Related APHA Policy Statements
APHA Policy Statement 200911 - Public Health’s Critical Role in Health Reform in the United States1
APHA Policy Statement 201011 - Reforming Primary Health Care: Support for the Health Care Home Model2
APHA Policy Statement 7819 - Occupational History Taking by Physicians and Other Health Personnel3
Nearly 60% of the US population is employed, and most of these individuals spend more than half of their waking hours at work. The work environment has a well-recognized influence on health through exposures to physical, chemical, and other hazards, as well as stress that results from work organization and other working conditions detrimental to physical and emotional health. Yet information about patients’ work is not routinely captured in medical records. Electronic health records (EHRs) that include occupational information provide an opportunity to improve public health surveillance interventions and clinical medicine. A 2011 Institute of Medicine (IOM) committee examined this issue, in light of the Health Information Technology for Economic and Clinical Health Act of 2009, and made a series of recommendations directed at the US Department of Health and Human Services and, in particular, the National Institute for Occupational Safety and Health. This policy resolution endorses the IOM committee’s report and its recommendations, including conducting demonstration projects and feasibility studies, developing meaningful use metrics, and developing models for storing and communicating occupational information in EHRs.
Current developments in the implementation of electronic health records (EHRs) in US health care offer great promise for improved health care delivery and population health. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act has provided the financial stimulus for EHRs to be widely adopted while establishing mechanisms to standardize core elements to be included. For a number of reasons, it is critical that occupational health information be accepted as one of those core elements.5 APHA uses the World Health Organization’s definition of “occupational,” which describes attributes related to one’s occupation (e.g., carpenter), industry (e.g., construction), employer, and work exposures (e.g., noise). Occupational illness, injury, and fatality refer to morbidity and mortality related to employment and the work environment. Work-related denotes a condition caused by or aggravated by work.6
The US population currently exceeds 308 million,7 and nearly 60% of the population is employed.8 These employed US residents spend almost half of their waking hours at work.9 The work environment can have a significant impact on workers’ health,10–13, as well as the health of their family members.14 Work is a well-recognized influence on health through exposures to physical, chemical, radiological, biological, and ergonomic hazards; psychosocial factors; and organizational attributes of the workplace.15 Less well understood by health care providers is how the demands and risks of work influence non-work-related health conditions. Health care providers who take full account of work-related issues when guiding their patients through recovery from acute or chronic illnesses can expect better healing and reduced likelihood of relapse and can manage chronic conditions with the expectation of better long-term outcomes.16,17 Readily available occupational information in the EHR would provide health care providers with this critical information to guide treatment, rehabilitation, and prevention of the recurrence of both work-related and non-work-related health conditions.18,19
In addition to the value that occupational information brings to the clinical setting, this information is of significant importance with respect to population health. Much has been learned about work-related cancer from occupational information obtained by cancer registries. This information is gathered directly from the clinical record. Should the opportunity presented by the HITECH Act to incorporate occupational information into electronic health records be disregarded, further advances would be greatly hindered. Current methods to identify occupationally related health outcomes currently must use evaluations of data from hospital discharge and emergency room records, a process that is time consuming and costly and often results in incomplete information.
In a related area, current surveillance systems do not fully capture the impact of the work environment on morbidity and mortality.20–29 Inadequate data on the effects of the work environment on health impede the ability of health care providers to diagnose and treat illnesses and injuries and hinder the application of appropriate public health interventions.
Proposed Recommendations Statement
The Board on Health Sciences Policy of the Institute of Medicine (IOM) issued a report in 2011 (“Incorporating Occupational Information in Electronic Health Records”) outlining the potential benefits of including information about individuals’ occupations, industry, and work environment in their electronic health records.15 Patients may already be asked to provide their job title or occupation for administrative and reimbursement purposes, but this information is rarely integrated with clinical data. Although a job title alone will not provide data on people’s work exposures, it can be an indicator to prompt a health care provider to consider it in diagnosis and treatment decisions. IOM’s report illustrated how existing occupational coding systems (e.g., the Bureau of Labor Statistics’ Standard Occupational Classification) have been linked to employer-specific job titles (e.g., as in the Dartmouth-Hitchcock Medical Center program), but such practices that identify employment data are the exception rather than the rule. Furthermore, IOM described how patients’ work experience could be integrated into their health record using existing coding schemes (e.g., the North American Industry Classification System), as is already done by state and federal agencies, workers’ compensation programs, and other organizations but is not typical in administrative or clinical records.
