The Role of Health Informatics in Facilitating Communication Strategies for Community Health Workers in Clinical Settings: A Scoping Review

Abstract

Background:

Community Health Workers (CHWs) have been identified as effective members of healthcare teams in improving health outcomes and reducing health disparities, especially among racial and ethnic minorities. There is a growing interest in integrating CHWs into clinical settings using health informatics based strategies to help provide coordinated patient care and foster health promoting behaviors.

Objective:

In this scoping review, we outline health informatics based strategies for CHW-provider communication that aim to improve integration of CHWs into clinical settings.

Design:

A scoping review was conducted.

Eligibility Criteria:

US-based sources between 2013–2018 were eligible.

Study Selection:

Literature was identified through PubMed and Google queries and hand searching key reference lists. Articles were screened by title, abstract, then full text.

Main Outcome Measures:

Health informatics based strategies for CHW-provider communication and their impacts on patient care were documented and analyzed.

Results:

31 articles discussed health informatics based strategies for CHW-provider communication and/or integration of CHWs into clinical settings. These strategies include direct CHW documentation of patient encounters in electronic health records (EHRs), and other web-based applications. The technologies were used to document patient encounters and patient barriers to healthcare providers, but were additionally used for secure messaging and referral systems. These strategies were found to meet the needs of providers and CHWs while facilitating CHW-provider communication, CHW integration, and coordinated care.

Conclusions:

Health informatics based strategies for CHW-provider communication are important for facilitating CHW integration and potentially improving patient outcomes and improving disparities among minority populations. This integration can support the development of future disease prevention programs and healthcare policies, in which CHWs are an established part of the public health workforce. However, further investigation must be done on overcoming implementation challenges (e.g., lack of time or funding), especially in smaller resource-challenged community-based clinics that serve minority patients.

Introduction

Racial and ethnic health disparities have been shown to consistently exist across various diseases in the United States,^1,2 contributing to earlier disease onset, greater severity of disease, and increased mortality rates.³ These disparities can stem from barriers posed by the organization of health systems, such as complex reimbursement procedures for health education and counseling efforts, limited access to culturally and linguistically appropriate services, and lack of referral sources for social services.³ Facilitating public health models that enhance linkages between community and clinical settings is one approach to reducing these barriers. Such approaches allow for the integration of culturally and linguistically tailored patient education programs into healthcare settings through multi-disciplinary, team-based care that leverages community strengths and resources.^4,5 Community-clinical linkage models provide opportunities to enhance patients’ awareness and self-efficacy related to disease prevention and management, and have the potential to improve quality of care and patient outcomes, resulting in decreased health disparities among minority populations, especially in the context of chronic disease.^4–7 However, the majority of prior research on reduction of health disparities has focused on targeting patients, rather than healthcare institutions and communities. Thus, the most effective way to facilitate community-clinical linkage programs across various healthcare contexts remains poorly understood and organizational structures for the development of such programs remain limited.⁷

There has been growing interest in the integration of community health workers (CHWs) into healthcare settings as a community-clinical linkage model with special promise to reduce health disparities through coordinated care and disease prevention^8,9. CHWs are public health professionals who are members of the community and share the same culture, language, socioeconomic status, and/or racial and ethnic backgrounds.¹⁰ CHWs provide culturally and linguistically tailored health education/outreach; offer social, emotional, and mental support; connect patients to community resources; and offer medical screening services with the intent of helping individual community members manage their health.^11–13 Due to their unique role, CHWs have been shown to have positive impacts on health outcomes, lifestyle modifications, and disease prevention,¹⁴ and the Community Preventive Services Taskforce has recommended that CHWs be integrated into services for cardiovascular disease prevention and diabetes prevention, and management.⁸ Moreover, CHW programs have been shown to be cost effective by reducing unnecessary healthcare utilization and increasing net savings for institutions.^15,16

