The Capability Gap in Occupational Health Information Management

BACKGROUND

At the American Occupational Health Conference in 2019, an occupational and environmental medicine (OEM) physician with Alcoa Corporation presented a growing body of evidence that welding is associated with the development of pneumonia and that offering pneumococcal vaccine to welders could reduce morbidity and mortality. On these grounds, Alcoa had implemented a program to offer pneumococcal vaccination to its welders.1 Navy OEM physicians sought to protect Navy welders similarly but ran up against a challenge. They were unable to identify the baseline rates of pneumonia in these workers based on existing military data systems, including through the Navy and Marine Corps Public Health Center’s EpiData Center, and were unable to demonstrate a benefit justifying the additional expense of this new effort.

This is just one example of how the lack of an integrated approach to data capture, information management, and analysis limits the contribution of OEM to protecting 2.3 million uniformed and civilian Department of Defense (DoD) workers. In the 1980s, the military services leaned into newly developing health information technology and built service-specific occupational health information management systems that incorporated medical, industrial hygiene, safety, and human resources data. These systems created the ability to glean enterprise-level insights into the health and wellness of employees, as well as to facilitate the management of occupational health programs.2^,3 Just as these systems were ready to be fully implemented in the 1990s, the military services defunded them when the Defense Occupational and Environmental Health Readiness System (DOEHRS)4 promised to provide an Occupational Medicine (OM) module that was expected to replace the service capabilities. The DOEHRS-OM module never came to fruition because of subsequent plans to instead add an occupational health module to the first electronic medical record, the Armed Forces Health Longitudinal Technology Application (AHLTA). Today, neither AHLTA nor its coming replacement, the Military Health System (MHS) GENESIS, includes capabilities relevant to occupational health.

When the services defunded occupational health information management systems, they then developed separate “safety and occupational health” information management systems to comply with Occupational Safety and Health regulations (such as the Navy’s “Enterprise Safety Management System” and “Risk Management Information,” the “Army Safety Management Information System 2.0” and “Army Safety and Occupational Health Information Management System,” and the “Air Force Safety Automated System”). These systems were designed without input from clinicians, and specifically the OEM community. The result of these decisions is today’s patchwork of information systems that creates information silos, leading to capability gaps in four key areas: (1) aggregating and analyzing occupational medicine exam data, (2) using medical surveillance to mitigate exposure incidents, (3) providing enterprise-level management of occupational medicine services, and (4) complying with privacy and recordkeeping law and regulation. The ongoing MHS transformation presents a unique opportunity to reassess the DoD’s public health capabilities and build a stronger system of prevention of occupational and environmental illnesses and injuries.5 These efforts will improve the readiness of not only our military service members but also civilian employees of the industrial base that is critical to maintaining our military materiel readiness. In this commentary, we provide a discussion of how information management systems are a critical component of this improved future state and how these systems could address each of the capability gaps.

WHY WE NEED THE ABILITY TO AGGREGATE AND ANALYZE OCCUPATIONAL MEDICAL EXAM DATA?

The purpose of occupational medical surveillance exams is 2-fold: (1) to detect pre-clinical disease resulting from occupational exposures in individual workers and (2) to provide feedback on the performance of exposure controls to prevent occupational illnesses in groups of workers. Longitudinal and aggregate analyses of the results are necessary to achieve the full benefit of performing these exams. For example, many medical surveillance programs require annual spirometry to assess lung function. Looking at multiple spirograms from an individual over time may reveal that although an isolated result is in the “normal” range, the rate of change in lung function from baseline is abnormal and requires further preventive action, and looking at spirograms from multiple workers aggregated by work center may identify work centers experiencing pulmonary impairment at higher than expected rates and lead to re-evaluation of existing controls or a search for previously unrecognized hazards.

