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Incorporating Occupational Information in Electronic Health Records
Pages 1-58

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From page 1...
... , the Institute of Medicine (IOM) appointed the ad hoc Committee on Occupational Information and Electronic Health Records (EHRs)
From page 2...
... focused on moving forward the efforts to incorporate occupational information into EHRs including feasibility studies, demonstration projects, and other actions. BOX 1 Recommendations Initial Focus on Occupation, Industry, and Work-Relatedness Data Elements Recommendation 1: Conduct Demonstration Projects to Assess the Collection and Incorporation of Information on Occupation, Industry, and Work-Relatedness in the EHR NIOSH, in conjunction with other relevant organizations and initiatives, such as the Public Health Data Standards Consortium and Integrating the Healthcare Enterprise (IHE)
From page 3...
... Recommendation 4: Assess Feasibility of Autocoding Occupational Informa tion Collected in Clinical Settings NIOSH should place high priority on completing the feasibility assessment of autocoding the narrative information on occupation and, where available, indus try that currently is collected and recorded in certain clinical settings, such as the Dartmouth-Hitchcock health care system, Kaiser Permanente, New York State Occupational Health Clinic Network, Cambridge Health Alliance, and hospitals participating in the National Electronic Injury Surveillance System. Recommendation 5: Develop Meaningful Use Metrics and Performance Measures Based on findings from the various demonstration projects and feasibility stu dies, NIOSH, with the assistance of relevant professional organizations and the Health IT Policy Committee, should develop meaningful use metrics and health care performance measures for including occupational information in the meaningful use criteria, beginning with the incorporation of occupation, industry, and work-relatedness data, and later expanding as deemed appro priate to include other data elements such as exposures and employer.
From page 4...
... Specifically, NIOSH should evaluate collection methods that involve x patient input through mechanisms such as web-based portals and personal health records, and x other means such as health-related smart cards, health insurance cards, and human resource systems. Recommendation 8: Develop Clinical Decision-Support Logic, Education Ma terials and Return-to-Work Tools NIOSH, relevant professional organizations, and EHR vendors should begin to develop, test, and iteratively refine and expand x clinical decision-support tools for common occupational conditions (e.g., work-related asthma)
From page 5...
... Wegman, Chair Committee on Occupational Information and Electronic Health Records
From page 6...
... This study was conducted by the 11-member ad hoc IOM Committee on Occupational Information and Electronic Health Records. The committee included members with expertise in occupational medicine, electronic health records, primary care, public health, biomedical informatics, information technology, and epidemiology (see Appendix C for committee biosketches)
From page 7...
... This will require the agency's demonstration of feasibility by 2013. An ad hoc committee will plan and hold data-gathering meetings, including a public workshop; conduct analysis; hold deliberations; and prepare a letter report with findings and recommendations that will address the following issues: x Significance -- What are the potential benefits to individual and public health of incorporating occupational information in electronic health records?
From page 8...
... . The current surveillance systems for occupational health, including BLS and workers' compensation databases, do not fully capture the impact of occupational injuries and illnesses (GAO, 2009)
From page 9...
... . A key factor that contributes to underreporting of occupational morbidity, particularly illnesses, is that reporting relies on the health care professional's recognition of a health condition as work related.3 Many such connections are overlooked or misdiagnosed (Landrigan and Baker, 1991; Steenland et al., 2003)
From page 10...
... and is expected to focus on patient-centered health information exchange and clinical decision support (42 CFR 412, 413, 422, and 495)
From page 11...
... In responding to the second part of the task on technical feasibility, the committee decided to examine the individual occupational data elements that are commonly used in occupational health data collection and are considered the most useful for clinical and public health purposes -- occupation, industry, work-relatedness, employer, and exposures. The committee also explored the steps, such as information modeling, that need to occur to provide detailed specifications for each of the data elements.
From page 12...
... resources for workers; and x integration of occupational and clinical health records and links to employer resources (e.g., employee assistance programs, health coaching, workability programs) , community primary care, and other resources.
From page 13...
... Many occupational health problems do not present with signs or symptoms that differ from non-work-related health problems. For example, low back pain occurs in approximately two-thirds of U.S.
From page 14...
