventions that do not reflect the client’s circumstances or priorities.35 The comprehensiveness of SOST creates a foundation for person-centered care, a person and healthcare team partnership that actively encourages and empowers individuals to share their strengths and identify solutions to their challenges.24 An efficient, effective, and scalable way to gather comprehensive patient-generated data is through patients completing a digital tool, for example, MSMH, before the clinic visit. Findings from a randomized control trial indicated that patients who completed a digital health tool that gathered patients’ values, goals, and barriers to care before the visit had higher provider-patient communication scores without lengthening the visit.36,37 Providers can use the pre-visit patient-generated data as a foundation for effective patient-provider communication.

The advantages of using existing standardized terminologies for SDOH assessment are many. Patients benefit from clinicians’ and organizations’ shared understanding of their strengths, challenges, and needs, facilitating communication and continuity of care across programs and settings.38 Organizations can aggregate, analyze, and use standardized SDOH to measure care quality and align resources to improve population health.12 Payers benefit from sharing and comparing interoperable data across systems to determine the effectiveness of care.39,40

Informatics solutions that use standardized terminologies can aid in representing SDOH within technology infrastructure.15 For example, an electronic platform such as MSMH allows individuals to include their voices as data within clinical encounters and data sets. Aggregating SDOH data provides individual- and community-level built and social asset profiles that can serve as a foundation for strengths- and resilience-based health promotion activities41 and resource allocation. Therefore, SOST has the potential to uncover the root causes of health disparities from the social and built environment and yield community asset data for health promotion interventions. Moreover, the digital platform, MSMH, can yield data for clinical and consumer use. In the clinical setting, clinicians can view MSMH results to guide person-centered plans of care based on patient-reported strengths, challenges, and needs. Consumers can review the summary of their MSMH responses to glean how their strengths, challenges, and needs change longitudinally.

To address the items not mapped to SOST, we recommend the following. First, financial abuse occurs when an abuser controls finances to maintain power in a relationship.42 This challenge could be added to the Abuse (Abuse) concept. Second, the summary score for Quality of Life found in one SIREN instrument43 presents an area for future research to map, compile, and examine a summary score of specific challenges in the My Mind & My Networks, My Body, and My Self-care domains that indicate overall health/well-being or quality of life.

This study has health policy, research, and practice implications. For example, the Centers for Medicare and Medicaid Services (CMS) began voluntary reporting of the Social Drivers of Health measure and Screen Positive Rate for Social Drivers of Health measure in the calendar year (CY) 2023. Mandatory reporting will begin in CY 2024, with payment determination in the fiscal year 2026.44 Using SOST in the clinical setting can satisfy the quality reporting requirements while reducing clinician documentation burden and improving data quality and value. Standardized data may also inform the development of future metrics for value-based risk prediction models or social needs phenotypes for various populations.45 There must be multisector alignment from vendors, health systems, and governmental bodies to advocate using standardized nursing terminologies to measure SDOH at the national policy level.

SOST mapping enabled us to see patterns across tools. The influence of the seminal IOM Social and Behavioral Determinants of Health report46 is evident across the tools. For example, the foundational concepts proposed by the IOM related to Income and Home are assessed by all tools, and Abuse is assessed by most tools, with variable items across the remaining concepts. Furthermore, the Medicare Total Health Assessment27 and Kaiser Your Current Life Situation28 tools include many concepts not present in other tools. There is potential to use the SOST/Omaha System as a rigorous taxonomy to harmonize and aggregate the information from various tools comprehensibly.

There are several limitations to this study. The authors mapped 15 SIREN social needs tools items to SOST, and examining additional social needs tools may yield different results. Furthermore, language is complex; there are many partial matches, and many social needs tool items are mapped to more than one SOST Challenge. This demonstrates the importance of implementing standardized terminologies to reduce ambiguity and ensure the shared meaning of the data generated in health care assessments. Toward that end, the SOST/Omaha System has been submitted to SIREN for inclusion in the curated list of SDOH instruments.

