Topic 9: Healthcare: Occupation in the electronic medical record
Introduction
This section focuses on occupational information in the electronic medical record (EMR). This topic has been raised in various reports and discussions. A key question is the purpose of having this information in the medical record. In the OHS system, it is often a desire to have this data in administrative databases for use in surveillance and research. However, the physician’s key purpose is caring for their patients. A key primary question is what information does the physician need to care for their patients.
While often the term medical records are used, as practice becomes more team-based, a more appropriate term is health record. In this discussion, we will use the term medical record, but it is important to realize that this will eventually be a more integrated health record. Medical and health records are generally transitioning from paper form to electronic form. The decision about whether to move to an electronic health record (EHR) is made by the practitioner, group or institution. While many individual and group practices have moved to an EMR, institutions are in different stages of transition and depending on the complexity of the institution, there may be different EHRs within the same institution.
Background
One regulatory requirement relates to the time the medical record has to be retained. For medical records, the time period is ten years from the date of the last entry. For medical records related to DS medical screening, the records must be retained for either 20 years from the date of the last entry or 40 years from the date of the first entry, whichever is the later date.
Originally medical records were paper-based. This is changing to electronic records. There are a variety of different electronic medical records provided by different vendors in use by physicians in Ontario. In Ontario, vendors are approved by OntarioMD, which sets minimum requirements for data elements in the EMR. This means that there are a number of different EMRs with different content and structures. Data elements for work information may explicitly be in the EMR or may be included in broader sections. Other healthcare institutions, such as hospitals, are in different phases of implementation of EMRs/EHRs and again there are different systems in use. One of the challenges is the communication between these various EMRs and also the data sources of health information that are pulled into the EMR. This is the setting in which the discussion of occupational information in the EMR is cited.
Current context
There are many statements made about physician practice regarding occupational information. Some say that there is no occupational information in the medical record/EMR. The reality is that we really don’t know.
Consultation and review summary
Ontario research findings
- Note a comprehensive summary of CREOD research is provided on the CREOD website. Several Ontario studies have examined physician practice related to taking an occupational history from both the physician and patient perspectives. Physicians reporting that they take an occupational history included 57% of family physicians, 92% of respirologists and 91% of dermatologists. From the patient perspective, those being investigated for possible work-related dermatitis reported that 67% of family physicians and 53% of dermatologists asked about their job.
- Patients being seen for possible work-related skin disease reported that over half of both family physicians and dermatologists asked about their job but rarely collected more detailed information.
- The main barriers to taking an occupational history included time constraints, lack of confidence in taking the history, patients not being able to provide the information, lack of knowledge of the compensation system, lack of adequate reimbursement, excessive forms, reporting that it was not their job and forgetting.
- Several studies have been done to get occupational information into the medical record. The settings include community health centres, lung cancer clinics and a family health team. While all the studies accomplished the capture of occupational information during the study period but the ongoing collection is not known. Barriers and facilitators to the recording of occupational information were identified.
There is a current ongoing study to document the occupational information in medical records to help provide baseline information related to the content of the medical record.
Summary review findings
- The healthcare system is in transition to EMRs with different implementation. There are a variety of different EMRs in use, making connection more difficult.
- We know that not all physicians take an occupational history, but some do.
- We know something about the barriers and facilitators to taking an occupational history.
- We don’t understand how primary care providers practice related to occupational health and OD specifically, specifically as to when and how they take an occupational history and what they include.
Recommendations
System goals
Appropriate occupational information in EMR to facilitate physician practice including the prevention, diagnosis and management of work-related disorders.
Short term recommendations
9.1 Complete baseline study of occupational information in EMR already underway.
9.2 For primary care, understand how the information is used in practice, who is best suited to collect information, what information is needed as a baseline for clinical care.
Implementation guidance:
- Observation and information collection from incubator FHT (Topic 6).