Occupational Health: Core Areas of Knowledge and Competence, Part 2

OHA’s can contribute by helping managers to manage sickness absence more effectively. The nurse may be involved in helping to train line managers and supervisors in how to best use the OH service, in how to refer staff, what type of information will be required, what to expect from occupational health. By developing transparent referral procedures, ensuring that medical confidentiality is maintained and that the workers’ rights are respected the OHA can do much to ensure that employees referred for assessment due to sickness absence are comfortable with the process.

OH nurses, with their close relationship with workers, knowledge of the working environment and trends in ill-health in the company are often in a good position to advise management on preventing sickness absence. In my experience referral to General Practitioners have a limited use for work related issues, and gain best results by as well as keeping the GP aware, referring to a specialist occupational physician.

Planned rehabilitation strategies, can help to ensure safe return to work for employees who have been absent from work due to ill-health or injury. The nurse is often the key person in the rehabilitation programme who will, with the manager and individual employee, complete a risk assessment, devise the rehabilitation programme, monitor progress and communicate with the individual, the OH physician and the line manager. Nurses have also become involved in introducing proactive rehabilitation strategies that aim to detect early changes in health before such conditions result in absence from work. Improving and sustaining working ability benefits many groups, the individual, the organization and society, as costly absence and other health care costs are avoided.

In many cases the OH nurse has to work within the organization as the clients advocate in order ensuring that managers appreciate fully the value of improving the health of the workforce. OH nurses have the skills necessary to undertake this work and may develop areas of special interest.

The occupational health nurse may develop pro-active strategies to help the workforce maintain or restore their work ability. New workers, older workers, women returning to work following pregnancy or workers who have been unemployed for a prolonged period of time may all benefit from health advice or a planned programme of work hardening exercises to help maintain or restore their work ability even before any health problems arise. Increasingly the problems faced by industry are of a psychosocial nature and these can be even more complex and costly to deal with. OH nurses, working at the company level, are in a good position to give advice to management on strategies that can be adopted to improve the psycho-social health and wellbeing of workers.

Health and safety

The OHA can have a role to play in developing health and safety strategies. Where large, or high risk, organizations have their own in-house health and safety specialists the OHA can work closely with these specialists to ensure that the nurses expertise in health, risk assessment, health surveillance and environmental health management is fully utilized into the health and safety strategy. Occupational health nurses are trained in health and safety legislation, risk management and the control of workplace health hazards and can therefore make a useful contribution to the overall management of health and safety at work, with particular emphasis on ‘health’ risk assessment.

Hazard identification

The nurse often has close contact with the workers and is aware of changes to the working environment. Because of the nurses expertise in the effects of work on health they are in a good position to be involved in hazard identification. Hazards may arise due to new processes or working practices or may arise out of informal changes to existing processes and working practices that the nurse can readily identify and assess the likely risk from. This activity requires and pre-supposed regular and frequent work place visits by the occupational health nurse to maintain an up to date knowledge and awareness of working processes and practices.

Risk assessment

Legislation in Europe is increasingly being driven by a risk management approach. OHA’s are trained in risk assessment and risk management strategies and, depending upon their level of expertise and the level of complexity involved in the risk assessment, the nurse can undertake risk assessments or contribute towards the risk assessment working closely with other specialists.

Advice on control strategies

Having been involved in the hazard identification and risk assessment the occupational health nurse can, within the limits of their education and training, provide advice and information on appropriate control strategies, including health surveillance, risk communication, monitoring and on the evaluation of control strategies.

Research and the use of evidence based practice

Specialist OHA’s utilize research findings from a wide range of disciplines, including nursing, toxicology, psychology, environmental health and public health in their daily practice. The principal requirement for an occupational health nurse in practice is that they have the skills to read and critically assess research findings from these different disciplines and to be able to incorporate the findings into evidence based approach to their practice. Research in nursing is already well established and there is a small, but growing, body of evidence being created by occupational health nursing researchers who investigate occupational health nursing practices. OHA’s should ensure that they have access to and the skills necessary to base their practice on the best available evidence. At the company level occupational health nurses may be involved in producing management reports on for example sickness absence trends, accident statistics, assessment of health promotion needs and in evaluating the delivery of services, the effectiveness of occupational health interventions. Research skills and the ability to transfer knowledge and information from published research to practice is an important aspect of the role.