There has been a recent call for the integration of CHWs into primary care teams to improve health disparities in minority populations, which has been supported by specific policy efforts. The Patient Protection and Affordable Care Act, for example, indicates that programs utilizing CHWs will be supported through grant funding and reimbursement opportunities.¹² The best practices for such integration, which involves the maximization of CHWs’ roles in healthcare teams while maintaining their unique function, have been identified as: well-defined CHW roles, training team members on the value of CHWs, organized workflows, and improved communication between CHWs and clinical teams.^6,7,9,11 Notably, improved communication allows for a stronger mutual understanding between CHWs and other healthcare providers, which maximizes CHWs’ impacts within care teams, including the public health workforce. Through regular interactions and better communication with CHWs, providers can have access to a broader scope of information on patients, allowing for a more patient-centered approach to coordination of care, and improved patient disease management and prevention.^11,13,17

While the benefits of CHW integration into care teams through improved CHW-team communication methods have been well documented, there has been limited data on specific mechanisms and tools to most effectively accomplish such integration.^4,18–20 Specifically, there has been recent interest in exploring health informatics to enhance integration and communication through CHW access to technologies that allow for inclusion of CHW collected data into workflows and care plans.^12,19–21 These technologies include electronic health records (EHRs), cloud-based services, medical devices, mobile apps, and other non-EHR web-based technologies that transmit information without acting as official patient health records.²² Health informatics can help organize and integrate patient social determinants of health (SDOH) data (e.g., income level and employment status) into clinical workflows to support actions such as referrals to community resources or appropriate patient education, potentially making them a useful tool for CHW documentation and communication²³. Under this framework, health informatics strategies can support integration and optimization of CHWs’ public health efforts by acting as an organizational platform where CHWs can document their work, which can then be interpreted by healthcare teams to better address SDOH needs and reinforce health promoting behaviors.²³

Accordingly, we conducted a scoping review on health informatics based strategies for CHW-provider communication that aim to improve integration of CHWs into clinical settings. We also discuss the advantages, limitations, and future directions to maximize these strategies in the context of clinical care.

Methods

A scoping review was conducted in order to identify and summarize strategies for communication between CHWs and medical providers in the context of improving CHW integration into clinical settings. A scoping review aims to examine literature using a broader framework with the intent of providing an overview of existing evidence and/or identifying gaps in literature rather than answering a specific question.²⁴ We utilized common procedures outlined by Levac et al’s recommendations on Arskey and O’Malley’s methodological framework for conducting scoping reviews (detailed in Figure 1).²⁵

Figure 1:

Overview of Methodology

Identifying the research question

The initial research question to guide the scoping review was “How can community health workers be integrated into the clinical setting?” Due to the wide breadth of strategies for integration, this question was narrowed down to focus on health informatics based strategies for communication between CHWs and clinic staff to allow for a more depth in exploration. The revised and final questions were “What are the various types of health informatics strategies that are currently being utilized to improve communication between CHWs and providers?” and “What is the impact of CHW use of health informatics on patient care?”

Identifying relevant studies

The searches were conducted in July 2018. Relevant literature was identified through PubMed queries and hand searching of reference lists for peer reviewed articles. Google searches were also conducted to identify grey literature, which includes materials produced by institutions outside of commercial publishing, such as government agency reports, research institute working papers, or organization technical guides.²⁶ A broad set of search terms were utilized to encompass healthcare persons similar to CHWs (detailed in Table 1).

Table 1.

Key Search Terms

Concept or intervention	Context
Community health worker(s)	Integration
CHW(s)	Strategy
Patient navigator(s)/navigation	Communication
Promotore(s)

Study selection

Identified literature was screened first by title, then abstract, then full text. Inclusion criteria for the study were: 1) the primary focus was CHW programs; 2) the CHW programs were implemented in clinical settings; 3) the CHWs did not have previous training in other healthcare careers (e.g., nursing, social work, etc.); and 4) specific health informatics based methods for how CHWs in the program communicated and/or interacted with medical providers were discussed. Manuscripts focusing on CHW programs based in countries outside the United States were excluded. Manuscripts published more than 5 years ago (before 2013) were excluded, unless they discussed strategies for CHW-provider communication not found in more recent literature. If multiple papers were discussing the same method for CHW-provider communication in the context of the same CHW program, only the most recent paper was included. One reviewer (AK) screened all the titles and abstracts; the methodology for study selection was reviewed and overseen by SL.

