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  • ACOEM Comments on Stage 3 Meaningful Use Criteria in EHRs

    January 9, 2013

    Farzad Mostashari, MD, ScM
    National Coordinator for Health Information Technology
    U.S. Department of Health and Human Services
    200 Independence Avenue S.W., Suite 729-D
    Washington, D.C. 20201

    Re: Request for Comment Regarding the Stage 3 Definition of Meaningful Use of Electronic Health Records (EHRs)

    Dear Dr. Mostashari:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to the Request for Comments, issued by the Health Information Technology (HIT) Policy Committee regarding proposed Stage 3 Meaningful Use Criteria for electronic health records (EHRs).

    Our comments are based on strong evidence that work affects health and health affects work. Approximately 140 million Americans are employed. Their health can affect their ability to work safely and productively, and in turn their jobs can affect their health. A basic knowledge of a worker’s job duties and hazards can be invaluable to all physicians in order to recognize and treat work‐related conditions and to prevent injury and illness in other workers. Furthermore, a physician’s knowledge of a patient’s job duties is foundational for facilitating a prompt and safe return to work. Finally, incorporating basic occupational demographic information into all EHRs could make important contributions to public health practice and research. Ignoring this fundamental determinant of health puts at risk several important societal priorities: achieving the “triple aim” of improving the experience of care, improving the health of populations, and reducing per capita costs of health care; reducing health disparities; improving population health; and providing the nation a productive workforce.

    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.

    Comments on SGRP-104
    ACOEM is pleased that the Committee has recommended making as a Criterion for certified electronic health records the coding of a patient’s occupation and industry. Research has shown occupation to be a predictor of health, and including industry and occupational information could have significant impact on the overall health and well-being of patients.

    ACOEM strongly supports this recommendation, believing that such information will prove valuable both for clinical management and for future epidemiologic investigations, including investigation into the causes of cancer and other chronic disabling conditions in the nation. Knowledge of occupation and industry informs both accurate diagnosis and management of occupational and personal health conditions. For example  treating asthma without recognition of occupational triggers can result in poor medical and vocational outcomes and high medical and disability costs. Since occupational health risk, personal health risk and disease burden and socioeconomic status disadvantage have been found to cluster, health system knowledge of occupation enhances the individual provider’s capability to target those most in need of care … thereby helping to address health disparities and improve population health.

    Collection of basic industry and occupational information in all medical settings is feasible and can be accomplished by administrative personnel without increasing the burden of clinicians. NIOSH, IOM and others have pointed to approaches for collecting this data. Clinicians can then probe for further occupational detail when relevant to the clinical context.

    Regarding the recommendation for including disability status under SGRP-104, we concur that there is an important distinction between current disability status as described by the patient, and disability status, “work-ability,” as recommended or prescribed by the health care provider during the encounter.

    ACOEM strongly supports the inclusion of “disability status” in the EHR though we prefer the term “functional status” or “workability.” Workability and social functional status is a key ingredient of a healthy and productive nation. Further, health care providers are the societal gatekeepers to disability benefits. Highlighting disability on the Problem List of the record as well as the demographic section is the first step in bringing attention to the importance of our medical system taking a more active role in the prevention, management, and assessment of disability.

    With regard to current disability status, we believe that the Problem List should record whether the patient is currently: a) capable of all activities without restriction; b) partially impaired with regard to work or other life functions; or c) totally disabled for any occupation. This recording of current work ability status, as reported by the patient, should be recorded, along with duration, on the patient problem list, including the option for the clinician to “resolve” a previous disability code.

    For future consideration:
    • We recommend that in the future, certified EHRs should have the capacity for providers to easily document and transmit the type of work capacity/restriction information uniformly required by workers compensation and other disability insurance programs.
    • ACOEM recommends that in a future set of Meaningful Use criteria consideration be given for one or more additional structured fields attached to the “activity prescription” to record additional information about the clinician’s reason for giving the specific set of restrictions or activity prescription, i.e., based on a functional capacity evaluation, physical exam or other data.
    • We further suggest that disability status should ultimately be included as comparable V-codes in ICD-9, or Z-codes in ICD-10.

    Comment on MU-01
    ACOEM acknowledges that some providers may initially find it burdensome to comply with all of the criteria. However, with regard to the proposed SGRP-104 criteria we believe that this compliance problem should best be addressed by adjusting the compliance target, rather than by making the whole criterion optional. We believe that work status, as recorded in an occupation and industry code, is important for essentially all medical specialties involved in the care of adult patients. Accordingly we urge HITPC to seek broad compliance with this criterion.

    Comments on MU-04 and 05
    Regarding the questions raised in MU04 and MU05, as outlined in the attached ACOEM opinion paper (General Health Electronic Health Records (EHRs) and Occupational Elements: A Call for New Meaningful Use Criteria) there are three important capabilities for interoperability that we believe all credentialed EHRs should have:

    1) An EHR system must have robust messaging capability, with the ability to include “message wrappers” to enable credentialing of message recipients. Such a capability should also address patient consents for record release to outside message recipients.

    2) To facilitate information transfer between the patient-centered medical home and other loci of care (such as the workplace), the EHR must be able to exchange a minimum set of occupational health data with the Personal Health Record (PHR).

    3) To take account of the confidentiality requirements imposed by ADA (Americans with Disabilities Act) and GINA (Genetic Information and Non-Disclosure Act), the EHR must have adjustable information “firewalls” to allow users with varying levels of credentialing to view different fields.

    Thank you for your consideration of our comments. Please do not hesitate to contact me or Pat O’Connor, ACOEM’s Director of Government Affairs, at 202-223-6222, should you have any questions regarding the concerns outlined above or this matter in general.

    Karl Auerbach, MD, MS, MBA, FACOEM

    Enclosure: ACOEM Opinion Paper: General Health Electronic Health Records (EHRs) and Occupational Elements: A Call for New Meaningful Use Criteria