... Health care professionals who understand their patients' work demands and occupational environment can draw attention to specific steps needed to minimize or eliminate hazards and increase the safety of the individual and, perhaps, other workers. For example, analysis and correction of ergonomic hazards may prevent recurrence of musculoskeletal disorders, allowing employees to recover and return to work more quickly.
From page 15...
... Workplace discrimination, unequal access to health care professionals with occupational health training, and literacy, language, or other communication barriers can also contribute to these disparities (Souza et al., 2010b)
From page 16...
... Engage Patients and Families in Their Health Care Provide Educational Resources Incorporating occupational information in EHRs could provide opportunities to educate patients and families about occupational risks and prevention strategies and could link patients with available services provided by employers, as well as other community organizations. For example, information about hazards and prevention strategies could be provided to patients diagnosed with common occupational health conditions (e.g., tendinitis, dermatitis)
From page 17...
... Sharing of health-related data could be improved through smart card technologies that allow easy transport of a patient's medical record and health history between health care professionals and that provide access to information on prescriptions, insurance, and reimbursements. This technology is in use in several European and Asian countries and under exploration in others.
From page 18...
... At present, this information (if available) is often dispersed across multiple paper and electronic record systems maintained by general or specialty health care professionals, administrative offices of health care professionals, non-employer-based occupational health clinics, individuals in their PHRs, personnel or human resource departments, and employee health records (if the person has consented to have it included)
From page 19...
... In many states, health care professionals are required to report certain work-related health conditions (e.g., silicosis, work-related asthma, elevated lead levels, serious injuries) to the state health department for surveillance purposes and potential public health intervention.
From page 20...
... Furthermore, the collection of occupational health information could help inform other public health efforts, such as vital records, disease registries, health policy studies, and environmental public health efforts. Often a first step in assessing the environmental cause of a community disease cluster is to rule out occupational exposures.
From page 21...
... Incorporating occupational information in EHRs could have additional benefits such as triggering decision support and monitoring the quality of recommended preventive services for at-risk groups, such as increasing the proportion of adults "who have discussed with a .
From page 22...
... FEASIBILITY Bearing these potential benefits of EHRs in mind, the committee considered the feasibility of getting occupational information into and out of the EHR most efficiently to improve clinical care and public health efforts. For each of the occupational data elements that are commonly used in occupational health data collection and that could potentially be included in the EHR (i.e., occupation, industry, workrelatedness, employer, and exposures)
From page 23...
... x The problem list section of the EHR included an option for the clinician to classify a health problem as suspected to be work related. x Patient and health care professional education materials about occu pational health conditions were included on the CHA intranet, which is available to clinicians.
From page 24...
... The occupational health EHR can be tracked by dif ferent variables (e.g., workgroup, shift, supervisor, job type) to assess population health.
From page 25...
... Current Environment and Technical Considerations for Each Occupational Data Element Occupation The data element "occupation" asks for the individual's job title, although a general description of a person's work may also be included. Being asked one's occupation is a familiar question to many people because it is asked on commonly completed forms and surveys.
From page 26...
... It would be useful for NIOSH to assess the extent to which the data element for industry is needed to accurately code occupation before making a final determination about the need to collect industry as well as occupation in the EHR. Technical considerations While the job title alone does not reveal specific exposures, it can suggest common risks, prompt the clinician to ask for details on exposures and work conditions, and provide access to clinical decision-support tools.
From page 27...
... Relevant work history information can be built over time by updating current occupation at each health care encounter or on a regular basis. "Usual" occupation, which is generally defined as the longest-held job, could be derived from the history.
From page 28...
... BOX 5 Example of the Use of Occupational Data Elements in the EHR: Work-Related Asthma Approximately 8 percent of adults in the United States have asthma (Moorman et al., 2011) , and nearly 20 percent of new-onset cases in the adult population are estimated to be caused by occupational exposures (Toren and Blanc, 2009)
From page 29...
... State workforce agencies collect and code information on the employer's industry for all establishments covered by unemployment insurance programs, but it is not clear how or if this information could be made 10 For example, the American Community Survey, the Current Employment Statistics Survey, the Current Population Survey, the Quarterly Census of Employment and Wages, and the Survey of Occupational Injuries and Illnesses.
From page 30...
