Product type: Carolina Health Workforce Research Center brief.
Authors: Lisa de Saxe Zerden, MSW, PhD, Erica L. Richman, MSW, PhD, Brianna M. Lombardi, MSW, PhD, Kim Shoenbill, MD, PhD, Erin Fraher, MPP, PhD.
Introduction: As one of the largest groups of clinically trained mental health providers in the United States, social workers are increasingly deployed on integrated health teams to address patients’ social determinants of health and provide behavioral health interventions. However, information about the specific content of social work practice in new models of healthcare is limited, and further exploration is needed to better define social worker roles and functions in integrated settings. This study aimed to demonstrate how EHR data can be used as a workforce research tool to assess the scope, contributions and value of social work, a profession still in the process of establishing its return on investment in health care.
Methods: To create a preliminary lexicon we conducted expert interviews and focus groups with 30 practicing social workers representing more than 20 primary care clinics, medical providers and informatics experts. These interviews, in conjunction with academic literature, formed the basis of the lexicon that was updated iteratively throughout the study. EHR data were obtained from the North Carolina Translational and Clinical Sciences Institute (TraCS), a broker of the Carolina Data Warehouse for Health (CDW-H), the data repository for the UNC Health Care System. A random sample of 60 patients who had clinical contact with a social worker between September 1, 2016 and August 31, 2017 were selected and 647 notes were reviewed and analyzed to evaluate social workers’ documentations.
Results: There were sizeable challenges to using EHR documentation to help clarify the role of social workers in integrated primary care settings. Because social workers do not bill for their services, they do not create their own clinical encounters and often append documentation to already existing provider notes. Furthermore, social workers were not consistently referred to as social workers but as case managers, care manager or other titles. However, in analyzing notes, we found social workers played broad roles in integrated primary care settings, both in direct patient care and management, and as part of a dynamic health care team.
Discussion: As this study helps demonstrate, EHR documentation shows social workers are regularly contributing to patient care and working as members of health care teams. Yet, if EHRs are to become a robust resource for workforce and health care researchers, informed and purposeful changes to the interface and usability of EHR systems are required in order to more fully understand the scope of practice and contributions of the social work health workforce.
- Applicability and Usability of the EHR. This study helped identify limitations of EHR structures that impact the way social workers can document their work. Allowing clinical encounters to be created by providers regardless of billing permissions could increase the data abstraction process and general usability of data found within the EHR. Further, social workers consistently referring to themselves in documentation as their profession (i.e. social worker) as opposed to their job title (i.e. care manager) could also help improve the quality and ease of obtaining data.
- Valuing Contributions of Social Work Interventions. One way to offset the challenge of understanding the complexity of social work interventions as documented in the EHR is to develop and expand how value is calculated.
- Social Work Education Needs to Include EHR Documentation Strategies. As the EHR becomes a key source for helping define the social work workforce in healthcare, social workers should be trained to document in clear and consistent ways that help alleviate common barriers to EHR research.