The initial search generated 7,315 records, of which 7,103 records were excluded due to not being within the past 5 years, not being based in the United States, and/or the titles not being relevant to the research question (Figure 2). The abstracts of the remaining 212 records were screened, of which 137 were excluded. The full text articles of the remaining 75 records were screened; 44 were excluded, resulting in 31 articles included in the scoping review.

Figure 2:

Study Selection Process

Charting the data

Information from the selected literature was documented in Microsoft Excel by recording key aspects of the CHW programs discussed, including name of the program, affiliated institutions, location, target population, target disease, CHW roles, strategies for and content of CHW-provider communication, and evaluation of strategies.

Collating, summarizing, and reporting results

The data from each article was first deductively coded with the research questions in mind to provide a basic analysis of the characteristics and context of the literature. Second, the data was inductively coded using descriptive thematic analysis and narrative synthesis. Thematic analysis involves sorting of data, searching for themes by identifying patterns through tables or maps, and defining the themes.²⁷ Narrative synthesis includes exploring relationships in the data and assessing the validity of the data.²⁸ The data was coded by AK; the coding scheme and final themes were reviewed by SL.

Results

31 papers were included in the review and are summarized in Tables 2 and 3. Seven of the strategies utilized web-based or mobile applications while twenty-four used EHRs. Thirteen of the papers were evaluations/descriptions of CHW programs, eleven were analyses (including randomized controlled trials) of CHW program outcomes, three were grey literature guides to implementation of CHW programs, two were perspective pieces, one was a case study, and one was a review. CHW programs were based in a variety of settings, including: academic hospitals or health systems (11); community clinics (8), two of which were closely affiliated with academic institutions; federally qualified health centers (3); and patient-centered medical homes (2), both of which were affiliated with academic institutions.

Table 2.

