Environmental Exposure Modules for EHR and PHR Systems

Shepherdstown 24 August 2010While there has been tremendous progress over the past decade in the design and development of electronic health record (EHR) and personal health record (PHR) systems, we still have a long way to go. Over the next decade we will see the emergence of new software modules that will be incorporated into the EHR and PHR systems of the future. These will include genetic information, environmental exposure data, integrative medicine software modules, and more. This article is aimed at providing managers of health IT and health care provider organizations with a high level overview of health information projects or systems designed to capture data related to an individual's exposure to occupational and environmental hazards. In particular, we will be honing in on exposure initiatives that include some form of interface to EHR and PHR systems.

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Background

There is growing evidence among scientists and the public about possible health risks associated with exposure to occupational or environmental hazards. There may be short term or long term consequences to people who have been exposed to radiation, chemicals, asbestos, pollution, electro-magnetic transmissions, and hazardous waste. We need to better understand the impact of environmental exposure on children and adults with regards to autism, asthma, cancers, diabetes, obesity, and so many other conditions and diseases.

While great strides have been made to date, our understanding of the relationship between environmental exposures and a person's health is still not well understood. Without more data on personal exposure information, researchers have a limited ability to identify the impact occupational or environmental conditions may have in elevating disease risk. The time has come to begin systematically capturing data on exposure to occupational and environmental hazards in electronic health record (EHR) and personal health record (PHR) systems.

Occupational & Environmental Exposure

Occupational and environmental exposure involves the contact of people with a particular stressor for a specific duration of time. Stressors can include chemicals, radiation, asbestos, hazardous waste, electro-magnetic transmissions, traumatic events and much more. Exposure science studies the links between these occupational and environment hazards and target organisms such as the human body. See http://www.epa.gov/nerl/who.html

Exposure Projects & Software Solutions - Examples

There are a growing number of projects and software solutions related to the capture of occupational and environmental exposure information on patient populations. Many of these involve the use of EHR and PHR systems. What follows are brief descriptions of some of these pioneering efforts:

Defense Occupational & Environmental Readiness System (DOEHRS)) - DOEHRS is an integrated Environmental, Safety, and Occupational Health application supporting the Department of Defense (DoD) initiatives to capture, store, and analyze environmental exposure history of military and civilian personnel. An interface to the AHLTA electronic health record (EHR) system is planned. DoD is also working with the VA to share environmental exposure information between their EHR systems that may be relevant to the health concerns or diseases that veterans may experience. The DOEHRS suite currently includes:

  • DOEHRS-HC (Hearing Conservation) provides noise exposure surveillance, diagnostic evaluation, hearing loss and injury referrals, and more.
  • DOEHRS-IH (Industrial Hygiene) provides the ability to capture workplace and environmental exposure information, actively track air, water, and soil environmental hazards in garrison and theater operations, and more.

My Family Health Portrait is an internet based software tool that provides a structured way to collect medical information about individual family members to help medical professionals trace inheritable conditions from generation to generation. A family history provides a unique look into the family's genetic makeup as well as environmental exposures, including tobacco use, high-fat diets, and a range of other occupational or environmental hazards. My Family Health Portrait (http://familyhistory.hhs.gov) is a free online tool developed by the National Human Genome Research Institute (NHGRI) and the Surgeon General's Office as a part of the Family History Initiative.

eMERGE - The eMERGE Network is a national consortium formed to develop, disseminate, and apply approaches to research that combine DNA biorepositories with electronic medical record (EMR) systems for large-scale, high-throughput genetic research. There is a new NIH grant being awarded on "Electronic Medical Records and Genomics (eMERGE) Network" that will specifically perform genome-wide studies in participants with phenotypes and environmental exposures derived from electronic medical records (EMR). See http://grants2.nih.gov/grants/guide/rfa-files/RFA-HG-10-009.html

DHHS Genes & Environment Initiative - NIH plans to implement a Genes & Environment Initiative (GEI) have been approved by Congress. Federal funding began in FY 2007 and will continue through 2010, with $26 million annually going to genetic analysis and $14 million designated annually for the development of new tools to measure environmental exposures that affect health. The Genetics Program is spearheaded by NIH's National Human Genome Research Institute (NHGRI). The Exposure Biology Program is led by NIH's National Institute of Environmental Health Sciences (NIEHS). For more detail on their various programs, research projects, sensor technologies and various software tools, visit http://gei.nih.gov/index.asp and http://www.niehs.nih.gov/health/topics/index.cfm

Research Program on Genes, Environment & Health, (RPGEH) - The NIH has awarded a $25 million Grand Opportunities (GO) grant to conduct genotyping on 100,000 Kaiser Permanente (KP) members participating in the RPGEH project that includes the largest population-based bio-bank in the U.S. The bio-bank will be linked to their comprehensive EHR system. The RPGEH project is based at the KP Division of Research in Oakland, California. See http://www.dor.kaiser.org/external/DORExternal/rpgeh/index.aspx

