Short Description

Testing Gravity’s Social Determinants of Health Data Exchange IG, to include the following use-cases:

  1. Patient assessment of needs using a standard SDOH questionnaire (PRAPARE),
  2. In the role of a Provider, establish Goals associated with relevant health concerns prioritized with the patient – leading to a CBO referral,
  3. In the role of a CBO end-user, test the various workflows enabled by the IG (accept, reject, et al.). 

A stretch goal will be to demonstrate the use of the STU 2 specification related to using a structured Questionnaire to enable the patient/client/member/consumer to self-report their REL+SOGI attributes.

For this connectathon, we will be focused on these interactions which is a subset of the functionality supported by the IG.

Long Description

The goal of the Gravity Project is to develop consensus-based standards for the exchange of social determinants of health (SDOH) data within the health care sector and between the health care sector and other sectors for patient/person-centered care, care coordination between the health and human services sectors, population health management, value-based payment, quality reporting, and clinical research. To advance this interoperability goal, the Gravity Project joined the HL7 FHIR Accelerator Program in August 2019 and is developing specifications to support the use of SDOH data using FHIR. The specification includes the creation and administration of SDOH focused assessments, creation of goals and interventions/referrals and tracking them to completion. It provides for workflow specifications between the various participants in documenting and managing social risks. The complete IG includes features that build on these basic interactions that are not in the scope of this connectathon track - to include:

  • Consent - a profile of the Consent Resource that is configured to document the authorization of the patient to share 
  • Exchange of referral related information with patient/client applications
  • Aggregation for exchange/reporting - a profile of the Group Resource to facilitate information sharing with 3rd Parties such as Funders, Payers and Government entities


Test an implementation guide -demonstrate the core flow supported by the IG with scope constrained to the closed-loop Direct Provider to CBO scenario where the inputs to the assessment phase are performed using the PRAPARE.

Related Tracks?

Call for participants

Providers & EHRs, Community Health Centers & vendors, Care Management solution vendors, Payers, and other related HIT vendors

Track Prerequisites

Read the IG, Interest on SDOH

Track Lead(s)

Track Lead Email(s),,,

Specification Information

2023 - 01 Gravity SDOH Exchange

Latest CI Build of SDOH Clinical Care IG:

SDOH Clinical Care IG Deep Dive(from Connectathon and WGM+)

Zulip stream

Test Scripts

Track Kick off Call

Gravity Project Technical Public Bi-Weekly – April 26, 2023 at 3PM ET 

Presentation (PPT)
Recording (to-be-posted)

Testing Scenario:

System roles:

Provider System - Assigns task for patient survey, receives results, submits referral to CBO, reviews CBO provided information

Consumer/Patient App/Portal - Completes a survey and submits to the provider

Community Based Organization (CBO) System - Receives referral, accepts, and provide feedback

Use Case 1: Patient Assessment using a Standards based Questionnaire


Provider assigns a PRAPARE survey to be completed by a Patient

Step 1 - Assign Survey (Provider Role)


On "Referring App" (Provider Facing or CBO Facing for CBO → CBO referrals)

  1. Login as Practitioner
  2. Select Survey
  3. Select Patient
  4. Assign PatientTask


  • PRAPARE survey has been loaded as Questionnaire resource to the FHIR Server

Success Criteria:  

Validate via the Reference Application that PatientTask.

Step 2 - Patient Submission (Consumer Role)


On Patient facing App (mobile, RI or EHR based app)

  1. Login as Patient
  2. Complete assigned Questionnaire 
  3. Submit

Success Criteria:  

Validate that

  • PatientTask.status is now complete
  • QuestionnaireResponse(s) have been created
  • Observations have been created
  • HealthConcerns have been created


Use Case 2: Provider actions related to the referral process.


Practitioner works with Patient to establish Goals based on HealthConcerns derived from the completed assessment; make referral to CBO.

Using a Provider Controlled App:

Step 1: Evaluate HealthConcerns (Condition Resource) derived from the submitted QuestionnaireResponse.

Step 2: With the Consumer, determine which of these HealthConcerns to escalate to the Problem list and establish Goal(s) with the Patient.

Step 3: For a given Goal make a referral to a CBO. 


  • Consumer has completed the assigned Questionnaire and submitted their response.

Success Criteria:  

Validate that

  • Goal(s) have been created
  • Associated with those Goal(s) are at least one ReferralTask and ServiceRequest assigned to a CBO

Bonus point:

Use a Provider facing app provide visualization of the status of Referrals. 

Bonus point:

Demonstrate using a Consumer Controlled App the display of goals and the referrals related to those goals. 


Use Case 3: CBO actions related to the referral process.

Scenario Step 1 - CBO Acceptance

Use a CBO app (RI or other) to accept the referral


On CBO App (mobile, RI or EHR based app)

  1. Login as Care Coordinator
  2. View referrals
  3. Select Referral
  4. Accept

Success Criteria:  

Validate via the Reference Application that

  • Task.status is now "accepted" or "in-progress"

Scenario Step 2 - Task Completion

Use a CBO app to complete the task


On CBO App (mobile, RI or EHR based app)

  1. Login as CBO end-user
  2. View tasks
  3. Update task to complete

Success Criteria:  

Validate via the Reference Application that

  • Task.status is now "completed"


Use Case 4: Provider reviews CBO provided information

Scenario Step 1 - Provider reviews CBO activity Actions:

On Provider App (mobile, RI or EHR based app)

  1. Login as Provider
  2. View Referral Output from CBO
  3. Determine next steps

Success Criteria:  

Validate via the Provider Application that

  • Task.status is now "Complete"

Scenario Step 2 - Task Completion

Use a Provider app to review CBO feedback


On CBO App (mobile, RI or EHR based app)

  1. Login as CBO end-user
  2. View tasks
  3. Update task to complete

Success Criteria:  

Provider reviews CBO feedback and ascertains that the Patient has received services.  

Determines next steps with Patient

TestScript(s): TBD

Security and Privacy Considerations:

Video of DemonstrationVideo of demonstration

If your organization intends to bring technology to this connectathon, please add yourself to this list and comment on each component. 

OrganizationPoint of ContactUse Case Scenario / Testing Focus Area



  • Name,
  • email,
  • Confluence user (@)
Description of the scenario that you intend to test, e.g. Use Case 1,2,3,4, other (tell us about it)
MITRE (FHIR Server) (FHIR Server)