Characteristics of Included Studies Utilizing Health Informatics Strategies

Type of Health Informatics Technology	Primary Role of Health Informatics in Communication	First Author	Study Type	Setting	Comments on Strategy
EHR – Direct Access	Direct CHW Communication with Providers	Allen et al, 201518	Evaluation of CHW perspectives	CHWs recruited from American Public Health Association	CHWs used EHRs to communicate directly and indirectly with providers, make appointments, and track patients
		Valaitis et al29	Scoping review	Patient navigator programs across US	Navigators used EHRs to share information with providers
	Documentation of CHW Encounters	Gunn et al, 201430	Exploratory study	Patient navigation programs across US	Navigators used EMRs, charts, or other systems to document patient care
		Gunn et al, 201731	Mixed-methods analysis	Patient Navigation Research Program	Navigators documented/communicated patient progress with providers via EMR/IT systems
		Horny et al32	Retrospective cohort study	Boston Medical Center	Navigators recorded information, including patient barriers, in detailed navigator template forms in EMRs
		Johnson et al21	Perspective on CHWs	Children’s Hospital of Wisconsin	CHWs used EHRs to receive providers’ referrals and document patient progress
		Jolly et al33	Description of program	Cleveland Clinic	Navigators used EHR templates to document/communicate patient data
		King et al34	Evaluation of programs	Navajo clinics in Southwest US	CHWs documented patient encounters in EHR
		Ngo et al35	Guide	Sinai Urban Health Institute	CHWs documented case notes in EHRs
		Ramachandran et al36	Secondary analysis	Boston Patient Navigation Research Program	Navigators documented patient encounters, barriers to care, care plans, and progress in a template in EHR
		Reinschmidt et al13	Evaluation of programs	Federally Qualified Health Centers in Arizona	CHWs documented patient encounters into EHRs (directly during visits or copy from paper
		Rohan et al37	Randomized trial	Boston Medical Center	Navigators documented patient notes in medical records system form
		Spiro et al38	Description of CHW model	Massachusetts General Hospital Chelsea Community Health	CHWs entered patient progress into EMRs
		Vora et al39	Report on program	Charles B Wang Community Health Center	Navigators updated patient flow sheet in EMR; navigators reviewed patient history and patients’ barriers in EMR
EHR – Indirect Access	Documentation of CHW Encounters	Wennerstrom et al40	Description and evaluation of program	Patient Centered Medical Home in Louisiana	CHWs tracked patient information in electronic spreadsheets; medical office assistants attached spreadsheets to EHR
	Other	Lopez et al19	Protocol for randomized controlled trial	Community clinics in New York City	EHR intervention (routine patient registry reports, medical alerts, culturally tailored order sets) combined with CHW program
Mobile Applications	Direct CHW Communication with Providers AND Documentation of CHW Encounters	Cherrington et al41	Description of web application	Congregations for Public Health and Cooper Green Mercy Health System	CHWs used web based mobile application to document progress reports, track patients, and communicate with healthcare team
Cloud Based Systems	Direct CHW Communication with Providers AND Documentation of CHW Encounters	Kangovi et al, 201442 Kangovi et al, 201743	Randomized clinical trial	University of Pennsylvania IMPaCT Model	CHWs utilized cloud based software that integrates with EHRs to track workflow, analyze patient progress, create reports, and can be used to message providers
Web-Based Systems	Documentation of CHW Encounters	DeGroff et al44	Randomized control trial	Boston Medical Center	Navigators documented participant barriers in navigator database
		Justvig et al45	Prospective description	Stony Brook University Hospital	CHWs documented patient visits in Research Electronic Data Capture
		Kane et al46 Walton et al47	Analysis of CHW program outcomes	Baylor Health Care System/Baylor Scott and White Health community clinics	CHWs and providers utilized a HIPAA compliant web-based system to record patient progress and create reports that were added to patient’s medical records
		Percac-Lima et al48	Randomized clinical trial	Massachusetts General Primary Care Practice Research Network	Navigators used IT application to track/contact patients and document interventions

Table 3.

Characteristics of Included Studies Recommending Health Informatics Strategies

Type of Health Informatics Technology	Primary Role of Health Informatics in Communication	First Author	Study Type	Setting	Comments on Strategy
EHR – Direct Access	Documentation of CHW Encounters	Allen et al, 201420	Guide	CHW programs in US	Recommend giving supervisor access to EHR or CHW access to EHR templates
		Brown et al49	Evaluation of provider views	Bellevue and VA NY Harbor Hospitals	Suggest CHWs enter patient updates into EHRs
		Collinsworth et al50	Evaluation of programs	Community clinics in Dallas	Suggest giving CHWs access to EHRs
		Ingram et al51	Qualitative analysis	Federally qualified health centers	Suggest CHWs use EHRs to collect data
		Matiz et al52	Case study	Patient Centered Medical Homes in New York City	Suggest CHW data collection via EHRs rather than paper forms
		Whiteman et al53	Perspective on programs	N/A	Suggest CHWs should record patient progress summaries in EMRs
Mobile Applications	Documentation of CHW Encounters	Broderick et al54	Guide	CHW programs in California	Recommend partnering with mobile health technology organizations to utilize CHW mobile data collection strategies