CONCLUSION

This study mapped the SOST assessment to 15 SIREN social needs tools. Compared to these tools, SOST more thoroughly and succinctly assesses social and behavioral determinants of health. These are known factors for understanding a comprehensive and holistic view of health and healthcare outcomes.41,47,48 Because SOST is a consumer-facing translation of a rigorous standardized nursing terminology, there is potential to use SOST in clinical informatics solutions for interoperability and exchange of critical whole-person health information, including social and behavioral determinants of health.12

Supplementary Material

ocad092_Supplementary_Data
Click here for additional data file. (357.3KB, zip)

Contributor Information

Jeana M Holt, College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA.

Robin R Austin, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.

Rivka Atadja, School of Nursing, St. Catherine University, St. Paul, Minnesota, USA.

Marsha Cole, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.

Theresa Noonan, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.

Karen A Monsen, School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

AUTHOR CONTRIBUTIONS

All authors contributed significantly to the manuscript. JMH, RRA, KAM were responsible for the design and execution of the study. All authors contributed to the analysis, drafting the manuscript, and final approval of the manuscript.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Journal of the American Medical Informatics Association online.

CONFLICT OF INTEREST STATEMENT

The authors have no competing interests to declare.

DATA AVAILABILITY

The data underlying this article are available in the article and in its online supplementary material.

