Taking Action on Health Equity: A Tale of 2 Clinics

It was the best of timing, it was the worst of timing.

As an Occupational Medicine physician, my patients describe their work to me every day. Through these descriptions, I learn a lot about their health and well-being. Managing health in the work environment is important to overall health; yet work information is not captured in a standardized way in most medical encounters. Timely interventions to address hazardous work exposures are an actionable component of ensuring health equity, where everyone has a fair and just opportunity to attain their highest level of health. This may even impact the course of a person’s life.

Joe was 47 years old when the treatments he received for cough symptoms no longer enabled him to keep working. He had been advised to follow up with his primary care provider after each of his urgent visits to Clinic A, but as the primary breadwinner of his family, he didn’t have time to schedule a health visit during working hours. He worked for a construction company and was paid per job. When he began to call off work, a friend mentioned to Joe that his work might be affecting his health, so he submitted a workers’ compensation claim and was referred to an occupational health clinic. A full workup revealed that Joe had irritant-induced asthma, a type of asthma that can be caused by exposure to inhaled irritants at work. Since Joe had been exposed to these irritants over a long time without receiving a diagnosis or sufficient treatments, his asthma had become severe. He was advised to avoid work in construction or other jobs with exposure to respiratory irritants and filed for disability.

John was 27 years old when he developed cough symptoms and sought evaluation at Clinic B. When John returned for the second time requiring steroids and nebulizer treatments to control his cough symptoms, the electronic health record (EHR) alerted the clinician that he might benefit from an evaluation for occupational asthma since he had new-onset adult asthma and worked in construction. He was referred to an occupational health clinic. His workup revealed that he did indeed have work-related irritant-induced asthma. John was the primary breadwinner of the family and did not have options for alternate employment. The irritants could not be removed from his workplace so John continued in his job but did all he could to use dust controls, wear his respirator when around dust or fumes, remove his clothing and shoes before he entered back home, and work with his healthcare provider to bring his asthma under optimal control. He was able to continue working in construction and saved enough money to start his own company.

Environmental factors at work can promote health or sometimes present hazards. Income level is also associated with work and is one of the most powerful social determinants of health. With new requirements for electronic health record (EHR) system certification arising from the 21^st Century Cures Act, there is potential to obtain valuable data to address these factors and help patients, like Clinic B did for John. Occupation and Occupation Industry are included in version 3 of U.S. Core Data for Interoperability (USCDI), the “standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.”  When these data elements are captured using the Occupational Data for Health (ODH) framework created by the National Institute for Occupational Safety and Health (NIOSH), EHR systems could be built to help providers identify occupational factors that may affect health, such as John’s construction work. This could lead to other benefits such as:

• healthcare organizations querying their EHR system to identify emerging health conditions or populations of workers for which preventive efforts are needed,
• providers utilizing decision support tools that prompt preventive screening such as chest x-rays for workers whose occupation or industry may expose them to respiratory hazards where screening is indicated,
• providers generating personalized instructions through the EHR for patients written in a patient’s native language, such as job specific exercises or ergonomic education to prevent low back pain, and
• work information included in data collected and used by public health generating new knowledge.

We saw firsthand through the COVID pandemic how frontline workers were disproportionately affected. These positions are often held by women, people of color, and immigrants, all for whom health equity may be a challenge. According to the World Health Organization, “Health and health equity are determined by the conditions in which people are born, grow, live, work, play and age, as well as biological determinants.” However, as the saying goes, if you can’t measure it, you can’t manage it. ODH provides a valuable method of measuring work through interoperable data exchange.

October 24-28 is Global Health Equity Week, “celebrating the power of information and technology to improve access to healthcare for all communities.” During this week, take some time to consider how your organization might use Occupational Data for Health (ODH) to include work information with other demographic and clinical variables. By this sharing data in a meaningful, appropriate way, we can obtain actionable information for individual patient, population and public health efforts and create a society where the health of all working people is supported. Talk to your electronic health record (EHR) vendor about ODH!

Michele Kowalski-McGraw, MD, MPH, FACOEM, is an Associate Physician Diplomate with UC San Diego Health, Community Care/Occupational and Environmental Medicine. Dr. Kowalski-McGraw is an Occupational Medicine Consultant with the NIOSH Respiratory Health Division working on an EHR project.