The Occupational Safety and Health Administration (OSHA) requires only that medical surveillance exams be performed, not an analysis of the exam data, and the DoD does not systematically analyze its occupational medical exam data. This leads to missed opportunities to prevent illness in individuals and in groups of workers. As demonstrated by recent Congressional hearings regarding burn pit exposures,6 National Defense Authorization Act requirements to test firefighters’ per- and polyfluoroalkylated substances levels,7 and an OSHA notice of proposed rulemaking on blood lead levels, public and Congressional expectations regarding the tracking of exposure-related health outcomes are growing. Furthermore, maintaining the health and productivity of our workforce should be a priority for the DoD and MHS. Systematic analyses of occupational medical surveillance data are an important part of monitoring exposure-related health outcomes in the workforce.

The other category of exams routinely performed in occupational health clinics is medical certification (or qualification) exams. These exams are performed to advise the management of employees’ ability to safely perform essential job functions or meet a specific medical standard.8 Some of the medical exams required by the DoD for specific job tasks are nearly 50 years old, such as the Navy’s forklift operator medical exam. As a result of the lack of integration of safety data with medical exam data, analyses of rates of mishaps related to health conditions are not performed to develop or update these medical requirements. This represents a missed opportunity to prevent occupational injuries and their associated workers’ compensation and disability costs and to reduce the cost associated with performing unnecessary exams.

WHY WE NEED THE ABILITY TO CONDUCT MEDICAL SURVEILLANCE AFTER AN EXPOSURE INCIDENT?

While every effort should be made to prevent them, environmental exposures, deployment-related exposures, and excessive occupational exposures still occur. Recent exposure incidents in the news include the Red Hill water contamination event and concerns about mold in military housing.9^,10 Data systems to support an OEM response to such incidents are critically needed. DoD Instruction 6055.2011 directs that appropriate medical surveillance and routine analyses should be conducted to identify adverse health effects associated with past environmental exposures that present scientifically plausible significant health risks. Currently, no means exists to perform routine analyses of medical surveillance following environmental exposures, much like the previously described concerns with occupational medical surveillance. When exposure incidents happen, we need a means to prospectively monitor populations to determine if adverse health effects occur and take appropriate steps to mitigate these effects.

WHY WE NEED ENTERPRISE-LEVEL MANAGEMENT OF OCCUPATIONAL MEDICINE SERVICES?

Human resources personnel are key customers of occupational health clinics, which provide them with pre-placement exams, medical certification (qualification) exams, fitness for duty exams, and workers’ compensation program support. These occupational medicine services are managed only at the installation level, with no enterprise-level visibility on the consistency or quality of services provided. We cannot verify that these services meet the needs of our customers in terms of timeliness, access to support, and appropriate cost avoidance. Providing this support is made more complex by the differing organizational structures of human resources and the medical community. Up to 10 different human resources offices located across the country may be responsible for the civilian workforce on a single base.

Pre-placement exams are key steps in onboarding new employees. These exams can be performed by the nearest available occupational health clinic. No metrics are tracked to monitor the wait time for these exams. Additionally, access is particularly problematic for pre-placement exams when the human resources office may not know the points of contact or occupational health service resources available. As an example, an OEM physician recently received an e-mail request to complete a pre-placement exam for a candidate at a duty station to which the physician had not been assigned for 6 years. The human resources officer reached out directly via the global email because she had received no response from other former occupational health clinic professionals. Although the human resources officer was eventually connected with the current point of contact, the pre-placement exam, and therefore the onboarding process, was delayed considerably. This is just an anecdotal example, but better metrics are not available. A workflow to track requests for these exams, to direct them to the nearest DoD occupational health service provider, and to enable consistency of how these exams are performed would improve access to these services and provide a tool to improve quality.

Military occupational health clinics currently have a limited role in the federal workers’ compensation program. However, by DoD Instruction 1400.25-V810,12 medical officers must review all workers’ compensation claims of occupational illness and should review complex or controversial occupational injury claims on request of program administrators. Better infrastructure to support this mission area has the potential to lead to hundreds of millions of dollars in cost avoidance for the DoD. As an example, the Uniformed Services University’s Occupational and Environmental Medicine Residency Program has partnered with the Navy Fleet Forces Command to review these cases by residents as a part of their training program. Since January 2019, this program has led to $1.98 million of cost avoidance on two cases alone, with five additional cases pending further review by the Department of Labor’s Office of Workers’ Compensation Programs.13 Fleet Forces Command alone has nearly 1,300 cases pending an occupational medicine review. The total number of cases needing review across the DoD is currently unknown. The addition of an information management system to refer these cases and manage expeditious and high-quality reviews has the potential for a highly significant impact across DoD.

