1. Development of Interface Requirements for Patient Entry of Occupational History Information in an Electronic Health Record: What Questions Need to be Asked? Presented by Catherine Staes, BSN, MPH, PhD CSTE 2013 Pasadena CA

2. Outline Background Project –Objectives for research presented today Methods/Findings(1) Methods/findings (2) Methods/findings (3) Discussion Next steps

3. Diagnosis: –consider work-related exposures and risks Treatment and management: –Consider impact of working patterns (shift) on treatment/management decisions. –Address safe ‘return to work’ for patient and community. Secondary use of data: –Public health activities, registries, vital records…. Benefits

4. What is your occupation?

5. What are the needs? Clinicians need: –Ability to view textual information about a patient’s occupation and industry (I&O) Systems need: –Access to structured and standardized (coded) information to perform clinical decision support or surveillance

6. Census Occupation classification system (2000) >31,000 Occupation Titles (labels in Census Alphabetical Indexes) http://www.cdc.gov/niosh/topics/coding/faq.html#Information

7. Census Occupation classification system (2000) >31,000 Occupation Titles (labels in Census Alphabetical Indexes) 509 occupation categories (label and code) Rollup to http://www.cdc.gov/niosh/topics/coding/faq.html#Information

8. Census Occupation classification system (2000) >31,000 Occupation Titles (labels in Census Alphabetical Indexes) 23 major occupational groups (label and code) 509 occupation categories (label and code) Classified into Rollup to Fire Fighters (374) Fire fighter Fire patrol Fire crew worker Protective service occupations (33) http://www.cdc.gov/niosh/topics/coding/faq.html#Information Frontline supervisors/Managers of fire fighting and prevention workers (372) Fire chief

9. Census Industry classification system (2000) >21,000 IndustryTitles (labels in Census Alphabetical Indexes) 20 major industry sectors (label and code) 265 industry categories (label and code) Classified into Rollup to Justice, public order, and safety activities (947) City fire department Fire Department Public administration (92) http://www.cdc.gov/niosh/topics/coding/faq.html#Information

10. Industry sectors Agriculture, Forestry, Fishing and Hunting Mining, Quarrying, and Oil and Gas Extraction Utilities Construction Manufacturing Wholesale Trade Retail Trade Transportation and Warehousing Information Finance and Insurance Real Estate and Rental and Leasing Professional, Scientific, and Technical Services Management of Companies and Enterprises Administrative and Support and Waste Management and Remediation Services Educational Services Health Care and Social Assistance Arts, Entertainment, and Recreation Accommodation and Food Services Other Services (except Public Administration) Public Administration

11. Project goal To define questions and suggested wording to gather codable I&O information through a patient user interface (e.g., PHR or patient portal) with limited burden. The coded I&O information should be useful for public health surveillance and clinical decision support

12. Objectives: initial research Evaluate logic in guidance for gathering and coding I&O Identify and evaluate questions (and answer sets) currently used in national surveys and EHR Assess clinical guidelines for I&O requirements

13. Methods (1) Reviewed guidance documents for: –Funeral directors to complete death certificates (DHHS (NIOSH) Publication No. 2012-149) –Cancer registrars to abstract from the medical record. (DHHS (NIOSH) Publication No. 2011-173) –Vital records coders to code entries on death certificates (DHHS, Instruction manual part 19: industry and occupation coding for death certificates, 2003) –BRFSS interviewers provided by Massachusetts Dept of Public Health

14. Data flow for gathering I&O

16. *Illustration may not be complete

17. Data flow for gathering I&O

18. Funeral director can ask for detail Reference: Funeral directors to complete death certificates (DHHS (NIOSH) Publication No. 2012-149)

19. Funeral director can ask for detail

21. Cancer registrar’s abstract from EHR Reference: A Cancer Registrar’s Guide to Collecting Industry and Occupation

22. Vital record coders apply heuristics when products are mentioned Reference: Instruction Manual Part 19 Industry and Occupation Coding for Death Certificates, effective 2003

23. Concepts mentioned in the guidance

25. Method (2) Evaluated questions in surveys: –The American Community Survey –National Health Interview Survey (NHIS) –Multi-Ethic Study of Atherosclerosis (MESA) –Death certificate –National Health and Nutrition Examination Survey (NHANES) –Behavioral Risk Factor Surveillance System (BRFSS) 2013 I/O Module –REGARDS study –Current Population Survey Assessed EHR entry screens (general/specialty)