The IOM committee examined how “work-relatedness” could be integrated into an EHR, particularly those variables that would help to characterize the relationship between a health issue, event, or outcome and the patient’s work environment. However, the IOM report explains that most clinicians receive little if any training on the effects that work exposures and working conditions can have on health, and some practitioners will avoid exploring the work-relatedness of a condition to avoid a foray into the workers’ compensation reimbursement system. Despite these challenges, the report suggests that a data element denoting work-relatedness could prompt practitioners to recognize and seek information about the connections among work exposures, other working conditions, and health status.
The American Public Health Association recognizes the potential to improve individual and population health with enhancements and investments in information technology,1 including models of care that rely on electronic health records.2 Notably, APHA views the HITECH Act of 2009 as a powerful tool for improving and transforming medicine and as a means for ongoing evaluation of disease prevention and health promotion programs.
The IOM committee and others have assessed preliminarily the five EHR “meaningful use” criteria. Researchers with the Migrant Clinicians Network and the National Farm Medicine Center have described how occupational information contained in EHRs could improve health care quality, safety, and efficiency and reduce health disparities. They note that occupational information could inform a clinician about alternative causes for common presentations and lead to improved diagnosis, management, and prevention. Racial and ethnic disparities due to underdiagnosis, nonuse of workers’ compensation, and lack of hazard awareness, which all lead to disproportionate impacts, could be addressed. Population health could be enhanced by occupational information in EHRs through symptom surveillance, analyses of workplace health impacts, and resulting interventions.30
Clinicians serving at-risk and vulnerable populations may already recognize the role of workplace factors (e.g., hazardous exposures, psychosocial stressors, and work organization) on their patients’ health. The IOM committee’s report acknowledged this and proposed that integrating occupational information in EHRs would be another tool for identifying and addressing issues that contribute to health disparities in vulnerable populations. Some clinicians, such as those serving individuals at migrant and community health centers, already integrate their patients’ occupational information and history into their treatment plans and approaches. They understand the precarious nature of some individuals’ employment situation (e.g., immigration status, fear of reprisal for raising safety concerns, fear of job loss). Such clinicians have mastered techniques to gain their patients’ trust so that work-related factors can be discussed as potential causes of or contributors to health conditions or can be considered when developing treatment protocols. The culturally sensitive methods used by these health care practitioners should be examined and considered guides and models for larger-scale integration of occupational information in EHRs.
The IOM committee explored the feasibility, challenges, and opportunities associated with moving occupational information into and out of the EHR for the purpose of improving public health surveillance, prevention, and clinical use. The committee examined pilot projects in which occupational information was recorded and extracted from EHRs, including programs at the Dartmouth-Hitchcock Medical Center, Kaiser Permanente, and the Long Island Occupational and Environmental Health Center. One collaboration between the Cambridge Health Alliance Primary Care Center and the Massachusetts Department of Public Health went beyond the data collection component to identify work-related health conditions and implement interventions.
The American Public Health Association concurs with the IOM’s Board on Health Sciences Policy on the benefits of including patients’ occupational information in electronic health records and all of the recommendations contained in the board’s September 2011 report. Benefits include more informed clinical diagnosis and treatment plans, interventions, and prevention strategies to improve the overall health of the working population.
We are not aware of any organized opposition to this proposal. An opposing argument might involve additional time and resources for data entry, although the overall conversion to electronic health records is expected to reduce data entry demands.
- The US Department of Health and Human Services and its National Institute for Occupational Safety and Health should implement the recommendations outlined in IOM’s 2011 report “Incorporating Occupational Information in Electronic Health Records.” These recommendations are as follows:
- Conduct demonstration projects to assess the collection and incorporation in EHRs of information on occupation, industry, and work-relatedness.
- Define the requirements and develop information models for storing and communicating occupational information in the EHR.
- Recommend that the Health Information Technology Standards Committee adopt the Standard Occupational Classification and North American Industry Classification System to code occupation and industry in the EHR.
- Assess the feasibility of auto-coding occupational information collected in clinical settings.
- Develop “meaningful use” metrics and performance measures.
- Convene a workshop to assess ethical and privacy concerns and challenges associated with including occupational information in EHRs.
- Develop and test innovative methods to collect occupational information for linking to the EHR.
- Develop clinical decision support logic, educational materials, and return-to-work tools.
- Develop and assess methods for collecting standardized exposure data.
- Assess the impact of incorporating occupational information in the EHR on “meaningful use” goals.
- American Public Health Association. Policy No. 200911. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1386. Accessed December 31, 2011.
- American Public Health Association. Policy No. 201011. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1403. Accessed December 31, 2011.
- American Public Health Association. Policy No. 7819. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=896. Accessed December 31, 2011.
- Title XIII, Public Law No. 111-5 (2009).
- Council of State and Territorial Epidemiologists. Inclusion of occupation and industry as core data elements in electronic health record (EHR) systems and in recommended elements in other minimum data sets. Available at: http://www.cste.org/ps2012/12-OH-01FINAL.pdf. Accessed December 31, 2011.