REFERENCES

  • 1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health—Final report of the commission on social determinants of health. World Health Organization; 2008. https://www.who.int/publications/i/item/WHO-IER-CSDH-08.1. Accessed September 19, 2022.
  • 2.World Health Organization. Social Determinants of Health. 2021. https://www.who.int/health-topics/social-determinants-of-health. Accessed November 9, 2021
  • 3. Hood CM, Gennuso KP, Swain GR, Catlin BB.. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med 2016; 50 (2): 129–35. [DOI] [PubMed] [Google Scholar]
  • 4. Remington PL, Catlin BB, Gennuso KP.. The county health rankings: rationale and methods. Popul Health Metr 2015; 13: 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. Irwin A, Scali E.. Action on the social determinants of health: a historical perspective. Glob Public Health 2007; 2 (3): 235–56. [DOI] [PubMed] [Google Scholar]
  • 6. Tapia Granados JA, Christine PJ, Ionides EL, et al. Cardiovascular risk factors, depression, and alcohol consumption during joblessness and during recessions among young adults in CARDIA. Am J Epidemiol 2018; 187 (11): 2339–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Boston D, Cohen D, Stone J., et al. Integrating patient-generated health data into electronic health records in ambulatory care settings: A practical guide prepared under contract 75Q80120D00019 / 75Q80120F32001. Rockville, MD: Agency for Healthcare Research and Quality; 2021 Dec. Report No.: AHRQ Publication No. 22-0013. https://digital.ahrq.gov/sites/default/files/docs/citation/pghd-practical-guide.pdf. Accessed January 31, 2022.
  • 8. Stemerman R, Arguello J, Brice J, Krishnamurthy A, Houston M, Kitzmiller R.. Identification of social determinants of health using multi-label classification of electronic health record clinical notes. JAMIA Open 2021; 4 (3): ooaa069. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Freij M, Dullabh P, Lewis S, Smith SR, Hovey L, Dhopeshwarkar R.. Incorporating social determinants of health in electronic health records: qualitative study of current practices among top vendors. JMIR Med Inform 2019; 7 (2): e13849. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Gottlieb L, Fichtenberg C, Adler N. Introducing the social interventions research and evaluation network. San Francisco, CA: SIREN. 2017. https://sirenetwork.ucsf.edu/sites/sirenetwork.ucsf.edu/files/SIREN_Issue_Brief_Updt.pdf. Accessed December 11, 2020.
  • 11. Monsen KA, Austin RR, Jones RC, Brink D, Mathiason MA, Eder M.. Incorporating a whole-person perspective in consumer-generated data: social determinants, resilience, and hidden patterns. Comput Inform Nurs 2021; 39 (8): 402–10. [DOI] [PubMed] [Google Scholar]
  • 12. Monsen KA, Brandt JK, Brueshoff BL, et al. Social determinants and health disparities associated with outcomes of women of childbearing age who receive public health nurse home visiting services. J Obstet Gynecol Neonatal Nurs 2017; 46 (2): 292–303. [DOI] [PubMed] [Google Scholar]
  • 13. Monsen KA, Kapinos N, Rudenick JM, Warmbold K, McMahon SK, Schorr EN.. Social determinants documentation in electronic health records with and without standardized terminologies. West J Nurs Res 2016; 38 (10): 1399–400. [DOI] [PubMed] [Google Scholar]
  • 14. Schorr EN, Kapinos N, Rudenick JM, Warmbold K, McMahon S, Monsen KA.. Use of standardized terminologies to document social and behavior determinants of health in electronic health records: a comparative analysis. Nurs Outlook 2017; 65 (1): 135. [Google Scholar]
  • 15. Monsen KA, Rudenick JM, Kapinos N, Warmbold K, McMahon SK, Schorr EN.. Documentation of social determinants in electronic health records with and without standardized terminologies: a comparative study. Proc Singapore Healthcare 2019; 28 (1): 39–47. [Google Scholar]
  • 16. Kerr MJ, Gargantua-Aguila SDR, Glavin K, et al. Feasibility of describing community strengths relative to Omaha System concepts. Public Health Nurs 2019; 36 (2): 245–53. [DOI] [PubMed] [Google Scholar]
  • 17. Ardic A, Turan E.. Nursing care management based on the Omaha System for inpatients diagnosed with COVID-19: an electronic health record study. J Adv Nurs 2021; 77 (6): 2709–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Austin RR, Mathiason MA, Lu S-C, et al. Toward clinical adoption of standardized mHealth solutions: the feasibility of using MyStrengths+MyHealth consumer-generated health data for knowledge discovery. Comput Inform Nurs 2022; 40 (2): 71–9. [DOI] [PubMed] [Google Scholar]
  • 19. Hyun S, Park HA.. Cross-mapping the ICNP with NANDA, HHCC, Omaha System and NIC for unified nursing language system development. International Classification for Nursing Practice. International Council of Nurses. North American Nursing Diagnosis Association. Home Health Care Classification. Nursing Interventions Classification. Int Nurs Rev 2002; 49 (2): 99–110. [DOI] [PubMed] [Google Scholar]
  • 20. Zielstorff RD, Tronni C, Basque J, Griffin LR, Welebob EM.. Mapping nursing diagnosis nomenclatures for coordinated care. Image J Nurs Sch 1998; 30 (4): 369–73. [DOI] [PubMed] [Google Scholar]
  • 21. Torres FBG, Gomes DC, Ronnau L, Moro CMC, Cubas MR.. ISO/TR 12300:2016 for clinical cross-terminology mapping: contribution to nursing. Rev Esc Enferm USP 2020; 54: e303569. [DOI] [PubMed] [Google Scholar]
  • 22. Austin RR, Martin CL, Jones CR, et al. Translation and validation of the Omaha System into English language simplified Omaha System terms. Kontakt 2022; 24 (1): 48–54. [Google Scholar]