Type of CHW access to health informatics

A majority of strategies for CHW-provider communication leveraged EHRs in the context of a variety of settings including community clinics and academic health systems. Nine papers reported CHWs having access to EHRs or EMRs, and five papers suggested this access should occur, but none of the paper specified in what format information would be captured.^{13,18,21,29–31,34,35,38,49–53} Six papers discussed CHWs having access to specific forms, structured questionnaires, or templates in EHRs.^{20,32,33,36,37,39} In one study, some of the CHWs input patient information directly into the EHR during the patient visit, while others took notes on paper and later input them into the EHR.¹³ One paper suggested giving only CHW supervisors access to EHRs²⁰ while another had medical office assistants attach CHW documentation to the EHRs.⁴⁰ Two papers reported utilizing or suggested utilizing mobile applications for CHWs to collect patient information.^41,54 One program had CHWs document patient updates into an online research database,⁴⁵ while three utilized other web-based or cloud-based systems.^{42,43,46–48} Of the programs using non-EHR web-based applications, all were associated with academic health systems; in one of these programs, reports generated from the system were faxed to the patient’s provider to be added to the patient’s medical record.⁴⁷

Role of health informatics for CHW documentation

A majority of papers reported utilizing health informatics to document patient notes/progress from CHW encounters. Because a majority of papers indicate that the purpose of documentation is to share this information with providers, degree of documentation may allow for increased potential amount of communication. In one program, this included documenting patients’ health concerns and referrals made to social services.⁴⁰ The patient notes also included clinical indicators and sociodemographic characteristics (e.g., literacy, blood pressure) as well as patients’ knowledge of their disease, physical activity, and quality of life.⁴⁷ In another program, screening test results alerting the provider to follow up with the patient were documented.³⁹ CHWs also documented specific SDOH barriers in health information systems,^32,36,37,44 such as transportation, housing, and childcare³² as well as actions taken to these address barriers.³⁷ All of the papers that described documentation of patient barriers were associated with multiple studies conducted within one academic institution in an urban setting. In three papers, it was explicitly discussed that CHWs documented and/or shared the patient’s care plan or intervention.^36,43,48 Of note, less than half of the papers described the variables that were documented by CHWs.

Role of health informatics for direct CHW-patient and CHW-provider communication

Of the studies utilizing health informatics for CHW-provider communication, many had uses beyond documentation of encounters. CHWs used EHRs to generate reminders for patient follow-up,¹⁸ to make appointments with patients,^18,21 or to view patients’ histories before patient visits.^13,39 Three papers utilized web-based/cloud-based applications to generate reports on data from CHW encounters, such as frequency of contact with patients and achievement of patient goals.^42,43,46,47 CHWs also used health informatics to communicate with providers through secure direct messaging systems^18,41 or referral systems.²¹ Additionally, in one program, EHRs were used to augment the work of CHWs by implementing culturally tailored ordered sets;¹⁹ order sets consist of a “bundle” of evidence-based guidelines and/or educational materials that help providers order the appropriate prescriptions/labs, and counsel patients in a standardized manner.^19,55 In a different program, clinical pathways were embedded into web-based applications to prompt CHWs to contact providers immediately when urgent concerns, such as critically abnormal blood pressures or glucose measurements, arose.⁴⁶ In another study, CHWs used an IT application to directly contact patients and provide them with educational resources.⁴⁸ Of the papers that recommended health informatics strategies, none mentioned uses beyond documentation of patient encounters.

Impact of health informatics on CHW-provider communication

Several studies found that CHW utilization of EHRs and other health information technologies improved communication between CHWs and providers.^18,33,38,50 Two papers found that it allowed for CHWs to maintain continuous communication with providers with real-time patient updates.^37,53 CHW use of EHRs also increased the ability of CHWs to contact providers regarding patient concerns, augmenting the overall amount of communication.³⁴ In two papers, the improved CHW-provider communication resulting from utilization of EHRs was shown to be key in enhancing the role of CHWs in clinical teams.^21,30 In focus groups conducted among CHWs, it was found that CHWs were more likely to be recognized and valued by providers due to the improved communication. This was found to be a necessary step in helping providers consider CHWs a part of their care teams.³⁴

