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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 Draft 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

CMS 2022 - 07 FHIR Connectathon 3


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.

Track Lead(s)

Gregory Harris, Aaron Seib

Track Lead Email(s), 

Specification Information

Latest CI Build of Gravity IG:

Note/Disclaimer regarding Personal Characteristic Value SetsProcess for selecting Value Sets for Draft Personal Characteristics Profiles
1.    The value sets were selected to minimize LOE in selecting/creating value sets for these POC, draft profiles. Where possible, an off-the-shelf, existing value set was be used (whether US Core, Nationally, USCDI, etc.). 
2.    In the future, the value sets can be aligned with vetted value sets (e.g., from the Gender Harmony Project).
3.    Specific disclaimers may also be added for specific draft value sets of specific draft profiles (e.g., for the Sexual Orientation Value Set to acknowledge that “asexual” will be represented in a future value set.)
4.    The need to conform to a consistent structure with respect to how “null” values (e.g., unknown) are handled may impact the use of existing values sets as follows:
o    Race and Ethnicity - Allow multiple answers. Therefore, null values are best handled in the Observation.dataAbsentReason value set and are excluded from the Observation.value value sets. 
o    Sexual Orientation, Gender Identity, Recorded Sex and Gender, Pronouns - Do not allow multiple answers. Therefore, null values are allowed in the value set for Observation.value.

Call for participants

We are encouraging all parties interested in implementing standards based solutions to enable inter-sector data exchange to improve outcomes for those we all serve to join us at the Connectathon.

In advance of the connectathon the following participants are working together to prep for the upcoming Connectathon, including:

  • HealthLX - RI operators -support all three scenarios
  • SAFFRON Labs- Scenarios 1 & 2
  • Open City Labs, MayJuun, Zane (?)
  • EMI Advisors - Scenario 1
  • MiHIN - Scenario (?)
  • OCHIN (?)
  • MaxMD - Demonstrate completion of the Personal Characteristic Survey

Please don't hesitate to reach out to either of the track leads if you have code and are interested in participating as one of the Actors in the use cases detailed below.

All observers are welcome to attend as well!

Zulip stream

Track Implementers Connection Call

FHIR IG Work Group Meetings (repurposed for Connectathon)

Weekly Gravity Track Connectathon ScheduleFHIR IG Work Group Meetings (repurposed for Connectathon)

Testing Scenarios:

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"

Bonus point:

Use a Provider facing app to review status of Referrals and display any additional information provided by the CBO.