  • 23. National Academies of Sciences, Engineering, and Medicine. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press; 2021. [PubMed] [Google Scholar]
  • 24. Austin R, Monsen K, Alexander S.. Capturing whole-person health data using mobile applications. Clin Nurse Spec 2021; 35 (1): 14–7. [DOI] [PubMed] [Google Scholar]
  • 25. Martin KS. The Omaha System: A Key to Practice, Documentation, and Information Management, Reprinted 2nd ed. Omaha, NE: Health Connections Press; 2005. [Google Scholar]
  • 26. Hripcsak G, Forrest CB, Brennan PF, Stead WW.. Informatics to support the IOM social and behavioral domains and measures. J Am Med Inform Assoc 2015; 22 (4): 921–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Monsen K, Melton-Meaux G, Timm J, et al. An empiric analysis of Omaha System targets. Appl Clin Inform 2011; 2 (3): 317–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28. Monsen KA, Finn RS, Fleming TE, Garner EJ, LaValla AJ, Riemer JG.. Rigor in electronic health record knowledge representation: lessons learned from a SNOMED CT clinical content encoding exercise. Inform Health Soc Care 2016; 41 (2): 97–111. [DOI] [PubMed] [Google Scholar]
  • 29. Austin RR, Monsen KA, Schulz C.. An informatics approach to interprofessional management of low back pain: a feasibility study using the Omaha System. JHI 2017; 24 (3): 268. [DOI] [PubMed] [Google Scholar]
  • 30. DeVon HA, Block ME, Moyle-Wright P, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh 2007; 39 (2): 155–64. [DOI] [PubMed] [Google Scholar]
  • 31. Pruinelli L, de Lucena A, Monsen KA.. Empirical evaluation of international health system data interoperability: mapping the Wanda Horta theory to the Omaha System ontology. Res Theory Nurs Pract 2016; 30 (3): 229–41. [DOI] [PubMed] [Google Scholar]
  • 32. Monsen KA, Peterson JJ, Mathiason MA, et al. Data visualization techniques to showcase nursing care quality. Comput Inform Nurs 2015; 33 (10): 417–26. [DOI] [PubMed] [Google Scholar]
  • 33.Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool. 2018. https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf. Accessed October 8, 2021.
  • 34. Sundar KR. Universal screening for social needs in a primary care clinic: a quality improvement approach using the your current life situation survey. Perm J 2018; 22: 18–089. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Col NF, Solomon AJ, Springmann V, et al. Whose preferences matter? A patient-centered approach for eliciting treatment goals. Med Decis Making 2018; 38 (1): 44–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Holt JM, Cusatis R, Winn A, et al. Impact of pre-visit contextual data collection on patient-physician communication and patient activation: a randomized trial. J Gen Intern Med 2021; 36 (11): 3321–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37. Holt JM, Spanbauer C, Cusatis R, et al. Real-world implementation evaluation of an electronic health record-integrated consumer informatics tool that collects patient-generated contextual data. Int J Med Inform 2022; 165: 104810. [DOI] [PubMed] [Google Scholar]
  • 38. Lundberg C, Brokel JM, Bulechek GM, Butcher HK, Giarrizzo-Wilson S.. Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online J Nursing Informatics 2008; 12: 1–19. [Google Scholar]
  • 39. Murray GF, Rodriguez HP, Lewis VA.. Upstream with a small paddle: how ACOs are working against the current to meet patients’ social needs. Health Aff 2020; 39 (2): 199–206. [DOI] [PubMed] [Google Scholar]
  • 40. Mechanic R, Fitch A. Working with ACOs to address social determinants of health. Health Affairs Forefront. 2023. Accessed January 21, 2023.
  • 41. Gottlieb LN, Gottlieb B.. Strengths-based nursing: a process for implementing a philosophy into practice. J Fam Nurs 2017; 23 (3): 319–40. [DOI] [PubMed] [Google Scholar]
  • 42.Financial Abuse. https://www.womenshealth.gov/relationships-and-safety/other-types/financial-abuse. Accessed January 8, 2023.
  • 43.Kaiser Permanente. Medicare Total Health Assessment. 2013. https://sirenetwork.ucsf.edu/sites/default/files/Medicare%20THA%20questionnaire%20v2%20%28rvd%2012-5-14%29%20with%20Sources.pdf. Accessed October 8, 2021.
  • 44.Centers for Medicare & Medicaid Services. FY 2023 hospital inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS) final rule—CMS-1771-F. 2022. https://www.cms.gov/newsroom/fact-sheets/fy-2023-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective. Accessed January 21, 2023.
  • 45. Gao G, Kerr MJ, Lindquist RA, et al. A strengths-based data capture model: mining data-driven and person-centered health assets. JAMIA Open 2018; 1 (1): 11–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46. National Institute of Medicine. Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2. Washington, DC: The National Academies Press; 2014. [PubMed] [Google Scholar]
  • 47. Gottlieb LN. Strengths-based nursing. Am J Nurs 2014; 114 (8): 24–32; quiz 33, 46. [DOI] [PubMed] [Google Scholar]
  • 48. Rashid T, Anjum A, Chu R, Stevanovski S, Zanjani A, Lennox C.. Strength based resilience: integrating risk and resources towards holistic well-being. In: Fava GA, Ruini C, editors. Increasing Psychological Well-Being in Clinical and Educational Settings: Interventions and Cultural Contexts. Dordrecht: Springer Netherlands; 2014: 153–176. [Google Scholar]

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