Incorporating Occupational Information in Electronic Health Records: Letter Report
The National Academies Press
The National Academies Press (NAP) was created by the National Academies to publish the reports issued by the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council, all operating under a charter granted by the Congress of the United States. The NAP publishes more than 200 books a year on a wide range of topics in science, engineering, and health, capturing the most authoritative views on important issues in science and health policy. The institutions represented by the NAP are unique in that they attract the nation’s leading experts in every field to serve on their award-wining panels and committees. The nation turns to the work of NAP for definitive information on everything from space science to animal nutrition.Author:
David H. Wegman, Catharyn T. Liverman, Andrea M. Schultz, and Larisa M. Strawbridge, Editors; Committee on Occupational Information and Electronic Health Records; Institute of Medicine
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Each year in the United States, more than 4,000 occupational fatalities and more than 3 million occupational injuries occur along with more than 160,000 cases of occupational illnesses. Incorporating patients' occupational information into electronic health records (EHRs) could lead to more informed clinical diagnosis and treatment plans as well as more effective policies, interventions, and prevention strategies to improve the overall health of the working population. At the request of the National Institute for Occupational Safety and Health, the IOM appointed a committee to examine the rationale and feasibility of incorporating occupational information in patients' EHRs. The IOM concluded that three data elements - occupation, industry, and work-relatedness - were ready for immediate focus, and made recommendations on moving forward efforts to incorporate these elements into EHRs.
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) International, should conduct demonstration projects involving EHR vendors and health care provider organizations (diverse in the services they provide, populations they serve, and geographic locations) to assess the collection and incorporation of occupation, industry, and work-relatedness data in the EHR at different points in the workflow (including at registration, with the medical assistant, and with the clinician). Further, to examine the bidirectional exchange of occupational data between administrative databases and clinical components in the EHR, NIOSH in conjunction with IHE should conduct an interoperability-testing event (e.g., Connectathon) to demonstrate this bidirectional exchange of occupational information to establish proof of concept and, as appropriate, examine challenges related to variable sources of data and reconciliation of conflicting data.
Recommendation 2: Define the Requirements and Develop Information Models for Storing and Communicating Occupational Information
NIOSH, in conjunction with appropriate domain and informatics experts, should develop new or enhance existing information models for storing occupational information, beginning with occupation, industry, and work-relatedness data and later focusing on employer and exposure data. The information models should consider the various use cases in which the information could be used and use the recommended coding standards. For example, NIOSH should consider how best to use social history templates to collect a work history and the problem list to document exposures and abnormal findings and diagnoses with optional work-associated attributes for possible, probable, or definite causes; exposures; and impact on work.
Recommendation 3: Adopt Standard Occupational Classification (SOC) and North American Industry Classification System (NAICS) Coding Standards for Use in the EHR
NIOSH, with assistance from other federal agencies, organizations, and stakeholders (e.g., Bureau of Labor Statistics, Census Bureau, Council of State and Territorial Epidemiologists [CSTE], National Library of Medicine, National Institute of Standards and Technology, National Uniform Billing Committee, Health Level 7 International [HL7]), should recommend to the Health Information Technology (IT) Standards Committee the adoption of SOC and NAICS to code occupation and industry. Furthermore, NIOSH should develop models for reporting health data from EHRs by occupation and industry at different levels of granularity that are meaningful for clinical and public health use.
Recommendation 4: Assess Feasibility of Autocoding Occupational Information Collected in Clinical Settings
NIOSH should place high priority on completing the feasibility assessment 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 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 studies, 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 appropriate to include other data elements such as exposures and employer.
Recommendation 6: Convene a Workshop to Assess Ethical and Privacy Concerns and Challenges Associated with Including Occupational Information in the EHR
NIOSH should convene a workshop involving representatives of labor unions, insurance organizations, health care professional organizations, workers’ compensation-related organizations (e.g., International Association of Industrial Accident Boards and Commissions, National Council on Compensation Insurance), and EHR vendors to
.. assess the implications for the patient and clinician of incorporating work-relatedness in the EHR, with respect to workers’ compensation; and
.. propose guidelines and policies for protecting the patient’s non-workrelated health information from inadvertent disclosure and to ensure compliance with the Health Insurance Portability and Accountability Act, workers’ compensation, and other privacy standards.
Enhance the Value and Use of Occupational Information in the EHR
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 vendors, and other stakeholders to develop and test methods for collecting occupational data from innovative sources. Specifically, NIOSH should evaluate collection methods that involve
.. patient input through mechanisms such as web-based portals and personal health records, and
.. other means such as health-related smart cards, health insurance cards, and human resource systems.
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
.. clinical decision-support tools for common occupational conditions (e.g., work-related asthma);
.. tools and programs that could be easily accessed for education of patients and caregivers about occupational illnesses, injuries, and workplace safety;
.. training modules for administrative staff to collect occupational information in different care settings; and
.. tools to improve and standardize functional job assessment and return- to-work documentation in EHRs, including standards for the transmission of these forms.
Recommendation 9: Develop and Assess Methods for Collecting Standardized Exposure Data
NIOSH should continue to work with occupational and environmental health clinics and other relevant stakeholders to develop and assess methods for collecting standardized exposure data for work-related health conditions. NIOSH should explore the feasibility of
.. listing possible or probable exposures in the problem list or elsewhere in the EHR;
.. linking occupational information in the EHR to online occupational, toxicological, and hazardous materials databases, such as the Occupational Information Network (O*NET), the Association of Occupational and Environmental Clinics, and Haz-Map, to enhance diagnosis and treatment of work-related illnesses and injuries; and
.. automatically generating codes for exposures based on narrative text entries.
Recommendation 10: Assess the Impact of Incorporating Occupational Information in the EHR on Meaningful Use Goals
NIOSH, in conjunction with relevant stakeholders (e.g., Public Health Data Standards Consortium, CSTE, Association of State and Territorial Health Officials), should
.. develop measures and conduct periodic studies to assess the impact of integrating occupational information in EHRs, and
.. estimate the economic impact of EHR-facilitated return-to-work practices for both work-related and non-work-related conditions.
