We launched the Gravity Project in May 2019, a time when social determinants of health (SDOH) had emerged as an important topic in the quest to address whole-person care. The 'why' for our work was presented in an EMI end-of-year reflection blog where we invited the community at large to join us in building the foundation needed to facilitate social care integration in health systems.

Since that time, the Gravity Project has made significant strides in SDOH data interoperability. The standards emerged while we bore witness to the COVID-19 pandemic and its disproportionate impact on vulnerable populations. COVID not only magnified the importance of our work but also illuminated the systemic health inequities persistent in the way we document, use, and act on an individual's social needs data. Under this lens, addressing SDOH is increasingly recognized as an approach that can be used to improve equity and reduce disparities. 

Our Shared Success

Over the past three years, the Gravity Project team has convened over 3,000 individuals (and counting) to develop consensus-based data standards to improve how we use and share information on SDOH. These data standards encompass both the language and words that give meaning to this information (i.e., Gravity Terminology) and the technical specifications that allow for the seamless electronic exchange of this information across disparate systems (i.e., Gravity FHIR Implementation Guide).

 We attribute success not only by the number of standards we collaboratively publish but also by how these standards are integrated into policy, payment models, programs, grants, other national standards activities, workflow/practice, research models, and new innovative tools and technologies.

Our key accomplishments include:

• Publication of expert-driven, evidence-based data sets for 17 SDOH domains that align with Healthy People 2030 objectives and health equity priorities.

• Publication of 100+ value sets in the National Library of Medicine Value Set Authority Center ready for implementation and reference in U.S. quality measure development and U.S. health data policy.

• Recognition and inclusion of the SDOH data class in the Office of the National Coordinator (ONC) United States Core for Data Interoperability (USCDI) V2.

• Submission and publication of coded terminologies for SDOH domains in LOINC, ICD-10-CM, and SNOMED-CT.

• Publication of the first HL7 FHIR SDOH Clinical Care Implementation Guide and associated Reference Implementation.

• Publication of draft guidance for capturing race and ethnicity data.

• Recognition of Gravity standards in federal program guidance: CMS Medicaid Guidance and CMS Medicare Advantage (MA) and Part D Requirements for Special Needs Plans.

• Integration of Gravity and SDOH standards in federal grant programs administered by the ONC, the Administration for Community Living (ACL), the Administration for Children & Families (ACF), and the Centers for Disease Control (CDC).

Scaling a Trusted Framework

One of the pillars of our work at EMI is creating spaces for problem solving that engender trust through an open, transparent, and inclusive process. For Gravity, we ensure multi-stakeholder views are heard and integrated every step of the way. This happens across our Public Collaborative meetings, our HL7 FHIR SDOH Workgroup meetings, and our Governance Committees. This approach is now being adopted across other national projects building data infrastructure to advance health equity and person-centered care coordination.

• The CDC SDOH Data Exchange for Chronic Disease Prevention. The CDC and EMI convene a public workgroup to develop a consensus-based SDOH public health business case and high-priority use cases for chronic disease prevention and health promotion.

• NIDDK/ AHRQ Multiple Chronic Conditions (MCC) electronic Care Plan Initiative. NIDDK, AHRQ, and EMI bring together broad stakeholder groups to define data concepts and coding terminologies for long COVID and to test SMART-on-FHIR apps that support standards-based care planning data exchange.

• ONC SDOH Information Exchange Toolkit and Learning Forum. The ONC and EMI have developed a toolkit and are facilitating a learning forum focused on foundational elements needed for SDOH information exchange across the health and human services ecosystem.

• ACL Social Challenge Program. EMI provides technical assistance to the ACL Social Care Referrals Challenge Teams that are implementing scalable approaches for standardized SDOH and person-centered plan data sharing.

• HL7 Human and Social Services Work Group. EMI supports the ACF in the facilitation of a new HL7 Work Group that convenes human services sector stakeholders and HL7 experts to define requirements, design, and validate HL7 specifications for interoperable human services data exchange.

Moving Data into Action for a Person-Centered Learning Health System

We are at a pivotal time to move from standards development to standards implementation to data evaluation. The Gravity Project, after all, is a data standards project, tackling one piece of the puzzle in establishing an interoperable SDOH ecosystem and an equitable learning health system. More work is needed to address prevailing challenges as highlighted in recent national reports from the National Alliance to Impact the Social Determinants of Health, Physician-Focused Payment Model Technical Advisory Committee, White House Office of Science & Technology Policy, and pending SDOH and Health Equity legislation including:

• Using existing data infrastructure and technologies to capture and share a prioritized set of data elements. The standards are now available for use by electronic systems that capture patient encounter data, administer social risk assessments, support care coordination, aggregate patient data, and evaluate intervention outcomes. More work is needed to define what is the most important information that should be collected electronically by the person/patient, the health provider, the community-based organization (CBO), the state agency, the public health agency, and the health plan. At the same time funders need to provide equitable financial incentives to facilitate data collection and sharing.

• Designing and evaluating new workflows. Integrating new workflows for documenting, addressing, and tracking social risks and social needs is new to many clinical groups; at the same time, many CBOs have limited experience working with technology platforms and integrating the functions of these tools into existing workflows. 

• Establishing sustainable and non-burdensome funding models. There are a plethora of funding mechanisms across the country that continue to create barriers towards adopting standards-based technologies. Most of these funding sources have particular data capture and reporting requirements that make it challenging for end users to only use one system to receive and report on social referrals.

The Village Needs Your Help!

The Gravity Project was co-founded by EMI and SIREN in 2018 with the generous support of the Robert Wood Johnson Foundation. EMI is the contracted program manager, and as a small business, relies heavily on the funding and in-kind support of our sponsors that include the federal government, health plans, foundations, associations, academia, and technology vendors. The consensus-based standards developed and curated by the Gravity Project are a freely-available public good. While we are grateful for the financial support received, the current sponsorship will not sustain the level of effort required to expand and grow this body of work. 

We need your help.

 To learn more about how to become a Gravity Sponsor and the value proposition for engagement, contact gravityproject@emiadvisors.net. 

 To learn how EMI Advisors can support your digital health equity strategy, contact hello@emiadvisors.net.

Evelyn Gallego, MBA, MPH, CPHIMS, is the CEO and Founder of EMI Advisors LLC. EMI was started to further Evelyn’s mission of delivering value-driven health data management advisory services to her government and commercial clients. Evelyn is a trusted advisor in helping her clients bridge the gap between health information technology policy and standards and business requirements.