- Identification and Control of Work-Related Diseases. Geneva, Switzerland: World Health Organization; 1985.WHO technical report series 714.
- US Census Bureau. USA quick facts. Available at: http://quickfacts.census.gov/qfd/states/00000.html. Accessed December 31, 2011.
- US Bureau of Labor Statistics. Employment situation, November 2011. Available at: http://www.bls.gov/news.release/empsit.nr0.htm. Accessed December 31, 2011.
- US Bureau of Labor Statistics. American Time Use Survey, 2010 results. Available at: http://www.bls.gov/news.release/atus.nr0.htm. Accessed December 31, 2011.
- Clougherty JE, Souza K, Cullen MR. Work and its role in shaping the social gradient in health. Ann N Y Acad Sci. 2010;1186:102–124.
- Commission to Build a Healthier America, Robert Wood Johnson Foundation. Work matters for health. Available at: http://www.commissiononhealth.org/PDF/0e8ca13d-6fb8-451d-bac8-7d15343aacff/Issue%20Brief%204%20Dec%2008%20-%20Work%20and%20Health.pdf. Accessed December 31, 2011.
- Schulte PA. Characterizing the burden of occupational injury and disease. J Occup Environ Med. 2005;47(6):607–622.
- Steenland K, Burnett C, Lalich N, Ward E, Hurrell J. Dying for work: the magnitude of US mortality from selected causes of death associated with occupation. Am J Ind Med. 2003;43(5):461–482.
- US Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Protecting workers’ families: a research agenda report on the Workers’ Family Protection Task Force. Available at: http://www.cdc.gov/niosh/docs/2002-113/. Accessed December 31, 2011.
- Board on Health Sciences Policy, Institute of Medicine. Incorporating Occupational Information in Electronic Health Records: Letter Report. Washington, DC: National Academies Press; 2011.
- Seven ‘Principles’ for Successful Return to Work. Toronto, Ontario, Canada: Institute for Work & Health; 2007.
- Returning to Work After a Heart Attack. London, England: British Heart Foundation; 2005.
- Rosenstock L, Landrigan PJ. Occupational health: the intersection between clinical medicine and public health. Annu Rev Public Health. 1986;7:337–356.
- Coye MJ, Rosenstock L. The occupational health history in a family practice setting.
- Am Fam Physician. 1983;28(5):229–234.
- Oleinick A, Zaidman B. The law and incomplete database information as confounders in epidemiologic research on occupational injuries and illnesses. Am J Ind Med. 2010;53(1):23–36.
- Pransky G, Snyder T, Dembe A, Himmelstein J. Under-reporting of work-related disorders in the workplace: a case study and review of the literature. Ergonomics. 1999;42(1):171–182.
- Davis LK, Hunt PR, Hackman HH, McKeown LN, Ozonoff VV. Use of statewide electronic emergency department data for occupational injury surveillance: a feasibility study in Massachusetts. Am J Ind Med. 2012;55(4):344–352.
- Mazurek JM, Filios M, Willis R, et al. Work-related asthma in the educational services industry: California, Massachusetts, Michigan, and New Jersey, 1993–2000. Am J Ind Med. 2008;51(1):47–59.
- Azaroff LS, Levenstein C, Wegman DH. Occupational injury and illness surveillance: conceptual filters explain underreporting. Am J Public Health. 2002;92(9):1421–1429.
- Fan ZJ, Bonauto DK, Foley MP, Silverstein BA. Underreporting of work-related injury or illness to workers’ compensation: individual and industry factors. J Occup Environ Med. 2006;48(9):914–922.
- Thomsen C, McClain J, Rosenman K, Davis L. Indicators for occupational health surveillance. MMWR Recomm Rep. 2007;56(RR-1):1–7.
- Rosenman KD, Kalush A, Reilly MJ, et al. How much work-related injury and illness is missed by the current national surveillance system? J Occup Environ Med. 2006;48(4):357–365.
- Stanbury M, Rafferty AP, Rosenman K. Prevalence of hearing loss and work-related noise-induced hearing loss in Michigan. J Occup Environ Med. 2008;50(1):72–79.
- US House of Representatives, Committee on Education and Labor. Hidden tragedy: underreporting of workplace injuries and illnesses. Available at: http://www.cste.org/dnn/Portals/0/House%20Ed%20Labor%20Comm%20Report%20061908.pdf. Accessed December 31, 2011.
- Keifer M, Liebman AK. A look at meaningful use: occupational and environmental history and the coming of electronic health records. Paper presented at: 1st National Conference on Eliminating Health and Safety Disparities at Work, September 2011, Chicago, IL.
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