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  • ACOEM Supports NIOSH Efforts to Include Occupational Health Data (OHD) in a National Standard for Use of EHRs

    August 4, 2011 

    John Howard, MD
    National Institute for Occupational Safety and Health
    395 E Street, S.W., Suite 9200
    Patriots Plaza Building
    Washington, DC 20201 

    Dear Dr. Howard, 

    On behalf of the American College of Occupational and Environmental Medicine, I am writing to support NIOSH’s efforts for the inclusion of occupational health data (OHD) in a national standard for the meaningful use of Electronic Health Records (EHRs). Although many vendors have developed specialized EHR systems for Occupational Medicine, EHRs for general group health have not typically included features related to a patient’s work life, such as data fields to code a patient’s occupational risks or work capacity – despite clear evidence that such data can be critically important for quality care in almost any field of medical practice. Though ACOEM has participated in a NIOSH sponsored Institute of Medicine workshop on this topic and will be publishing its own policy paper, we hope to emphasize our key points directly with you. 

    As the pre-eminent medical organization that champions the health and safety of workers, ACOEM represents nearly 5,000 physicians and other allied health professionals who are specialists in the field of occupational and environmental medicine. Though our members have specialty based reasons for expanding the inclusion of OHD in EHRs, we strongly believe that this data will enhance the capability of the clinical and public health systems to improve the health of individuals and populations. Given that a small percentage of work-related health conditions are managed by trained occupational medicine physicians, the rest of the medical workforce must collect and use the basic data essential for providing decent quality care to the American workforce. For primary care and population management in particular, attention to occupational exposures and overall functional status is as important as attention to other lifestyle factors that correlate with good health. 

    About 140 million Americans work in the private sector. In 2009, the Bureau of Labor Statistics reports that 3.6% of the workforce was injured or became ill as the result of their work.  For these people, and their families, medical knowledge of the hazards and demands associated with their work may not only be useful in treating their conditions, but is essential in preventing reinjury or aggravation of their medical conditions. This  is the foundation for primary prevention. 

    As well, the general health of a worker may affect their ability to work and the safety with which they perform their jobs. Medical assessment of fitness for duty and informed decision-making about return to work is simply not possible without basic knowledge of a worker’s job and capacity. 

    Occupational epidemiology has identified specific hazards that significantly raise the risk of occupational diseases, such as asbestos related diseases, lead poisoning, or noise-related hearing loss. Knowledge of these sentinel occupational exposures provides a worker’s health care team the sine qua non necessary for correct diagnosis and management of an exposure related condition. 

    These basic points about the utility of occupational health data are not new. Indeed, the Centers for Disease Control’s Healthy People publication has long advocated for increasing the percentage of physicians who collect a basic occupational history. Sadly, this advocacy has not been effective despite decades of effort devoted to trying to incorporate occupational history-taking into mainstream medicine. 

    What is different in 2011?  First,  the incentive to transition health care to use of electronic records provides technology that can help automate the collection of occupational health data through linkage with existing public health data bases, such as O* Net. Second, the standardization of certain data sets essential for “meaningful use” of EHRs provides the opportunity and financial incentive to collect occupational health data on a broad scale. Thirdly, the transformation of the health care delivery system from the traditional physician centric model to a patient-centered team-based model will facilitate the collection and use of occupational data by the most appropriate people on a health care team. The appropriate people may be a patient registrar at a front desk, a health coach, a nurse, or another team member who can use this information in collaboration with a physician to assure safe and speedy return to work after injury or illness (no matter what the cause). Further, these team members can help assure that the physician or mid-level provider on a team has information useful to appropriate diagnosis and treatment.  

    Finally, ACOEM urges NIOSH to advocate that EHR vendors develop software functionalities which meet the legal exigencies for data privacy, surveillance, and communication inherent to the use and transmission of occupational health data. If OSHA or other federal agencies want to review medical records, employers rely on health care providers to disaggregate occupational from personal health information and open these job-related records to the auditing agency.  A provider conducting mandated health assessments such as  preplacement exams, DOT physicals or medical surveillance is acting as an agent of the employer and should not, without consent, have access to an examinee’s personal health information. Providers need to be able to easily communicate work capacity statements stripped of personal health information to a variety of stakeholders. And finally, an employee/patient should be able to complete a health risk assessment at work or in their primary care office and expect that this data will populate both their personal health record and be aggregated for an employer for purposes of population health management. 

    In sum, we propose six recommendations for advancing personal and population health by incorporating occupational health data as a standard of care for the meaningful use of the certified EHR. 

    1. The EHR should contain standardized fields to capture a patient’s functional capacity or work capacity, with a required minimum set of data elements.
    2. The EHR should record and retain a standardized code (such as the Standard Occupational Classification) reflecting the patient’s job, together with the date that the job code was recorded, in a searchable way.
    3. The EHR should record certain “sentinel” occupational exposures or risk factors, with a capability to use these sentinel risks for later clinical management and decision support. 
    4. The EHR should be able to exchange context-specific “messages” (including legally mandated forms) in a secure way among credentialed stakeholders, including outside stakeholders who are not EHR users.
    5. The EHR should be able to exchange specified data elements that are relevant to occupational safety and health, including Health Risk Appraisals (HRA’s), with Personal Health Record (PHR) systems.
    6. The EHR should allow for adjustable “firewalls” – allowing users of the EHR to see a limited subset of fields, relevant to occupational health and safety, under certain circumstances.

    We hope that NIOSH, IOM, and the Office of the National Coordinator (ONC) will consider including these recommendations among their upcoming stage 3 “meaningful use” criteria and requirements for a certified EHR, and we also urge software vendors to consider incorporating these capabilities into future releases of EHR systems, whether for Occupational Medicine or for the Group Health market. 

    Sincerely, 

    T. Warner Hudson MD, FACOEM, FAAFP
    President
    American College of Occupational and Environmental Medicine