26. Occupation American community survey What kind of work was this person doing? (For example: registered nurse, personnel manager, supervisor of order department, secretary, accountant) Death certificateDECEDENT'S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED). MESAWhat kind of work do/did you do or what was your job title? (e.g. registered nurse, personnel manager, auto mechanic, accountant, grinder operator, etc.) NHANESWhat kind of work {were you/was SP] doing? (For example: For example: farming, mail clerk, computer specialist.) NHISWhat kind of work were you doing? (For example: farming, mail clerk, computer specialist.) REGARDS (if currently ‘employed for wages’) 1.What is your job title? 2.What are your main job activities or job duties? BRFSS 2013What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanic Prompt: if respondent is unclear, ask: “What is your job title?” Current Population Survey What kind of work (DO/DOES/DID) (name/you) do, that is, what (is/was) (your/his/her) occupation? For example: plumber, typist, farmer

27. Job duties Survey/FormQuestion/Name American community survey What were this person’s most important activities or duties? (For example: patient care, directing hiring policies, supervising order clerks, typing and filing, reconciling financial records) Death certificateNone MESAWhat are/were your most important activities or duties? (e.g. patient care, directing hiring policies, repairing automobile, reviewing financial records, operating grinding mill, etc.) NHANESWhat were {your/SP’s} most important activities on this job? (For example: sell cars, keeps account books, operates printing press.) NHISWhat were your most important activities on this job or business? (For example: sell cars, keeps account books, operates printing press.) REGARDSWhat are your main job activities or job duties? BRFSS 2013None Current Population Survey What (are/were) (your/his/her) usual activities or duties at this job? For example: typing, keeping account books, filing, selling cars, operating printing press, laying brick.

28. Industry Survey/FormQuestion/Name American community survey What kind of business or industry was this? Describe the activity at the location where employed. (For example: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank) Death certificateKIND OF BUSINESS/INDUSTRY MESAWhat type of business or industry is/was this? (e.g., hospital, newspaper publishing, mail order house, auto repair shop, bank, etc.) NHANESWhat kind of business or industry is this? (For example: TV and radio mgt., retail shoe store, state labor department, farm.) NHISWhat kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor) REGARDSWhat kind of business or industry is this? BRFSS 2013What kind of business or industry do you work in? For example, hospital, elementary school, clothing manufacturing, restaurant. Current Population Survey What kind of business or industry is this? *Read if necessary: What do they make or do where (you/he/she) (work/works)?

29. Industry Sector SurveyQuestion/NameValue set American community survey Is this mainly – Mark (X) One box. 1 - Manufacturing? 2 - Wholesale trade? 3 - Retail trade? 4 - Other (agriculture, construction, service, government, etc.)? Death certificateNone MESANone NHANESNone NHISNone REGARDSNone BRFSS 2013None Current Population Survey Ask if necessary: Is this business or organization mainly manufacturing, retail trade, wholesale trade, or something ELSE? 1 - Manufacturing 2 - Retail trade 3 - Wholesale trade 4 - Something else

30. Feedback about EHRs Usability issues: 1. It is within "Socioeconomic” section and limited 2. Requires multiple clicks to find I&O information

31. Concepts captured in EHR screens evaluated (n=3) conceptsGeneral EHROccupation clinic EHR Current status of work Structured list Employer nameFree-text IndustryCoded (NAICS) Industry Sector OccupationFree-textStructured from picklist EducationFree-text AgederivableNumeric

32. Summary of key concepts: those gathered or required by logic Availability in records…Mentioned in logic for… Gathered in survey (n=8) Sample General EHR Sample Occup EHR Cancer registrar Funeral director Vital record coder Industry description (narrative) 8--codexxx Industry sector 2-- xxx Employer name 6text x--x Branch of armed forces 2-- x x Occupation narrative 8textstruct.xxx Job title 3-- xx Job duties 6-- x x Role (supervisor) 1-- xx gaps needs

33. Methods (3) Evaluated I&O required for occupationally-related clinical guidelines : –Disease: work-related asthma –Exposure: asbestos –Risk factor: shift work What are the triggers for clinical decision support?

