When clinical teams have information on patients' social risks (adverse social determinants of health), they can make care plan adjustments to account for those risks, e.g., by prescribing lower-cost medications. Come hear about a team that worked with stakeholders from primary care community health centers to develop a set of EHR-based tools intended to support making such adjustments in care for patients with hypertension and / or diabetes. This talk will describe the tool development process, results from pilot testing the tools in three clinic sites, and how the tools were revised in response to pilot process learnings.

Data standards initiatives and the Uniform Data Set (UDS) Modernization initiative aim to reduce reporting burden through easing data exchange, improve data quality, and better measure services and outcomes. In the coming years, health centers will be expected to use FHIR, a data standard that is becoming more common, to submit UDS+ along with other information (such as public health reporting). Experts involved in preparation for UDS+ and similar initiatives with CMS will join to share their experiences and reflect on what health centers should be aware of as they prepare for the future of UDS and other reporting