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, PhDCSTE 2013

Pasadena CA

Outline

• Background• Project

– Objectives for research presented today • Methods/Findings (1)• Methods/findings (2)• Methods/findings (3)• Discussion • Next steps

• 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

What is your occupation?

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

Census Occupation classification system (2000)

>31,000 Occupation Titles (labels in Census Alphabetical Indexes)

http://www.cdc.gov/niosh/topics/coding/faq.html#Information

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

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 fighterFire patrolFire 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

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 departmentFire Department

Public administration (92)

http://www.cdc.gov/niosh/topics/coding/faq.html#Information

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

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

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

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

Data flow for gathering I&O

*Illustration may not be complete

Data flow for gathering I&O

Funeral director can ask for detail

Reference: Funeral directors to complete death certificates (DHHS (NIOSH) Publication No. 2012-149)

Funeral director can ask for detail

Funeral director can ask for detail

Cancer registrar’s abstract from EHR

Reference: A Cancer Registrar’s Guide to Collecting Industry and Occupation

Vital record coders apply heuristics when products are mentioned

Reference: Instruction Manual Part 19 Industry and Occupation Coding for Death Certificates, effective 2003

Concepts mentioned in the guidance

Concepts mentioned in the guidance

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)

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 certificate DECEDENT'S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).

MESA What 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.)

NHANES What kind of work {were you/was SP] doing? (For example: For example: farming, mail clerk, computer specialist.)

NHIS What 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 2013 What kind of work do you do? For example, registered nurse, janitor, cashier, auto mechanicPrompt: 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

Job dutiesSurvey/Form Question/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 certificate None

MESA What are/were your most important activities or duties? (e.g. patient care, directing hiring policies, repairing automobile, reviewing financial records, operating grinding mill, etc.)

NHANES What were {your/SP’s} most important activities on this job?(For example: sell cars, keeps account books, operates printing press.)

NHIS What were your most important activities on this job or business?(For example: sell cars, keeps account books, operates printing press.)

REGARDS What are your main job activities or job duties?

BRFSS 2013 None

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.

Industry Survey/Form Question/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 certificate KIND OF BUSINESS/INDUSTRY

MESA What type of business or industry is/was this? (e.g., hospital, newspaper publishing, mail order house, auto repair shop, bank, etc.)

NHANES What kind of business or industry is this? (For example: TV and radio mgt., retail shoe store, state labor department, farm.)

NHIS What kind of business or industry was this? (For example: TV and radio mgt., retail shoe store, State Department of Labor)

REGARDS What kind of business or industry is this?

BRFSS 2013 What 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)?

Industry SectorSurvey Question/Name Value 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 certificate None NoneMESA None NoneNHANES None NoneNHIS None NoneREGARDS None NoneBRFSS 2013 None NoneCurrent 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

Feedback about EHRs

Usability issues:1. It is within "Socioeconomic” section and limited2. Requires multiple clicks to find I&O information

Concepts captured in EHR screens evaluated (n=3)

concepts General EHR Occupation clinic EHR

Current status of work

Structured list

Employer name Free-text Free-text

Industry Coded (NAICS)

Industry Sector

Occupation Free-text Structured from picklist

Education Free-text

Age derivable Numeric

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 OccupEHR

Cancer registrar

Funeral director

Vital record coder

Industry description (narrative) 8 -- code x x x

Industry sector 2 -- -- x x x

Employer name 6 text text x -- x

Branch of armed forces 2 -- -- x -- x

Occupation narrative 8 text struct. x x x

Job title 3 -- -- -- x x

Job duties 6 -- -- x -- x

Role (supervisor) 1 -- -- -- x x

gaps

needs

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?

Work-Related Asthma

Jewelry, alloy and catalyst makersPolyurethane, foam coatings, adhesives production, and end-use settings (eg, spray painters, and foam and foundry workers)Alloy, catalyst, refinery workersSolderers Soldering flux (colophony)Plastics industry, dye, insecticide makers, organic chemical manufactureFoam workers, latex makers, biologists, and hospital and laboratory workersPrinting industryMetal plating BakersWoodworkers and furniture makersLaboratory workers and animal researchersDetergent formulators Seafood (crab, snow crab, and prawn) workersHealth-care workers and nursesLaxative manufacture and packingHairdressers and manicurists

Occupation

Industry

Diagnosis and Management of Work-Related Asthma: ACCP Consensus Statement. Chest. 2008 Oct;134(4):892

Asbestos-related Disease

• Manufacture of asbestos productsAsbestos mining and millingConstruction trades (including insulators, sheet metal workers, electricians, plumbers, pipefitters, and carpenters)Power plant workersBoilermakersShipyard workers Occupation

Industry

Diagnosis and Initial Management of Nonmalignant Diseases Related to AsbestosAm J Respir Crit Care Med Vol 170. pp 691–715, 2004

Shift Workers

• NursesPhysiciansFirefightersPolice officersMilitary personnelPilotsDrivers

Occupation

Industry

Shift-work Disorders. January 2010, Vol 59, No 1. Supplement to The Journal of Family Practice

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.

Limitations

• Limited review of EHR screens• Limited analysis of clinical guidelines

• 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

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

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

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

occupation major groups11-0000 Management Occupations13-0000 Business and Financial Operations Occupations15-0000 Computer and Mathematical Occupations17-0000 Architecture and Engineering Occupations19-0000 Life, Physical, and Social Science Occupations21-0000 Community and Social Service Occupations23-0000 Legal Occupations25-0000 Education, Training, and Library Occupations27-0000 Arts, Design, Entertainment, Sports, and Media Occupations29-0000 Healthcare Practitioners and Technical Occupations31-0000 Healthcare Support Occupations33-0000 Protective Service Occupations35-0000 Food Preparation and Serving Related Occupations37-0000 Building and Grounds Cleaning and Maintenance Occupations39-0000 Personal Care and Service Occupations41-0000 Sales and Related Occupations43-0000 Office and Administrative Support Occupations45-0000 Farming, Fishing, and Forestry Occupations47-0000 Construction and Extraction Occupations49-0000 Installation, Maintenance, and Repair Occupations51-0000 Production Occupations53-0000 Transportation and Material Moving Occupations55-0000 Military Specific Occupations