ACTION:

Request for public comments.

SUMMARY:

The National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS) requests public comments to inform its approach in recommending the inclusion of work information in the electronic health record (EHR). NIOSH requests input on these issues (including answers to the three questions listed below). The instructions for submitting comments can be found at www.regulations.gov. Written comments submitted to the Docket will be used to inform NIOSH with its planning and activities in response to the 2011 letter report “Incorporating Occupational Information in Electronic Health Records” written by the Institute of Medicine (IOM) Committee on Occupation and Electronic Health Records.

DATES:

Public Comment Period: Comments must be received by August 27, 2012. Comments should reference docket number CDC-2012-0008.

ADDRESSES:

Written comments: You may submit comments by any of the following methods:

• Federal eRulemaking Portal: http://www.regulations.gov. Follow the instructions for submitting comments.
• Mail: NIOSH Docket Office, Robert A. Taft Laboratories, MS-C34, 4676 Columbia Parkway, Cincinnati, OH 45226.

Instructions: All submissions received must include the agency name and docket number. All relevant comments, including any personal information provided, will be posted without change to http://www.regulations.gov.

• Email: nioshdocket@cdc.gov.

All information received in response to this notice will be available for public examination and copying at the NIOSH Docket Office, 4676 Columbia Parkway, Cincinnati, Ohio 45226.

NIOSH includes all comments received without change in the docket, including any personal information provided. All material submitted should reference docket number CDC-2012-0008 and must be submitted by August 27, 2012 to be considered by the Agency.

I. Background

Health care in the United States is undergoing a significant change as providers of health care transition from paper-based records to electronic health records (EHRs). EHRs represent the potential for cost savings and other efficiencies and improvements in the way that information is used to inform health care. The Office of the National Coordinator (ONC) for Health Information Technology promotes a nationwide health information technology (HIT) infrastructure that allows for the electronic use and exchange of health information. More information on the ONC and on electronic health records can be found at http://healthint.hhs.gov.

NIOSH, along with other centers of CDC, works to promote and protect population health. Public health researchers and practitioners, including those promoting occupational public health, are working to ensure that public health goals are met through the use of EHRs. NIOSH is working to ensure that EHRs will contribute to improvements in individual and population health by meeting the need to support occupational considerations during clinical care and by enhancing public health professionals' understanding of work-related conditions so they can identify effective treatment and prevention strategies. Currently, systematic collection and recording of patient work information in the clinical setting is not widespread. Where work information is collected and recorded in the EHR, that information may not be standardized or converted to structured data (i.e., coded), thus limiting its utility for clinical decision making and public health surveillance. For example, standardized patient occupation and/or industry information could be linked to resources that provide clinical decision support, such as job-specific information about exposures and associated potential health problems, as well as information that would facilitate appropriate determination of return-to-work recommendations.

In 2011, at the request of NIOSH, the Institute of Medicine (IOM) of the National Academies of Science appointed a committee to examine the rationale and feasibility of incorporating occupational information in the EHR. The committee concluded that inclusion of occupational information in the EHR “could contribute to fully realizing the meaningful use of EHRs in improving individual and population health care”. The Committee provided NIOSH with a set of ten recommendations, including “Recommendation 1: Conduct Demonstration Projects to Assess the Collection and Incorporation of Information on Occupation, Industry and Work-Relatedness in the EHR.” The purpose of this Request for Information (RFI) is to gather information from providers of primary care and occupational medicine, vendors and creators of EHR software, and the public to inform NIOSH's response to this and other IOM recommendations. Gathering information through this RFI will enable NIOSH to understand opportunities and challenges in collecting occupational information and how and why health care providers collect and use this information. The IOM report with the 10 recommendations can be downloaded at: http://iom.edu/Reports/2011/Incorporating-Occupational-Information-in-Electronic-Health-Records-Letter-Report.aspx.

NIOSH has released this RFI to learn about how the following types of patient work information are collected and used:

Employment status (e.g., employed, unemployed, disabled, retired, part time/full time, shift)

Patient's current occupation(s)

Patient's current industry(s)

Patient's usual (longest held) occupation(s)

Patient's usual (longest held) industry(s)

Employer(s) name

Employer Address(es)

Work-relatedness of patient's health condition(s)

Other information about patient's work, such as information about exposures at work.

II. Questions of Interest

Input from primary care providers, occupational and public health specialists, EHR vendors and others with interest in the topic is sought on the questions listed below pertaining to the collection and use of work information in the clinical setting. NIOSH is interested in input both from those who are currently using EHRs as well as those who are not.

(1) For providers of primary health care: When do the clinicians in your practice setting currently ask patients about their work?

Specifically, what information on patients' work is collected?

If you currently use an EHR:

Where in the health record (either paper or electronic) is patient work information stored and/or viewed? For example, is the work information entered in the `social history' section of an EMR? Where would you prefer patient work information to be stored and/or viewed in the EHR?

Does your EHR maintain a history of the information so that you can identify how long and when a patient was in a given occupation?

If you currently do not use an EHR, where do you record this information in the paper record? Is it available to the care provider during the patient encounter? Is there a history of the patient's work information available to the care provider?

In your clinical practice, who (which personnel) besides the clinicians collect patients' work information (e.g., registration personnel or nursing assistants)?

Have those personnel been trained specifically in how to collect information about patient's work i.e., how to gain an accurate job title etc.?

Do you collect work information from teenagers?

Do you collect work information from retirees?

Are questions about work routine question or triggered based on specific complaints?

How is work information used to inform patient care?

Please provide an example/description of the usefulness of patient work information in providing care to a patient.

Please provide any additional comments you have about collection or use of patient work information in the clinical setting.

(2) For providers of occupational (specialty) health care: At your clinical facility, how is the patient's work information collected?

Specifically, what information on patients' work is collected?

Is the work information entered in the administrative record used for billing purposes?

Is patient work information collected on paper or in an EHR? Is it available to the care provider during the patient encounter?

Is there a history of the patient's work information available to the care provider?

If you use a standardized form to collection information about patients' work, please briefly describe its main elements.

In your clinical practice, who (which personnel) besides the clinicians collect (e.g., registration personnel or nursing assistants)?

Have those personnel been trained specifically in how to collect information about patient's work i.e., how to gain an accurate job title, etc.?

Where in the health record (either paper or electronic) is the information stored? For example, is the work information entered in the `social history' section?

What are the most important ways that clinicians can use to inform clinical care of patients?

Please provide an example of the usefulness of work information in providing care to a patient.

Do you have any other comments about collection or use of patient work information in the clinical setting?

(3) For developers and vendors of EHR/software: Does your base/basic EHR product contain pre-ordained fields for Industry, Occupation, Employer or other information about patients' work? If not, have you been asked to provide these fields?

Regardless of whether they are in the base system or added on request, how are the values in the fields for Industry, Occupation, or other work information formatted (e.g., narrative text, drop-down menus, other)?

Are these values coded and if so, what coding schema are used (e.g., NAICS, SOC, Census codes, user defined)?

To the best of your knowledge, how are the data captured in these fields used by end users of your EHR/product?

Please share challenges you anticipate in managing a history of employer, industry and occupation (current and usual) for multiple employment situations as both text and coded fields in your system, if your system does not already perform these functions?

Could your system access and retrieve information from another web-based system via web services (such as an automated coding system for coding industry and occupation)?

Your comments are appreciated. They will be used to improve NIOSH's electronic health records efforts.

FOR FURTHER INFORMATION CONTACT:

Kerry Souza, NIOSH, 395 E Street SW., Suite 9257, Washington, DC 20002, telephone (202) 245-0639, Email hkv4@cdc.gov.