34. Work-Related Asthma Jewelry, alloy and catalyst makers Polyurethane, foam coatings, adhesives production, and end-use settings (eg, spray painters, and foam and foundry workers) Alloy, catalyst, refinery workers Solderers Soldering flux (colophony) Plastics industry, dye, insecticide makers, organic chemical manufacture Foam workers, latex makers, biologists, and hospital and laboratory workers Printing industry Metal plating Bakers Woodworkers and furniture makers Laboratory workers and animal researchers Detergent formulators Seafood (crab, snow crab, and prawn) workers Health-care workers and nurses Laxative manufacture and packing Hairdressers and manicurists Occupation Industry Diagnosis and Management of Work-Related Asthma: ACCP Consensus Statement. Chest. 2008 Oct;134(4):892

35. Asbestos-related Disease Manufacture of asbestos products Asbestos mining and milling Construction trades (including insulators, sheet metal workers, electricians, plumbers, pipefitters, and carpenters) Power plant workers Boilermakers Shipyard workers Occupation Industry Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos Am J Respir Crit Care Med Vol 170. pp 691–715, 2004

36. Shift Workers Nurses Physicians Firefighters Police officers Military personnel Pilots Drivers Occupation Industry Shift-work Disorders. January 2010, Vol 59, No 1. Supplement to The Journal of Family Practice

37. Key findings Clinical guidelines revealed I&O information required to trigger decision support logic. Current EHRs interfaces were missing information, especially industry-related concepts. Documentation of either or both occupation and industry is necessary to trigger clinical decision support.

38. Limitations Limited review of EHR screens Limited analysis of clinical guidelines

39. Information in surveys and EHR often varies and inadequate for applying logic in guidelines. The analysis revealed content needed to capture I&O from users (patients) with goal of automated conversion to structured/coded I&O. Some heuristics in coding logic may be avoided if persons can document their own I&O information. Strategies needed to allow users to: –document textual I&O information –Select appropriate categories and codes for decision support and surveillance. Conclusion

41. Next steps Testing trial questions and workflow –Capture current I&O, then usual and past Strategies for capturing I&O in web interface: –Provide guidance (good/bad examples) –‘Force’ with branching logic –Prompt for more complete/accurate response –Autocode narrative information using heuristics –Present relevant terms (census ‘categories’) based on user’s input, and allow user to drill

42. Next steps Interactive user-centered design to test interface usability: –Iterative rounds of 5-9 users (total 36 users) –Compare: Supervisor’s description (alternate-form reliability) Participant’s entry into interface (today vs 2 weeks later (test-retest reliability) Participant’s description during interview (criterion validity) Participant’s selection in NIOSH intelligent dropdown tool Document requirements

43. Acknowledgements Genevieve Luensman, PhD CDC Jitsupa Peelay, MS University of Utah Sherry Baron, MD CDC Hannah Edwards, MD University of Utah Other collaborators that provided input from state public health and NIOSH Funding support from NIOSH: –SHEPheRD RFTOP Number: 2012-005: Development of Interface Business Requirements for Patient Entry of Occupational History Information for Electronic Health

44. occupation major groups 11-0000 Management Occupations 13-0000 Business and Financial Operations Occupations 15-0000 Computer and Mathematical Occupations 17-0000 Architecture and Engineering Occupations 19-0000 Life, Physical, and Social Science Occupations 21-0000 Community and Social Service Occupations 23-0000 Legal Occupations 25-0000 Education, Training, and Library Occupations 27-0000 Arts, Design, Entertainment, Sports, and Media Occupations 29-0000 Healthcare Practitioners and Technical Occupations 31-0000 Healthcare Support Occupations 33-0000 Protective Service Occupations 35-0000 Food Preparation and Serving Related Occupations 37-0000 Building and Grounds Cleaning and Maintenance Occupations 39-0000 Personal Care and Service Occupations 41-0000 Sales and Related Occupations 43-0000 Office and Administrative Support Occupations 45-0000 Farming, Fishing, and Forestry Occupations 47-0000 Construction and Extraction Occupations 49-0000 Installation, Maintenance, and Repair Occupations 51-0000 Production Occupations 53-0000 Transportation and Material Moving Occupations 55-0000 Military Specific Occupations