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AI-Powered SDOH Intelligence
for Your EHR

Embed social determinants of health insights directly into Epic and Oracle Health. Reduce ED revisits by 15%. Increase referral completion by 25%.

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SDVOSB Certified
FedRAMP Ready
HIPAA Compliant
SAIC Partner
15%

Reduction in ED Revisits

For targeted high-risk cohorts within 6 months

25%

Increase in Referral Completion

Social service referrals completed successfully

<2s

Time to Insight

Real-time SDOH intelligence in workflow

The SDOH Gap

SDOH screening is widespread, but actionable insights remain fragmented and rarely available at the point of care

Data Fragmentation

SDOH data scattered across systems, disconnected from clinical workflows, and invisible to care teams when it matters most.

Missed Interventions

Without in-workflow alerts, clinicians miss critical social needs leading to preventable ED visits and readmissions.

No Explainability

Existing tools provide risk scores without context, making it impossible to understand root causes and take action.

How SDOH Risk Works

Seamlessly embedded intelligence that transforms social determinants data into clinical action

01

In-Workflow Alerts

CDS Hooks cards appear automatically when clinicians open patient charts, surfacing composite SDOH risk scores and top contributing factors—no context switching required.

  • Patient-view CDS cards trigger on chart open
  • Composite risk with SHAP-based driver breakdown
  • One-click actions for referrals and interventions
  • Order-select hooks for medication adherence risks

SDOH Risk Alert

CDS Hooks • Patient Chart Open

Composite SDOH RiskUpdated: Today
0
High Risk

Elevated risk for ED revisit within 30 days

Top Contributing Factors

Housing Instability+34

Recent eviction notice (Z59.0)

Food Insecurity+21

PRAPARE screen positive (Z59.4)

Transportation Barriers+18

3 missed appointments (Z59.82)

Recommended Actions

Source: SDOH Risk Intelligence • Gravity FHIR
Confidence: 94%
02

Explainable AI

Drill down into causal drivers with timelines, factor interactions, and recommended next steps. Every prediction comes with transparent, auditable explanations.

  • SHAP values show contribution of each factor
  • Interactive timelines of SDOH changes
  • Bias detection and fairness monitoring
  • FedMCP audit trails for all AI decisions

SHAP Explainability Analysis

Feature contributions to SDOH risk score (Patient: Wilson, M. | MRN: 12845)

SHAP values show how much each factor contributes to the patient's risk score. Red bars increase risk, green bars reduce risk.
Housing Instability
+34
Recent eviction notice, unstable housing situation
Food Insecurity
+21
PRAPARE screening positive for food access issues
Transportation Barriers
+18
3 missed appointments in last 60 days
Social Isolation
+12
Limited social support network documented
Chronic Conditions
+9
Diabetes, hypertension with poor control
Community Support
-8
Active enrollment in local support programs
Medication Adherence
-5
Recent improvement in prescription fill rates
Click any factor above to see detailed breakdown
Risk Factors
Protective Factors
Model: SDOH Risk v2.4.1
Explainability: SHAP TreeExplainer
Bias Check: ✓ Passed
Last Updated: 2h ago
03

EHR Write-Back

Gravity FHIR-aligned write-back ensures SDOH insights become part of the permanent clinical record, driving continuity of care and quality reporting.

  • Observations with LOINC-coded risk scores
  • Z-code Conditions (ICD-10 SDOH codes)
  • ServiceRequests for community referrals
  • Goals and Tasks for care plan integration

Gravity FHIR Write-Back

Real-time data flow from SDOH Risk Intelligence to Epic/Oracle Health EHR

SDOH Risk Intelligence

AI model generates risk insights and recommendations

Gravity-Aligned FHIR Resources

Observation

SDOH risk score with LOINC codes

LOINC 96777-8 • Composite SDOH risk = 87
Condition

Social problem Z-codes

Z59.0 • Homelessness (housing instability)
Goal

Care plan objectives

Resolve housing insecurity within 90 days
ServiceRequest

Community referral orders

Refer to housing assistance program

Epic / Oracle Health EHR

Resources appear natively in patient chart

Gravity FHIR Compliant
Standards: US Core 6.1, USCDI v3
Authentication: OAuth 2.0 + SMART
Latency: < 200ms

Works with Your EHR

Built on SMART on FHIR and CDS Hooks 2.0, SDOH Risk integrates seamlessly with leading healthcare platforms

Epic

Full integration with Epic Hyperspace via SMART launch and CDS Hooks. Validated in Epic sandbox environments.

  • Patient-view hooks
  • Order-select integration
  • Flowsheet write-back
  • Epic App Market listed

Oracle Health (Cerner)

Native support for Oracle Health FHIR R4 endpoints. Designed for VA Oracle Health rollout.

  • SMART on FHIR launch
  • CDS Hooks 2.0
  • Problem list integration
  • VA deployment ready

+ Any SMART on FHIR Compliant EHR System

🇺🇸 Built for Federal Healthcare

Serving Those Who Served

As a Service-Disabled Veteran-Owned Small Business (SDVOSB), we understand the unique challenges of federal healthcare delivery.

SDVOSB Certified

Veteran-owned, veteran-built, veteran-focused

FedRAMP Ready

AWS GovCloud IL-4/5 infrastructure with FedMCP audit trails

SAIC Partnership

Subcontractor for VA Oracle Health modernization (171 medical centers)

Compliance First

HIPAA, Section 508, WCAG 2.1 AA, and FedRAMP controls

Ohio VA Pilot

Launching 2026

Cleveland VA (Louis Stokes)

200 high-risk veterans • Housing & chronic conditions

Cincinnati VA Medical Center

Parallel pilot • Reproducibility validation

Champion

Senator Casey Weinstein • Ohio State Senator, Air Force Academy

Prime Contractor

SAIC • VA Oracle Health implementation lead

Ready to Transform Care?

See how in-workflow SDOH intelligence can improve outcomes at your organization