Health Information Exchange-Enabled Investigation of Health-Related Social Needs Referral Process Retention and Fulfillment

Background Health-related social needs (HRSN) significantly influence health outcomes, yet healthcare organizations face persistent challenges tracking referrals to community-based organizations and interpreting referral outcomes across fragmented clinical and social care systems. Prior studies report low referral fulfillment rates, but much of this evidence derives from single organizations, manual data collection, or incentivized documentation workflows, limiting insight into how information infrastructure shapes what is observable at scale. Objective This study aimed to evaluate how HRSN referral initiation, documented outcomes, and time-to-fulfillment are captured when electronic health record (EHR) data and closed-loop HRSN platform data are integrated through a statewide health information exchange, and to identify informatics strengths and limitations affecting cross-system observability of referral processes. Methods We conducted a retrospective observational study of 1,628 adult patients from a federally qualified health center and three health systems. Linked EHR and HRSN platform data were used to examine referral initiation, documented fulfillment, and time to fulfillment across resource types. Results Patients received an average of two referrals, with approximately 80% addressing basic needs. Fewer than 3% were documented as fulfilled, reflecting constrained documentation workflows rather than confirmed absence of service delivery. Short-term needs were more likely to transition to documented outcome states and had shorter documented time-to-fulfillment, whereas long-term needs-particularly housing-exhibited wide variability and documentation patterns consistent with workflow-driven closure behavior. Conclusion Instead of examining referral fulfillment as a performance metric, the findings suggest how socio-technical infrastructure, workflow design, and documentation incentives affect what becomes observable in secondary use of HRSN data.