An ad hoc committee of the Institute of Medicine (IOM) identified a litany of potential benefits of including information about individuals' occupations, industry, and work environment in their electronic health records (EHRs). The reason the question was posed at all stems from a provision in the American Recovery and Reinvestment Act of 2009 which provides hefty incentives for health care providers to convert patients' medical records from paper to electronic form. At the time the bill was passed, one reporter noted that only about 8 percent of the nation's hospitals and 17% of its physicians were using interoperable electronic EHR systems. As the use of EHRs rapidly ramps up because of the HITECH Act, the public health community is eager to capitalize on the technology's potential to identify health disparities and devise effective intervention and prevention strategies.
The IOM committee notes promimently at the beginning of the report that many Americans spend half their waking hours at work. "The nature of the work and work tasks can have a significant impact on workers' health and even on the health of family members," the authors write. The more health care providers understand their patients' work environments, the better able to diagnose and treat them. The authors explain, however,
"Currently, clinicians might not consider work exposure in the etiology of a patient's illness until after a lengthy, inefficient, trial-and-error period."
Their assessment, contained in a report "Incorporating Occupational Information in Electronic Health Records" lays out the feasibility of incorporating such information from two perspectives: the current environment and technical considerations.
The IOM report indicates, for example, that a person's job title or occupation is already asked of patients for administrative and reimbursement purposes, but it is rarely integrated with clinical data. A job title alone won't provide data on the individual's work exposures, but can be an indicator to prompt to healthcare provider to consider it in diagnosis and treatment decisions. The report explains how existing occupation coding systems (e.g., BLS's Standard Occupation Classification (SOC) system) have been linked to employer-specific job titles, and gives examples of how its been done, such as in the Dartmouth-Hitchcock healthcare system. Similarly, a patient's work experience by industry could be integrated into their health record using existing coding schemes, such as the North American Industry Classification System (NAICS). The report notes that State and federal agencies, Dun & Bradstreet and other organizations already include industry codes in their employer databases.
Information about a patient's occupation and industry will take meaning when assessed in the context of the individual's health. The IOM committee examined how "work-relatedness" could be integrated into an EHR, in particular a factor that would help to characterize the relationship between the health event or outcome and the patient's work environment. Many adverse health events are not related to work per se, but those that are may not be recognized as such. The authors explain that most physicians receive little if any training on the effects that work exposures 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 authors suggest that a data element denoting work-relatedness could prompt practioners to recognize and seek information about the connections between work exposures and health status.
The data potentially most useful to clinicians is information about their patients' exposures to specific physical, chemical and radiological compounds, as well as psychosocial stressors. Such data is not systematically collected in medical records (or anywhere for that matter) and even if it was, its value to busy clinicians may not be obvious. The IOM committee recommends a few first steps, including that the CDC's National Institute for Occupational Safety and Health (NIOSH) work with clinical experts to explore the feasibility of collecting standardized exposure data for work-related conditions.
Moving to EHRs is not supposed to be adopting technology for technology sake, but rather that they will help improve health outcomes. The law encouraging their adoption mandates the "meaningful use" of EHRs to improve quality, safety and efficiency. The authors of the IOM report provide ample evidence demonstrating the "meaningful use" of occupational information in EHRs, and a reasonable roadmap for how key data on patients' work history could be included them.
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