... Rather, work-relatedness is a modifier of other data elements, such as symptoms, diagnosis, or exposure, to allow the clinician to denote the relationship between a health event and work risks or exposures. Documentation of work-relatedness in the EHR may facilitate patient management, individual patient access to workers' compensation benefits and other resources, public health reporting of notifiable conditions, and use of data for surveillance of work-related injuries and illnesses.
From page 31...
... . Many physicians receive little training in occupational medicine, may not be aware of the effects that specific work exposures can have on health, and may find it challenging to determine whether specific illnesses or disorders are work related.
From page 32...
... Having a data element or attribute to denote work-relatedness could prompt health care professionals to think about the potential for a connection between work and the health condition. Although more education for clinicians and patients is needed regarding these potential connections, this prompt in the EHR could be one of the starting points for early recognition of an association as well as for further education efforts.
From page 33...
... Developing ways to integrate this information into the EHR could be explored, as could occupational information available for Medicaid and Medicare beneficiaries. Technical considerations As noted above, a two-way interface with administrative data elements populating clinical records and vice-versa should be possible so that all parts of the EHR contain uniform, up-todate employer data.
From page 34...
... Current environment Documenting exposures can be important in cases of illness, but also in the absence of health conditions if ongoing monitoring is required or advised, or if an exposure (e.g., asbestos) interacts with other risk factors, such as smoking.
From page 35...
... Workerentered data on their own occupational exposures may be quite broad but, given certain health conditions, may be sufficient to prompt further questions. One initial step may be to ask patients if they have been exposed to hazardous toxins where the association with disease has been well documented (e.g., lead, asbestos)
From page 36...
... The following could improve patient care with regards to occupational health conditions: x using the EHR problem list to store occupational health informa tion, x examining the impact on clinical workflow on access to occupa tional information, x exploring the feasibility of using patient-entered or validated da ta, and x developing ways in which the EHR can support the patient's re turn to work. Use of the EHR Problem List The EHR problem list is one module that could be used to document or highlight information on the work-relatedness of diseases and injuries or on significant exposures that need ongoing monitoring.
From page 37...
... Health care professionals may not take the time to consistently update the problem list to reflect current status of treatment or evolution of the problem. In some health systems, the problem list for an individual patient may be shared across specialties or types of clinicians (M.D./R.N.)
From page 38...
... Considerations regarding specificity, reliability, validity, ownership, and currency complicate the potential ways that problem lists can be used and exchanged. The ability to note the work-relatedness of a health condition or exposure is feasible, but standardization of the information model across diverse workflows and care settings will be complicated and should be harmonized with other efforts to upgrade problem list maintenance for the EHR.
From page 39...
... Alternative ways of accomplishing this should be evaluated, in order to compile a set of "best practices." Feasibility of Using Patient-Entered or Validated Data Current environment While most EHR information is recorded by administrative staff and clinicians, strategies are increasingly available for patients to enter new information or validate existing information in the EHR. Patients may populate the EHR through electronic data entry forms, a patient portal directly linked to the EHR, or the exchange of information from a PHR independent of the EHR.
From page 40...
... Regardless of the cause of an illness or injury, a worker with a temporary or permanent impairment that might be exacerbated by work or that would make work difficult needs to be accommodated by the employer. Current environment Some EHRs include data that could be used to assess the impact that work has on injured or ill workers and could simplify the administrative transactions between health care professionals and employers.
From page 41...
... An information model provides the framework for defining data elements and their necessary attributes, the relationships among these elements, and the code systems required to support use cases. In addition, information modeling enables the interpretation of data elements in con
From page 42...
... This information could enable improved individual and population health care through betterinformed diagnoses, more focused treatment plans, and improved and streamlined return-to-work guidance. Additionally, occupational information in EHRs could make notifiable disease and injury reporting more efficient and allow for improved surveillance of hazards in the work environment, reduce workplace risks, and improve population health.
From page 43...
... As discussed throughout this report, the committee considered in depth the five data elements that are commonly used in occupational health data collection and are considered the most useful for clinical and public health purposes -- occupation, industry, work-relatedness, employer, and exposures. Of the five that were explored, three elements were deemed ready for immediate focus -- occupation, industry, and workrelatedness -- with the other two (employer and exposures)
From page 44...
