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

Engaging Oncology and Occupational Medicine to Inform Design of a Total Worker Health® Intervention to Address Employment, Financial, and Well-being Outcomes in Cancer Survivors

OBJECTIVES

Few Total Worker Health ® studies and fewer interventions examine well-being in the work context of cancer survivorship. We investigated the possibility of occupation and oncology professionals working together to address employed survivors' work-associated needs.

METHODS

We employed a community-based participatory research approach to examine the educational, contextual, and workflow needs of oncology care team members to inform intervention design. Focus groups were conducted with oncology care team members and occupational medicine physicians. Key themes from each group were then examined.

RESULTS

Themes included oncology care team's role in helping patients navigate resources, providing psychosocial support, and educating patients. Major themes for ways to better provide employment-related support during treatment included referring patients to employment experts and providing education on employment support.

CONCLUSIONS

Occupational health professionals in collaboration with oncology clinics could play an important role in assisting cancer survivors' ability to navigate employment challenges.

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.

Occupational Contributions to Respiratory Health Disparities

Occupation is an important contributor to disparities in respiratory disease, affecting financial status, health-care access, and exposure to hazardous substances. Although occupation and associated exposures are included in the socioecological models, work exposures remain persistently absent from research on health inequities and their contribution to health. This article focuses on the occupational contribution to disparities in asthma, chronic obstructive pulmonary disease, silicosis, coronavirus disease 2019, and lung cancer. Because occupational exposures are largely preventable through proper workplace controls, the recognition of occupational causes of disease can provide an opportunity for interventions to bring about health equity.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

BACKGROUND

Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.

METHODS

A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.

RESULTS

The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue".

CONCLUSIONS

The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

Occupational health within the bounds of primary care: Factors shaping the health of Latina/o immigrant workers in federally qualified health centers

BACKGROUND

Many workers seek care for work-related medical conditions in primary care settings. Additionally, occupational medicine training is not consistently addressed in primary care professional training. These patterns raise concerns about the health outcomes of low-wage Latina/o immigrant workers who make use of primary care settings to obtain care for work-related injuries and illnesses. The objective of this qualitative study was to investigate how primary care clinicians assessed and addressed the role of occupational exposures on the health and well-being of Latina/o immigrant workers.

METHODS

We conducted semistructured in-depth interviews with 17 primary care clinicians (physicians, resident physicians, and nurse practitioners) employed in an urban federally qualified health center (FQHC) with two sites located in Orange County, CA.

RESULTS

Using a constructivist grounded theory approach, we determined that primary care clinicians had a general understanding that employment influenced the health and well-being of their Latina/o immigrant patients. Clinicians delivered care to Latina/o immigrant workers who feared reporting their injury to their employer and to Latina/o immigrants whose workers' compensation claim was terminated before making a full recovery. Clinicians were responsive to patients' work-related concerns and leveraged the resources available within the FQHC. Although some clinicians offered suggestions to improve occupational health in the FQHC, a few clinicians raised concerns about the feasibility of additional health screenings and clinic-based interventions, and pointed to the importance of interventions outside of the healthcare system.

CONCLUSION

This study underscores the complexities of addressing occupational health concerns in urban FQHCs.

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.

Initiatives addressing precarious employment and its effects on workers' health and well-being: a protocol for a systematic review

BACKGROUND

Precarious employment is a significant determinant of population health and health inequities and has complex public health consequences both for a given nation and internationally. Precarious employment is conceptualized as a multi-dimensional construct including but not limited to employment insecurity, income inadequacy, and lack of rights and protection in the employment relation, which could affect both informal and formal workers. The purpose of this review is to identify, appraise, and synthesize existing research on the effectiveness of initiatives aiming to or having the potential to eliminate, reduce, or mitigate workers' exposure to precarious employment conditions and its effects on the health and well-being of workers and their families.

METHODS

The electronic databases searched (from January 2000 onwards) are Scopus, Web of Science Core Collection, and PubMed, along with three institutional databases as sources of grey literature. We will include any study (e.g. quantitative, qualitative, or mixed-methods design) evaluating the effects of initiatives that aim to or have the potential to address workers' exposure to precarious employment or its effects on the health and well-being of workers and their families, whether or not such initiatives were designed specifically to address precarious employment. The primary outcomes will be changes in (i) the prevalence of precarious employment and workers' exposure to precarious employment and (ii) the health and well-being of precariously employed workers and their families. No secondary outcomes will be included. Given the large body of evidence screened, the initial screening of each study will be done by one reviewer, after implementing several strategies to ensure decision-making consistency across reviewers. The screening of full-text articles, data extraction, and critical appraisal will be done independently by two reviewers. Potential conflicts will be resolved through discussion. Established checklists will be used to assess a study's methodological quality or bias. A narrative synthesis will be employed to describe and summarize the included studies' characteristics and findings and to explore relationships both within and between the included studies.

DISCUSSION

We expect that this review's findings will provide stakeholders interested in tackling precarious employment and its harmful health effects with evidence on effectiveness of solutions that have been implemented to inform considerations for adaptation of these to their unique contexts. In addition, the review will increase our understanding of existing research gaps and enable us to make recommendations to address them. Our work aligns with the sustainable development agenda to protect workers, promote decent work and economic growth, eliminate poverty, and reduce inequalities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020187544 .

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.

Opportunities at the intersection of work and health: Developing the occupational data for health information model

OBJECTIVE

The study sought to develop an information model of data describing a person's work for use by health information technology (IT) systems to support clinical care, population health, and public health.

MATERIALS AND METHODS

Researchers from the National Institute for Occupational Safety and Health worked with stakeholders to define relationships and structure, vocabulary, and interoperability standards that would be useful and collectable in health IT systems.

RESULTS

The Occupational Data for Health (ODH) information model illustrates relationships and attributes for a person's employment status, retirement dates, past and present jobs, usual work, and combat zone periods. Key data about the work of a household member that could be relevant to the health of a minor were also modeled. Existing occupation and industry classification systems were extended to create more detailed value sets that enable self-reporting and support patient care. An ODH code system, available in the Public Health Information Network Vocabulary Access and Distribution System, was established to identify the remaining value sets. ODH templates were prepared in all 3 Health Level 7 Internationalinteroperability standard formats.

DISCUSSION

The ODH information model suggests data elements ready for use by health IT systems in the United States. As new data elements and values are better defined and refined by stakeholders and feedback is obtained through experience using ODH in clinical settings, the model will be updated.

CONCLUSION

The ODH information model suggests standardized work information for trial use in health IT systems to support patient care, population health, and public health.

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

OBJECTIVE

This article outlines an approach to developing clinical decision support (CDS) for conditions related to work and health. When incorporated in electronic health records, such CDS will assist primary care providers (PCPs) care for working patients.

METHODS

Three groups of Subject Matter Experts (SMEs) identified relevant clinical practice guidelines, best practices, and reviewed published literature concerning work-related asthma, return-to-work, and management of diabetes at work.

RESULTS

SMEs developed one recommendation per topic that could be supported by electronic CDS. Reviews with PCPs, staff, and health information system implementers in five primary care settings confirmed that the approach was important and operationally sound.

CONCLUSION

This compendium is intended to stimulate a dialogue between occupational health specialists and PCPs that will enhance the use of work information about patients in the primary care setting.