Furthermore, improved communication with CHWs was found to fulfill the needs of providers and CHWs in enriching their abilities to provide care in academic and community health systems. Providers indicated that they wanted CHWs to enter patient progress updates in EHRs⁴⁹ and that this documentation facilitated their communication with CHWs.^49,50 Specifically, EHR notes from CHWs allowed providers to view patients’ clinical data at the same time as contextual information on sociocultural backgrounds to enhance their understanding of the patients’ motivations to seek care.^50,51 This system allows for data collected by CHWs to be imparted onto providers, thus increasing the level of communication. In one paper, it was found that sharing information about patient visits with providers through reports generated from a web-based application were useful in highlighting issues that may need to be addressed at subsequent visits with the provider.⁴⁷ Similarly, using EHRs allowed CHWs to tailor their patient education by allowing them to view patients’ histories and gain insight on the barriers the patient may be facing.³⁹

Impact of health informatics on patient care

Health informatics based communication between CHWs and providers was also found to impact patient care and outcomes. It was found that CHW utilization of EHRs and web-based applications facilitated better-coordinated care and improved patient outcomes in the context of community clinics, such as a 7% increase in colon cancer screening rates and decrease in mean hemoglobin A1C from 8.7% to 7.4% in diabetes patients after intervention.^39,47 Another paper found that a CHW based health informatics intervention was associated with improvement in smoking cessation (5.6 vs 1.3 mean decrease in cigarettes smoked daily in CHW-health informatics group compared to control group).⁴³

Barriers presented by health informatics

In a few papers, CHW use of health informatics was found to present certain challenges. For example, in a provider focus group, not all of the information documented by CHWs was found to be useful in clinical decision-making and was considered excessive by providers^40,49. On the other hand, certain information that is relevant to clinical care, such as social determinants of health, were found to be difficult to track via EHRs because these technologies have not been designed to document this information⁵¹. Additionally, in one CHW program, some providers were unaware that they were able to view CHWs’ notes in EHRs, which would limit the benefits of this form of communication. Furthermore, the providers who were aware of the CHW notes felt it was too complicated and time consuming to view the notes¹³.

Discussion

A majority of the health informatics based strategies for CHW-provider communication identified through the 31 papers in the scoping review suggested giving CHWs access to EHRs, templates within EHRs, or web-based/cloud-based applications in order to provide a tool for CHW documentation of patient progress as well as communication of patient sociodemographic characteristics, clinical indicators, barriers, and action plans with providers. They also support CHW-provider and CHW-patient communication through additional features such as secure messaging systems and generated reports. The papers found that these strategies may allow for increased communication between CHWs and providers, deeper provider understanding of the patient with more tailored care, though most evaluations for provider-CHW communication were qualitative in nature. Some of the papers also found these strategies to be associated with better coordination of care, with the potential to support improved patient outcomes through promotion of positive health behaviors and delay in disease progression. Given the wide distribution of cities and populations targeted in the reviewed literature, these findings suggest that using health informatics for communication between CHWs and providers may be a promising approach to increasing CHW engagement and integration into clinics accommodating diverse urban populations, racial and ethnic communities, and diseases. However, while the studies in this review suggest a potentially significant impact of use of health informatics tools to improve communication between CHWs, providers, and patients, none of the papers in this review included rigorous randomized control or pragmatic trial designs comparing health informatics with other methods of communication, presenting a clear opportunity to advance the science of CHW integration in the setting of community-centered interventions aimed at reducing racial and ethnic disparities.

Moreover, given the barriers to using health informatics in the context of smaller, community clinics, such as providers finding it too complicated or time consuming to view CHW notes in EHRs, there is also a need for additional studies that examine the use of health informatics strategies to facilitate CHW integration in such settings.^13,56 Limitations faced by these practices including time, staff, and funding leading to diminished administrative support for utilizing EHRs and accessing trainings, have been well documented and may further impact the use of health informatics to support CHW integration in such.⁵⁷ For example, in community clinics, CHWs may play an especially important supportive role to an already small team and have decreased capacity and time for accessing/entering data into EHRs. Further, many community clinics have limited opportunities to develop alternate web-based applications to facilitate CHW-provider communication. Small, community-based practices serve disproportionate numbers of minority patients;⁵⁸ thus, effectively implementing community-centered, culturally tailored, public health interventions and integrating CHWs into these clinics is especially critical and warrants further attention.