ORAU Environmental Assessments, EMR Systems, and Worker Health - As the nation's research facilities and laboratories place greater importance on ensuring that activities are performed in a safe and environmentally responsible manner, accurate measurement and analysis of occupational health issues is critical to mitigating the causes and effects of on-the-job exposures. ORAU captures exposure data in their electronic medical record (EMR) system. See http://www.orau.org/occupational-exposure-worker-health-studies/capabilities/data-management.aspx

Researchers at the Georgia Tech Research Institute (GTRI) have developed a sensor system that continuously monitors the air around persons prone to asthma attacks. Worn in the pockets of a vest, the new system could help researchers understand the causes of asthma attacks. This research was supported by the U.S. Department of Housing & Urban Development (HUD) and the GTRI Independent Research and Development (IRAD) program. Sensor data could potentially be fed into EHR or PHR systems. See http://gtresearchnews.gatech.edu/newsrelease/asthma-vest.htm

Virtual Lung Model - Understanding biological impacts from pollution has become more important as respiratory ailments have increased. A virtual lung model developed at the U.S. Department of Energy's (DOE) Pacific Northwest National Laboratory (PNNL) may help predict the impact of pollutants on respiratory systems and provide new insights into asthma. Research efforts will be enhanced as models like this are coupled with next generation EHR systems that collect and feed exposure data into public health data repositories for more detailed analysis. See http://www.pnl.gov/breakthroughs/issues/2007-issues/winter/special_report_pg7.stm

Selected Issues

Open Solutions - Much of the work done to date has been funded by the federal government and is collaborative in nature. An 'open community' has emerged around the projects. Many of the software tools that have been developed are being shared and are in the public domain or 'open source' arena. For example, GENII-LIN is an open source software system for calculating radiation dose and risk from radionuclides released to the environment that was developed at the Oak Ridge National Laboratory. See http://www-rsicc.ornl.gov

Standards - Many organizations are now working on data standards. The Healthcare Information Technology Standards Panel (HITSP) Personalized Healthcare Interoperability Specification has identified requirements to collect environmental exposure data. Standard data elements to be collected by EHR and/or PHR systems may include date of exposure, type of exposure, length of time, geographic location, and more. For more detail, see http://wiki.hitsp.org/docs/IS08/IS08-1.html

OSHA standards on "Access to Employee Exposure and Medical Records" (Title 29 of the Code of Federal Regulations (CFR) Part 1910.1020) include the following requirements:

  • Preserve and maintain accurate medical and exposure records for each employee.
  • Inform workers of the existence, location, and availability of their records.
  • Make records available to employees, designated representatives, and OSHA as needed.
  • Keep employee exposure records for at least 30 years.
The standard covers records documenting employee exposure to toxic substances and harmful physical agents such as metals and dusts (e.g. lead, cadmium, silica), biological agents (e.g. bacteria, viruses, fungi), and physical stressors (e.g. noise, heat, cold). See http://www.osha.gov/Publications/pub3110text.html

Conclusions & Recommendations

The situation is just going to get more complicated as new hazards emerge over time that could adversely affect humans. Consider the impacts of cell phones, new vaccines, bioengineered foods, and many other emerging man-made technologies have on humans, not to mention what else nature may have in store for us. The following are some major conclusions and recommendations managers should consider.

  • EHR and PHR systems of the future will continue to evolve and begin to include genomic information, occupational and environmental exposure data, integrative medicine modules, and other new software modules.
  • Standards Development Organizations (SDO) must accelerate efforts to develop needed occupational and environmental exposure data, terminology, and communication standards for EHR, PHR and HIE systems.
  • Over the short term (3-5 years), additional pilot projects or systems such as DOEHRS, eMERGE, and My Family Health Portrait that incorporate occupational and environmental exposure data need to be developed, implemented, and evaluated.
  • Over the long term (5-10 years), all health IT vendors are going to have to upgrade their EHR and PHR systems to include genomic information, occupational and environmental exposure, and integrative medicine software modules if they are to be competitive. Tapping into the open source community for assistance may prove cost beneficial to them.
  • NHIN and Regional HIE Networks under development need to include the capability to exchange occupational and environmental exposure data between EHR, PHR, and public health data repositories.
  • Research into occupational and environmental hazards and their impact on human using large, national data repositories will take a major step forward once exposure data is collected on a much wider scale by EHR and PHR systems across the country.

Selected Reference Web Sites

Author

Peter Groen is an author, lecturer, independent consultant, former hospital CIO, and one of the founders of the Shepherd University Research Corporation (SURC). Email: groenpj@cs.com


Peter Groen

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