... The committee's recommendations are intended to provide an ongoing line of reasoning that will support successively more sophisticated inclusion and use of occupational information in EHRs over a period of years. Initial Focus on Occupation, Industry, and Work-Relatedness Data Elements Demonstration projects focused on incorporating occupation, industry, and work-relatedness data elements into the EHR will provide NIOSH with the depth of information that is needed to show feasibility for enhancing patient care and public health across a range of care settings and locations.
From page 45...
... Issues regarding privacy and access to health information in the context of work-related health will need further exploration. Recommendation 1: Conduct Demonstration Projects to Assess the Collection and Incorporation of Information on Occupation, Industry, and Work-Relatedness in the EHR NIOSH, in conjunction with other relevant organizations and initia tives, such as the Public Health Data Standards Consortium and Inte grating the Healthcare Enterprise (IHE)
From page 46...
... Furthermore, NIOSH should develop models for reporting health data from EHRs by oc cupation and industry at different levels of granularity that are mea ningful for clinical and public health use. Recommendation 4: Assess Feasibility of Autocoding Occupa tional Information Collected in Clinical Settings NIOSH should place high priority on completing the feasibility as sessment of autocoding the narrative information on occupation and, where available, industry that currently is collected and recorded in certain clinical settings, such as the Dartmouth-Hitchcock health care system, Kaiser Permanente, New York State Occupational Health Clinic Network, Cambridge Health Alliance, and hospitals participat ing in the National Electronic Injury Surveillance System.
From page 47...
... Recommendation 7: Develop and Test Innovative Methods for the Collection of Occupational Information for Linking to the EHR NIOSH should initiate efforts in collaboration with large health care provider organizations, health insurance organizations, EHR ven
From page 48...
... Recommendation 8: Develop Clinical Decision-Support Logic, Education Materials, and Return-to-Work Tools NIOSH, relevant professional organizations, and EHR vendors should begin to develop, test, and iteratively refine and expand x clinical decision-support tools for common occupational conditions (e.g., work-related asthma) ; x tools and programs that could be easily accessed for educa tion of patients and caregivers about occupational illnesses, injuries, and workplace safety; x training modules for administrative staff to collect occupa tional information in different care settings; and x tools to improve and standardize functional job assessment and return-to-work documentation in EHRs, including stan dards for the transmission of these forms.
From page 49...
... 2011. Personal health records: A scoping review.
From page 50...
... PowerPoint presentation at the IOM Workshop on Occupa tional Information and Electronic Health Records, Washington, DC, June 2. http://iom.edu/~/media/Files/Activity%20Files/Environment/OccupationalHealth Records/Panel%203%20Cocchiarella.pdf (accessed July 12, 2011)
From page 51...
... https://iupdate.dnb.com/iUpdate/ companylookup.htm (accessed July 25, 2011)
From page 52...
... Power Point presentation at the IOM Workshop on Occupational Information and Electronic Health Records, Washington, DC, June 2. http://iom.edu/~/ media/Files/Activity%20Files/Environment/OccupationalHealth Records/ Panel%202%20Kreiss.pdf (accessed July 25, 2011)
From page 53...
... PowerPoint presentation at the IOM Workshop on Occupational Infor mation and Electronic Health Records, Washington, DC, June 2. http:// iom.edu/~/media/Files/Activity%20Files/Environment/Occupational Health Records/Panel%201%20McLellan.pdf (accessed July 12, 2011)
From page 54...
... PowerPoint presenta tion at the IOM Workshop on Occupational Information and Electronic Health Records, Washington, DC, June 2. http://iom.edu/~/media/Files/ Activity%20Files/Environment/OccupationalHealthRecords/Panel%203%20 Papanek.pdf (accessed July 12, 2011)
From page 55...
... 2010b. Surveillance of occupational health disparities: Challenges and opportunities.
From page 56...
... Power Point presentation at the IOM Workshop on Occupational Information and Electronic Health Records, Washington, DC, June 2. http://www.iom/~/ media/Files/Activity%20Files/Environment/OccupationalHealth Records/ Panel%204%20Taylor.pdf (accessed July 25, 2011)
From page 57...
... PowerPoint presentation at the IOM Workshop on Occupational Information and Electronic Health Records, Washington, DC, June 2. http://iom.edu/~/media/Files/Activity% 20Files/Environment/OccupationalHealthRecords/Panel%203%20Zuroweste.


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