Enhancing Worker Health Through Clinical Decision Support (CDS): An Introduction to a Compilation

Occupational Electronic Health Records: Recommendations for the Design and Implementation of Information Systems in Occupational and Environmental Medicine Practice-ACOEM Guidance Statement

OBJECTIVE

Occupational and environmental medicine (OEM) clinicians require specialized electronic health records (EHRs) to address the privacy, data governance, interoperability, and medical surveillance concerns that are specific to occupational health.

METHODS

The American College of Occupational and Environmental Medicine (ACOEM) Section of Health Informatics evaluated clinical workflow concerns, assessed health information requirements, and developed informatics recommendations through iterative consultation with ACOEM members.

RESULTS

The ACOEM presents 10 recommendations that specialized occupational EHR systems (OEHRs) should meet to serve the information needs and practice requirements of OEM clinicians. Common challenges in OEM practice and potential informatics solutions are used to illustrate each recommendation.

CONCLUSIONS

The recommendations serve as a framework for occupational health clinicians to consider in their adoption of OEHRs and provide software engineers a set of requirements to facilitate the development and improvement of OEHRs.

Importance of and Approach to Taking a History of Exposures to Occupational Respiratory Hazards

Occupational respiratory diseases are caused by exposure to respiratory hazards at work. It is important to document those exposures and whether they are causing or exacerbating disease because these determinations can have important impacts on diagnosis, treatment, job restrictions, and eligibility for benefits. Without investigation, it is easy to miss clinically relevant exposures, especially in those with chronic diseases that can have work and nonwork causes. The first and most important step in identifying exposures to respiratory hazards at work is to take an appropriate history. For efficiency, this is a two-step process. An initial quick screening history is done by asking only a few questions. Follow-up questions are asked if there are positive responses to the screening questions or if an occupational etiology is suspected based on the clinical presentation. Electronic health records have promise for facilitating this process. Follow-up to the screening history may include additional questions, evaluating additional sources of information about workplace exposures, and medical testing. Radiographic findings or tests conducted on noninvasive samples or lung tissue can be used as biomarkers. Online resources can be used to learn more about exposures associated with occupations and industries and to see if investigations evaluating exposures were performed in the patient's own workplace. It is important to adhere to the patient's wishes about contacting the employer. With patient consent, the employer can be an important source of information about exposures and, if a problem exists, has an important role in taking corrective action. Consultation for challenging cases is available from a variety of professional and governmental entities. If a clinician identifies a significant public health issue, such as an occupational disease outbreak, it is important to notify relevant public health authorities so that steps can be taken to prevent additional exposures and appropriately care for those already exposed.

Lung Cancer Screening in Asbestos-Exposed Populations

Asbestos exposure is the most important cause of occupational lung cancer mortality. Two large randomized clinical trials in the U.S. and Europe conclusively demonstrate that annual low-dose chest CT (LDCT) scan screening reduces lung cancer mortality. Age and smoking are the chief risk factors tested in LDCT studies, but numerous risk prediction models that incorporate additional lung cancer risk factors have shown excellent performance. The studies of LDCT in asbestos-exposed populations shows favorable results but are variable in design and limited in size and generalizability. Outstanding questions include how to: (1) identify workers appropriate for screening, (2) organize screening programs, (3) inform and motivate people to screen, and (4) incorporate asbestos exposure into LDCT decision-making in clinical practice. Conclusion: Screening workers aged ≥50 years with a history of ≥5 years asbestos exposure (or fewer years given intense exposure) in combination with either (a) a history of smoking at least 10 pack-years with no limit on time since quitting, or (b) a history of asbestos-related fibrosis, chronic lung disease, family history of lung cancer, personal history of cancer, or exposure to multiple workplace lung carcinogens is a reasonable approach to LDCT eligibility, given current knowledge. The promotion of LDCT-based screening among asbestos-exposed workers is an urgent priority.

A comprehensive assessment of environmental exposures and the medical history guides multidisciplinary discussion in interstitial lung disease

BACKGROUND

Multidisciplinary discussion (MDD) is widely recommended for patients with interstitial lung disease (ILD), but published primary data from MDD has been scarce, and factors influencing MDD other than chest computed tomography (CT) and lung histopathology interpretations have not been well-described.