Perhaps most importantly, review of occupational illness claims is a critical aspect of the medical surveillance process, to identify potential occupational illnesses and prevent future harm to other workers. Without this feedback mechanism, the quality of occupational medical surveillance cannot be evaluated. As an example, residents reviewing a workers’ compensation case in 2020 identified a DoD employee with likely occupational asthma. This employee had worked with a known cause of occupational asthma, di-isocyanates, in an area with levels measured above the OSHA permissible exposure limit but was never enrolled in medical surveillance for di-isocyanates. During his respirator exam, he was noted to have abnormal spirometry, but his di-isocyanate exposure went unrecognized and continued for two years until the case review, decreasing the likelihood of a full recovery.14 Today, enrollment in medical surveillance and certification programs is not standardized and relies on various actions by supervisors, safety professionals, industrial hygienists, and the OEM community. In addition to facilitating case reviews, integrated, enterprise-level systems that also incorporate industrial hygiene and safety information will also facilitate consistent enrollment in these programs and appropriate, timely preventive actions.

WHY WE NEED TO COMPLY WITH PRIVACY AND RECORDKEEPING LAW AND REGULATION?

For civilian applicants and employees who are also beneficiaries of the MHS, the current state MHS Electronic Health Record (either AHLTA or MHS GENESIS) leaves all their personal health information accessible to occupational health providers. This creates a potential for illegal, discriminatory treatment of these MHS beneficiaries. For applicants or employees who are not MHS beneficiaries, only the information they choose to provide is available for review by occupational health providers. Therefore, this difference in access to personal medical records may lead to differential treatment, including additional medical evaluations or administrative requirements to provide information based on diagnoses seen in the MHS beneficiary’s personal medical record. Additionally, occupational health providers are at the crossroads of an ethical and medicolegal dilemma when they are performing an exam for a safety-sensitive position, and they inadvertently see a condition that the applicant or employee has not reported to them. This introduces a liability risk, both for making a non-hire or disqualification recommendation based on information that should not have been seen, or for not acting on a condition that was inadvertently seen but ignored and subsequently leads to a bad safety outcome. An information management engineering solution that places less reliance on occupational health providers, many of whom have only on-the-job training, to be able to discern when to act on an inadvertently viewed condition would mitigate this liability risk.

SUMMARY AND DISCUSSION

In their current state, military information management systems available to OEM provide a patchwork of data that meets most regulatory compliance requirements but fails to achieve the true objectives of occupational health. As we have described, developing the capability to aggregate and analyze occupational medical examination data, perform medical surveillance following occupational and environmental exposure incidents, manage occupational medicine services at an enterprise level, and fully comply with privacy and recordkeeping laws and regulations hold promise to improve the quality of occupational medicine services, increase public trust in DoD handling of exposure incidents, achieve considerable cost avoidance for DoD, and increase readiness of the DoD’s workforce.

Although the OEM community has recognized and highlighted the capability gaps in occupational health information management for over 40 years, these gaps have proven to be very difficult to bridge. The integration required to make these systems effective will require deliberate action at the level of the DoD and Defense Health Agency (DHA). Most recently, these capability gaps were highlighted to the DHA in 2019 when an MHS portal requirement was submitted.15 Although the DHA’s Resource Oversight Board determined on May 19, 2022, that this item would not be funded in this fiscal year, the capability requirement is now being formally addressed at the DoD level, to include a business process reengineering effort. The ongoing major transitions throughout the MHS organization represent a unique opportunity to critically evaluate and redesign our occupational health programs and processes to achieve high reliability. As the MHS transformation becomes a reality, we are hopeful that the time may finally be right for the DoD to invest in developing data infrastructure capabilities to support provision of truly high-quality OEM services for its roughly 1 million civilian employees and 1.3 million service members.