Moving from Screening (SDOH) to Action: Expanding OpenEMR to Social Prescribing & CBO Networks

OpenEMR Development
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Hi Everyone,

Following up on my post from two weeks ago—Future Direction for SDOH Referral Development—where we discussed the need for a flexible, open-standards approach to SDOH screening and avoiding expensive, proprietary forms, I want to take the next logical step in this vision.

If our goal is true closed-loop referrals without dependence on expensive commercial platforms, we need to address the biggest bottleneck in the U.S. and global markets: the receiving end.

Currently, community-based organizations (CBOs) and social prescribing networks are trapped using proprietary databases (like Salesforce or Epic Care Link) that charge predatory per-license fees, or networks that cost clinics massive utilization fees.

What if we expand OpenEMR to allow it to be used within these social prescribing organizations as another specialized form of a clinic?

OpenEMR is already incredibly effective at being configured for specific medical specialties (Ophthalmology, Mental Health, etc.) via Layout-Based Forms (LBF) and Global Profiles. A social services organization is simply another specialty clinic. Instead of eye charts, their custom forms will capture housing status or food intake. Instead of medical surgeries, their billing sheets will load up the emerging insurance codes (like HCPCS and Z-codes) for “Food as Medicine” and housing navigation.

Furthermore, the future looks like a complete blending of healthcare and social services. We are moving toward a world where community organizations will send backward medical referrals to clinics. For example, many social service orgs are now conducting blood pressure screenings, BMI screenings, and diabetes checks. If we build a customized OpenEMR instance for these orgs, a high blood pressure reading taken at a food bank could trigger a FHIR Observation and ServiceRequest sent directly back to a primary care clinic—opening a vital patient care funnel. [1]

Next Steps & Grant Funding:
Stephen Nielson is already doing incredible work coding FHIR referral workflows into OpenEMR.

To bring this vision to the U.S. market and ensure it aligns perfectly with OpenEMR’s core code, I am putting together a team to pursue a US I-Corps grant. This will fund intensive customer discovery to map out exact UI/UX needs for non-profit volunteers and case managers.

I’d love to reopen the floor for feedback:

  1. What are your thoughts on configuring OpenEMR as a dedicated “Social Care” distribution or profile?
  2. Who is interested in collaborating on this architecture or participating in the I-Corps grant project?

Looking forward to your thoughts,
Char Miller

2 Likes
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Hi Char,

I like where you’re taking this, and I’ll go a step farther — the “receiving end” problem you describe is mostly a configuration and referral-plumbing problem, not a new-product problem. The timing is good because the screening half of the loop is landing in core right now.

For anyone following along, I have a PR up (#12880) that replaces the LForms browser layer with an OpenEMR-native FHIR Questionnaire Runtime and adds a Patient Dashboard → FHIR Assessments workflow. Details, screenshots, and an Up for Grabs demo are in my announcement topic: Announcing: FHIR Questionnaire Runtime and Patient Dashboard Assessments

Imported FHIR R4/SDC questionnaires (SDOH, behavioral health, PROMs, intake, etc.) now render natively, score with SDC calculated expressions, and persist as native QuestionnaireResponse resources. The PR also adds Questionnaire SMART launch context — and an outside assessment app is exactly what a CBO-facing tool is, so that launch path matters here.

The standard I think we should build the closed loop against is the Gravity Project SDOH Clinical Care IG. Its resource flow is:

screening Questionnaire → QuestionnaireResponse → derived Observations → Condition (health concern) → Goal → ServiceRequest → Task assigned to the CBO → completion closes the loop.

PR #12880 delivers the front of that chain. My next step, already noted on the PR, is deriving Observations from QuestionnaireResponses (with derivedFrom back-links) so screening results surface in CCDA and the FHIR API — that’s the next link. From there, ServiceRequest with SDOH category codes and Task-based referral state carry the referral half. Stephen has been doing great work coding FHIR referral workflows, so I’d want to coordinate there rather than duplicate effort.

On the “social services org as another specialty clinic” idea — agreed, and I think it’s even lighter than a distribution. A few releases back I added a Context Manager that switches dashboard widgets per care setting (Emergency, Primary Care, etc.). A “Social Care” context with its own widget set, assessment catalog, and a Z-code/HCPCS fee sheet gets a CBO instance most of the way there with configuration, and the questionnaire runtime handles their intake and follow-up instruments. Your backward-referral example — a BP screening at a food bank — is then just an Observation plus ServiceRequest flowing the other direction on the same rails.

On I-Corps: worth remembering it funds customer discovery, not development, which actually works in our favor. A working demo of screening → scored response → Observation → referral is exactly what makes those discovery interviews concrete, and it tees up an SBIR/STTR follow-on for the build-out. I’ll make sure the demo capability is there to show. The reimbursement tailwind belongs in the narrative too — CMS is already paying for this direction through Z-code capture and 1115 waiver programs, which answers “why now.”

Count me in on the architecture side. Once #12880 merges I suggest we sketch the Gravity resource flow against what’s in core and identify the remaining gaps. I’ll keep the community posted here and on my announcement thread as the Observation derivation work lands.
I also want to especially note to community that while you have brought this to the community by it helping us meet a concentrated need the structural work to support allows meeting many other Health Care discipline needs. Really exciting stuff, so thanks.

Jerry

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Great Stuff Jerry!!

We start the NSF I Corp regional with UC Berkeley on August 3rd. This 4 week round is just interviewing customers, which i plan on doing locally in SF and a few in SoCal. You are correct that the focus is just to understand the need and the market to test if our hypothesis of an OpenEMR instance works.

From there we would apply to the National ICorps where we would have travel budget to attend conferences and interview customers across the country, and possibly Canada. This would be 7 weeks long and interviewing 100 customers. The target customers are CBOs, clinics, FHIR/Gravity experts, possibly social prescription grant funders, etc..

We are not supposed to Demo anything at this point. This would all be to gather evidence to support the future build and drill down best possible build requirements. From there, we would apply for SBIF phase 1 to pay for the build portion and pilot.

I’ll be setting up calls biweekly with Stephen, possibly Brady, and can include you on these also to discuss the progress of interviews. I will also setup a more extensive document repository somewhere to host all these ideas and gather what has been done, etc. My day job is a PM so i’ll treat this like a project and can get statuses, updates, artifacts, plans, etc all together.

Really love the excitement!! fyi, you’re welcome to join our ICorps team. But i am trying to keep that small because it is strict requirement that Team Members must attend all 3 hour weekly seminars. So currently, my recently graduated biochemistry son, Sage Snyder, is the other team member to assist with interviews, documentation, scheduling, and will begin to dive into OpenEMR codebase.

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Thanks Char,
Due to my current status I avoid making long term commitments because I hate to disappoint or not meet expectations. What we’re doing here if precisely why I devote so much time to OpenEMR. My give back!
However, if any of you feel I may have something to contribute to a call or meeting please invite me and I’ll try to be sure to attend.