METHODS

Single institution MDD of 179 patients with ILD.

RESULTS

MDD consensus clinical diagnoses included autoimmune-related ILD, chronic hypersensitivity pneumonitis, smoking-related ILD, idiopathic pulmonary fibrosis, medication-induced ILD, occupation-related ILD, unclassifiable ILD, and a few less common pulmonary disorders. In 168 of 179 patients, one or more environmental exposures or pertinent features of the medical history were identified, including recreational/avocational, residential, and occupational exposures, systemic autoimmune disease, malignancy, medication use, and family history. The MDD process demonstrated the importance of comprehensively assessing these exposures and features, beyond merely noting their presence, for rendering consensus clinical diagnoses. Precise, well-defined chest CT and lung histopathology interpretations were rendered at MDD, including usual interstitial pneumonia, nonspecific interstitial pneumonia, and organizing pneumonia, but these interpretations were associated with a variety of MDD consensus clinical diagnoses, demonstrating their nonspecific nature in many instances. In 77 patients in which MDD consensus diagnosis differed from referring diagnosis, assessment of environmental exposures and medical history was found retrospectively to be the most impactful factor.

CONCLUSIONS

A comprehensive assessment of environmental exposures and pertinent features of the medical history guided MDD. In addition to rendering consensus clinical diagnoses, MDD presented clinicians with opportunities to initiate environmental remediation, behavior modification, or medication alteration likely to benefit individual patients with ILD.

Clinical Decision Support for Worker Health: A Five-Site Qualitative Needs Assessment in Primary Care Settings

BACKGROUND

Although patients who work and have related health issues are usually first seen in primary care, providers in these settings do not routinely ask questions about work. Guidelines to help manage such patients are rarely used in primary care. Electronic health record (EHR) systems with worker health clinical decision support (CDS) tools have potential for assisting these practices.

OBJECTIVE

This study aimed to identify the need for, and barriers and facilitators related to, implementation of CDS tools for the clinical management of working patients in a variety of primary care settings.

METHODS

We used a qualitative design that included analysis of interview transcripts and observational field notes from 10 clinics in five organizations.

RESULTS

We interviewed 83 providers, staff members, managers, informatics and information technology experts, and leaders and spent 35 hours observing. We identified eight themes in four categories related to CDS for worker health (operational issues, usefulness of proposed CDS, effort and time-related issues, and topic-specific issues). These categories were classified as facilitators or barriers to the use of the CDS tools. Facilitators related to operational issues include current technical feasibility and new work patterns associated with the coordinated care model. Facilitators concerning usefulness include users' need for awareness and evidence-based tools, appropriateness of the proposed CDS for their patients, and the benefits of population health data. Barriers that are effort-related include additional time this proposed CDS might take, and other pressing organizational priorities. Barriers that are topic-specific include sensitive issues related to health and work and the complexities of information about work.

CONCLUSION

We discovered several themes not previously described that can guide future CDS development: technical feasibility of the proposed CDS within commercial EHRs, the sensitive nature of some CDS content, and the need to assist the entire health care team in managing worker health.

Recognition of the Relationship Between Patients' Work and Health: A Qualitative Evaluation of the Need for Clinical Decision Support (CDS) for Worker Health in Five Primary Care Practices

OBJECTIVE

The aim of this study was to determine the perceived value and feasibility of increased access to information about workers' health for primary care providers (PCPs) by evaluating the need for clinical decision support (CDS) related to worker health in primary care settings.

METHODS

Qualitative methods, including semi-structured interviews and observations, were used to evaluate the value and feasibility of three examples of CDS relating work and health in five primary care settings.

RESULTS

PCPs and team members wanted help addressing patients' health in relation to their jobs; the proposed CDS examples were perceived as valuable because they provided useful information, promoted standardization of care, and were considered technically feasible. Barriers included time constraints and a perceived inability to act on the findings.

CONCLUSION

PCPs recognize the importance and impact of work on their patients' health but often lack accessible knowledge at the right time. Occupational health providers can play an important role through contributions to the development of CDS that assists PCPs in recognizing and addressing patients' health, as well as through the provision of referral guidelines.