Finally, regarding future directions of health informatics for CHW documentation, some papers in this review suggested amending EHRs for more detailed and easier documentation of SDOH data.^13,51 Interestingly, a majority of papers in this review did not mention the format in which SDOH data was documented, perhaps because the appropriate manner for capturing this information is still being established. One possible format includes EHR based flowsheets filled out by CHWs on factors such as patients’ financial limitations, social support, and education level.⁵⁹ By capturing this SDOH data, CHWs maximize their role in the public health workforce by enhancing providers’ capacity to address upstream factors that impact well-being. The SDOH data in EHRs can be interpreted by providers to enhance their contextual understanding of patients’ barriers to care in order to appropriately tailor patient outreach. This framework of EHR as a tool for communication and integration of data collected by CHWs amplifies CHWs’ efforts to foster patient disease self-management, medication adherence, lifestyle modifications, and other behaviors that prevent disease progression.

To optimize this integration, EHRs should be complemented by regular healthcare team trainings on how to most effectively understand and utilize the social context data entered by CHWs in clinical decision-making.¹³ This is important because CHWs are advocates for their patients and experts on their communities; effectively acknowledging their perspectives and integrating their work into clinic workflows creates a unique opportunity to provide enhanced, patient-centered, culturally tailored, and coordinated care in which cultural/linguistic barriers are reduced and patients are connected to appropriate community resources.⁹ This elevated care in minority communities is a crucial component of reducing disease severity and working towards health equity. Moreover, as CHWs continue to become more integrated into clinical settings, they are at risk of becoming medicalized and their identities and impacts are being lost. CHWs utilizing EHRs and becoming habituated to the clinical algorithms and medical pathways embedded into such systems may propagate this process. Guidance from both community members and healthcare leaders in order to clearly define CHW identities, expectations, and roles as well as tailoring EHRs and relevant trainings will help minimize medicalization while highlighting the perspectives of CHWs.⁶⁰

There are several limitations to this review. First, this review did not address the cost of different health informatics platforms as it was beyond the scope of the review, though it is an important area of research. The search, study selection, and study extraction were conducted by one reviewer, which could have allowed for selection bias. While the search was expanded to include terms alternately used for CHWs, papers using other terms for this role could have been missed. In addition, because papers were excluded based on titles and abstracts, it is possible that relevant papers were missed. However, this methodology allowed for us to identify a broader range of literature. Finally, because a scoping review, rather than a systematic review, was conducted, the quality of papers was not assessed using a standardized criteria.

Implications for Policy and Practice.

• Given current policies, such as the Patient Protection and Affordable Care Act, continue to support CHWs through grant funding, it is important to evaluate their impact in clinical settings and improve their efficiency and efficacy to optimize health outcomes, especially for racial and ethnic minority communities.

• To improve CHW integration into clinics and communication with providers, encouraging direct CHW utilization of EHRs may be a best practice, particularly for capturing SDOH data and other contextual factors faced by patients that CHWs are uniquely suited to discover and document. However, careful attention must be placed on setting clear expectations, maintaining community identities, defining a unique scope of work, and integrating workflows for CHWs through balanced health-community partnerships.⁶⁰

• To optimize CHW utilization of technology, further research should be done on conducting regular trainings for CHWs and healthcare providers regarding documentation and interpretation of SDOH data and other CHW-collected data on patient needs and experiences.

• To overcome implementation barriers in smaller community clinics, further research should be done on sustainability and efficacy of CHW use of health informatics in these settings to help guide local policies and municipal agencies in providing appropriate resources to support technologies that can be utilized by CHWs.