21 Aug
Social Data on FHIR gives clinical, behavioral, and community teams a shared way to document needs, make referrals, and confirm services in the record. EHRs speak the same language as community-based organizations, so housing, food, and transportation help is requested, fulfilled, and measured without manual chase. That is how upstream determinants move from insight to action.
Why this matters
Most teams already screen for food, housing, transportation, and behavioral health needs. The gap is action. Referrals stall, confirmations do not make it back to the record, and leaders cannot see which communities benefit. Programs such as Oregon’s SDOH Social Needs Screening and Referral metric and the SHARE reinvestment model show the rails, and FHIR is the common language that turns those rails into everyday work and population insight.
The HL7 SDOH Clinical Care guide defines a closed-loop referral pattern using ServiceRequest and Task. The SMART/HL7 Bulk Data API exports cohorts for equity and planning. Together, this moves organizations from “we screened” to “we served.”
How collaboration actually flows
- Clinic to CBO: a need is captured as FHIR Observation or Condition, a ServiceRequest is sent, and a Task carries status back into the EHR.
- Primary care and behavioral health: screeners like PHQ-9 and GAD-7 are coded as Observations, care steps live in CarePlan, and visit status flows as Task or Procedure so both teams see progress.
- Network to leadership or public health: Bulk Data exports cohort files for equity views, showing where food, housing, and transport gaps persist and where to invest next.
Examples that work in the real world
Food security that actually closes
A positive screener in the EHR becomes a structured referral to a food access partner. The partner updates status at intake, fulfillment, and follow up. The EHR receives write back, so care teams stop chasing phone calls. In markets like Oregon, using approved tools keeps screening consistent across sites.
Housing stability with transparent updates
When housing risk is identified, the referral includes the data the housing agency needs. The agency posts updates for waitlist, documents received, placement, or denial reason. These updates flow into the care plan, which lets care managers intervene when a case stalls.
Behavioral health that measures improvement
A positive PHQ-9 or GAD-7 triggers a warm handoff to therapy, scheduled and tracked as ServiceRequest and Task. Follow up scores write back as Observations, so teams see whether access led to symptom change, not just visit counts. Bulk Data helps trend access and outcomes by cohort and location.
Metrics that drive decisions
The collaboration flows above produce routine FHIR events: screeners as Observation, documented risks as Condition, referrals as ServiceRequest, status updates as Task, and cohort exports via Bulk Data, resulting in useful data points. By paying attention to a few simple measures, leaders can see if social risks are being addressed and decide where to put time, money, and effort.
Screening and positive rates
This shows how many people are being asked about social needs (like food, housing, or transportation) and how many say “yes, I need help.” If only a small share of patients are being asked, the system needs to expand screening. If many screen positive in certain areas, that’s a signal to shift more resources there.
Referrals and completed services
This shows whether people actually get the help they were referred for. It’s the difference between “we gave them a phone number” and “we know they received food, housing, or counseling.” Counting how many referrals were made and how many were completed helps identify which partners or services follow through best.
Time to first service
This shows how long people wait between being referred and actually getting help. If it takes weeks for someone to get food or housing support, the referral system is not doing its job. Shortening this time means adjusting forms, triage, or capacity to get people served faster.
Equity view
This shows who is benefiting and who is still left out. By looking at results by neighborhood, language, or race and ethnicity, leaders can see if some groups are not getting the same level of service. Funding and reinvestment can then be targeted to close those gaps. This aligns directly with Oregon’s SHARE program, which requires CCOs to reinvest savings into community-driven projects that address social determinants and health equity. Tracking equity gaps with FHIR data helps CCOs show that SHARE dollars are being spent where they make the most difference.
Why Aigilx Health
You do not need another standalone referral app. You need rails that connect EHRs and community platforms, record every handoff, protect behavioral health privacy, and give leaders a clean view for decisions. That is what Aigilx builds. We deliver a standards-first backbone that turns social risk into reliable action and measurable improvement.
- Coordinated care platform built for scale
The Aigilx’s Care Coordination Platform brings together clinical, behavioral, and social data in one place, serving as the operational hub for referrals, follow-up, and status tracking across sectors.
- Enhanced, analytics ready FHIR server that ingests clinical, behavioral, social, and claims data, exposes standard APIs, and supports Bulk Data for equity dashboards and program reporting.
- SDOH Clinical Care implementation that configures ServiceRequest and Task workflows with dependable EHR write back and CBO connectivity, following the published referral framework.
- Deep FHIR integration expertise
Aigilx isn’t just an implementer of standard solutions; it’s an experienced partner across diverse FHIR integration patterns, from custom coordination workflows to specialized consent and data segmentation patterns for behavioral health and 42 CFR Part 2 compliance.
- Consent aware exchange, so community organizations share just enough data to close the loop, with options to apply data segmentation for sensitive behavioral health information.
- A fast pilot pattern. Pick one domain, prove completion and time to service gains, then expand to adjacent services with the same rails.
If you want fewer stalled referrals and more data driven decisions, reach out to our experts to FHIR enable one end to end flow and build your first equity scorecard. We will wire your screeners, referrals, and outcomes to the SDOH Clinical Care workflow, and activate Bulk Data for cohort views. This is how you mitigate social risk with reliable, meaningful action.
Aigilx health specializes in developing Interoperability solutions to create a healthcare ecosystem and aids in the delivery of efficient, patient-centric and population-focused healthcare.
