It seems so obvious that social and behavioral factors play a huge role in determining a person’s overall health. But when you listen public discourse about improving health, most of the energy is focused on things like the healthcare system, medical science breakthroughs, and drug therapies.

Yet, the combined social + behavioral + genetic factors probably account for 80% of your health.

Pair Running

That leaves about 20% of your health attributable to your interactions with the healthcare system. As a clinician, this perspective is probably one of the most important, but difficult, things to keep in mind.

Recent attention

There is growing recognition that social and behavioral determinants of health are worth paying attention to. In the March/April 2016 issue of the Annals of Family Medicine, DeVoe et al argued that these factors influence health outcomes more than medical care, and described a helpful framework for integrating them into primary care practice.

In an accompanying article, Michael Laff explains:

For instance, factors specific to an individual such as race, income, obesity, and use of tobacco, alcohol or drugs are a strong predictor of health. From a population health perspective, low income at the neighborhood level may be associated with higher rates of low birth weight, infant mortality and sexually transmitted diseases.

Getting social and behavioral data in EHRs

One barrier to acting on this knowledge is that most electronic health records today don’t have easy ways to capture social and behavioral data in a standardized, reusable way.

Recently, the Institute of Medicine published a report Capturing Social and Behavioral Domains in Electronic Health Records: Phase 1. The committee identified six criteria for identifying high priority domains that should be included in EHRs. As described by Adler and Stead the committee developed a concise panel of measures by prioritizing standard measures with the greatest clinical usefulness and feasibility for capture in the clinical workflow.

Informed by the IOM work, the ONC finalized the 2015 EHR Certification Criteria on capturing social, psychological, and behavioral data. ONC explained their rational for including this EHR criterion:

We continue to believe that offering certification to enable a user to record, change, and access a patient’s social, psychological, and behavioral data will assist a wide array of stakeholders in better understanding how this data may adversely affect health and ultimately lead to better outcomes for patients. We also believe that this data has use cases beyond the EHR Incentive Programs, including supporting the Precision Medicine Initiative and delivery system reform. In addition, the Federal Health IT Strategic Plan aims to enhance routine medical care through the incorporation of more information into the health care process for care coordination and a more complete view of health, including social supports and community resources.

Key social, psychological, and behavioral measures in LOINC

The 2015 Certification Criterion enables a user to record, change, and access patient social, psychological, and behavioral data. It requires the use of specific LOINC codes as the universal identifiers to represent the standardized, validated, and prioritized questions and answers for key domains. The selected domains include:

  • Financial resource strain
  • Education
  • Stress
  • Depression
  • Physical activity
  • Alcohol use
  • Social connection and isolation
  • Exposure to violence

You can find all of the LOINC codes for these questions nested under the LOINC panel code:

[80216-5] Social, psychological and behavioral observations – 2015 Edition Health IT Certification Criteria set.

You can even see an example data capture widget for these LOINC items built on the open source NLM Forms.

Take-home message

If you are looking to capture, store, and exchange a short but powerful set of social and behavioral variables, this LOINC panel is a great place to start.

An aside

One interesting lesson from building the LOINC representations of this content was the sources for some assessment instruments are often misrepresented (e.g. authors who used an instrument but didn’t develop it). I’ve also seen places where a recommended instrument is labeled as being “public domain” or “open source”. This is almost never true for a standardized instrument. You actually want it to be copyright protected so there aren’t a million variations. But, as I lament in my LOINC tutorials, it remains incredibly painful and labor-intensive to get permission from the IP holders of each of these chosen questions/instruments for inclusion in LOINC.

The purpose of representing them in LOINC is to encourage their use by providing a universal identifier and uniform representation. And LOINC’s approach is to distribute the content at no cost worldwide, which goes against a lot of instrument developer’s business model with usage fees. (Which really irks me when they were developed with NIH funding).

Regardless, we’re eager to add the high value assessments to LOINC wherever we can obtain permission. Maybe at some point we’ll reach a state where peer pressure kicks in and the instrument owners will feel obliged to get their content represented in LOINC.


This post is dedicated in memory of Jaci Phillips, a heroic LOINCer, who we lost 3 years ago today. She’d be proud to see LOINC continue to grow in content for social, behavioral, and psychological data.



This material contains content from LOINC® ( The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2015, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and available at no cost under the license at