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.

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.

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.

Recommendations for a Clinical Decision Support System for Work-Related Asthma in Primary Care Settings.

OBJECTIVE: The aim of this study was to describe a recommended clinical decision support (CDS) approach for work-related asthma for incorporation in electronic health records (EHRs) for primary care health care providers. METHODS: Subject matter experts convened by the American Thoracic Society reviewed available guidelines and published literature to develop specific recommendations. RESULTS: It is important to recognize possible work-related asthma among persons with new-onset or worsening asthma. The work group recommends incorporating three simple questions about temporal relations between asthma symptoms and work in EHR systems and identified specific clinical conditions to trigger this intervention. Patients with positive responses to the three questions should have the asthma diagnosis documented and have further evaluation, education, and possible referral. CONCLUSION: An effective CDS system for improving recognition of work-related asthma may help reduce morbidity and mortality of asthma in adults.

Isocyanates and work-related asthma: Findings from California, Massachusetts, Michigan, and New Jersey, 1993-2008.

BACKGROUND: Isocyanates remain a leading cause of work-related asthma (WRA). METHODS: Two independent data systems were analyzed for the period 1993-2008: (1) State-based WRA case surveillance data on persons with isocyanate-induced WRA from four states, and (2) Occupational Safety and Health Administration (OSHA) Integrated Management Information System (IMIS) isocyanate air sampling results. RESULTS: We identified 368 cases of isocyanate-induced WRA from 32 industries and 678 OSHA isocyanate air samples with detectable levels from 31 industries. Seventeen industries were unique to one or the other dataset. CONCLUSION: Isocyanate-induced WRA continues to occur in a wide variety of industries. Two data systems uncovered industries with isocyanate exposures and/or illness. Improved control measures and standards, including medical surveillance, are needed. More emphasis is needed on task-specific guidance, spill clean-up procedures, skin and respiratory protection, and targeted medical monitoring to mitigate the hazards of isocyanate use.

Gender differences in work-related asthma: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-2008.

OBJECTIVE: To characterize work-related asthma by gender. METHODS: We analyzed state-based sentinel surveillance data on confirmed work-related asthma cases collected from California, Massachusetts, Michigan, and New Jersey during 1993-2008. We used Chi-square and Fisher's Exact Test statistics to compare select characteristics between females and males. RESULTS: Of the 8239 confirmed work-related asthma cases, 60% were female. When compared to males with work-related asthma, females with work-related asthma were more likely to be identified through workers' compensation (14.8% versus 10.6%) and less likely to be identified through hospital data (14.2% versus 16.9%). Moreover, when compared to males, females were more likely to have work-aggravated asthma (24.4% versus 13.5%) and less likely to have new-onset asthma (48.0% versus 56.5%). Females were also more likely than males with work-related asthma to work in healthcare and social assistance (28.7% versus 5.2%), educational services (11.8% versus 4.2%), and retail trade (5.0% versus 3.9%) industries and in office and administrative support (20.0% versus 4.0%), healthcare practitioners and technical (13.4% versus 1.6%), and education training and library (6.2% versus 1.3%) occupations. Agent groups most frequently associated with work-related asthma were miscellaneous chemicals (20.3%), cleaning materials (15.3%), and indoor air pollutants (14.9%) in females and miscellaneous chemicals (15.7%), mineral and inorganic dusts (13.2%), and pyrolysis products (12.7%) in males. CONCLUSIONS: Among adults with work-related asthma, males and females differ in terms of workplace exposures, occupations, and industries. Physicians should consider these gender differences when diagnosing and treating asthma in working adults.

Work-related reactive airways dysfunction syndrome cases from surveillance in selected US states.

The objective was to elaborate the descriptive epidemiology of work-related cases of reactive airways dysfunction syndrome (RADS). Cases of work-related asthma (WRA) were identified in four states in the United States during 1993-1995 as part of the Sentinel Event Notification Systems for Occupational Risks (SENSOR). Information gathered by follow-back interview was used to describe 123 work-related RADS cases and to compare them to 301 other WRA cases whose onset of disease was associated with a known asthma inducer. RADS represented 14% of all new-onset WRA cases identified by the state SENSOR surveillance systems. RADS cases had significant adverse medical and occupational outcomes identified by follow-back interview. In particular, 89% still had breathing problems, 78% had ever sought emergency care and 39% had ever been hospitalized for work-related breathing problems, 54% had applied for worker compensation benefits, and 41% had left the company where they experienced onset of asthma. These values equaled or exceeded the comparable figures for those WRA cases whose onset was attributed to a known inducer. Work-related RADS represents a minority of all WRA cases, but the adverse impact of this condition appears to equal that of other WRA cases.