Ethics

OHA’s, along with other health, environment and safety professionals in the workplace health team, are in a privileged position in society. They have access to personal and medical information relating to employees in the company that would not be available to any other group. Society has imposed, by law, additional responsibilities on clinical professionals to protect and safeguard the interest of patients. The ethical standards for each discipline are set and enforced by each of the professional bodies. Breaches of these codes of conduct can result in the professional being removed from the register and prevented for practicing. Nurses have a long and well-respected tradition in society of upholding the trust placed in them by patients. This level of trust in the occupational health nurse’s professional integrity means that employees feel that they can be open, honest and share information with the nurse in the confidence that the information will not be used for other purposes. This allows the nurse to practice much more effectively than would ever be possible if that trust was not there. The protection of personal information enables a trusted relationship between employees and the nurse to be developed and facilitates optimum working relationships and partnership. The International Commission on Occupational Health (ICOH) has published useful guidance on ethics for occupational health professionals’. This guidance is summarized below “Occupational Health Practice must be performed according to the highest professional standards and ethical principles. Occupational health professionals must serve the health and social wellbeing of the workers, individually and collectively. They also contribute to environmental and community health the obligations of occupational health professionals include protecting the life and the health of the worker, respecting human dignity and promoting the highest ethical principles in occupational health policies and programs. Integrity in professional conduct, impartiality and the protection of confidentiality of health data and the privacy of workers are part of these obligations. Occupational health professionals are experts who must enjoy full professional independence in the execution of their functions. They must acquire and maintain the competence necessary for their duties and require conditions which allow them to carry out their tasks according to good practice and professional ethics.”

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Rebuilding the Tower of Babel – A CEO’s Perspective on Health Information Exchanges

Defining a Health Information Exchange

The United States is facing the largest shortage of healthcare practitioners in our country’s history which is compounded by an ever increasing geriatric population. In 2005 there existed one geriatrician for every 5,000 US residents over 65 and only nine of the 145 medical schools trained geriatricians. By 2020 the industry is estimated to be short 200,000 physicians and over a million nurses. Never, in the history of US healthcare, has so much been demanded with so few personnel. Because of this shortage combined with the geriatric population increase, the medical community has to find a way to provide timely, accurate information to those who need it in a uniform fashion. Imagine if flight controllers spoke the native language of their country instead of the current international flight language, English. This example captures the urgency and critical nature of our need for standardized communication in healthcare. A healthy information exchange can help improve safety, reduce length of hospital stays, cut down on medication errors, reduce redundancies in lab testing or procedures and make the health system faster, leaner and more productive. The aging US population along with those impacted by chronic disease like diabetes, cardiovascular disease and asthma will need to see more specialists who will have to find a way to communicate with primary care providers effectively and efficiently.

This efficiency can only be attained by standardizing the manner in which the communication takes place. Healthbridge, a Cincinnati based HIE and one of the largest community based networks, was able to reduce their potential disease outbreaks from 5 to 8 days down to 48 hours with a regional health information exchange. Regarding standardization, one author noted, “Interoperability without standards is like language without grammar. In both cases communication can be achieved but the process is cumbersome and often ineffective.”

United States retailers transitioned over twenty years ago in order to automate inventory, sales, accounting controls which all improve efficiency and effectiveness. While uncomfortable to think of patients as inventory, perhaps this has been part of the reason for the lack of transition in the primary care setting to automation of patient records and data. Imagine a Mom & Pop hardware store on any square in mid America packed with inventory on shelves, ordering duplicate widgets based on lack of information regarding current inventory. Visualize any Home Depot or Lowes and you get a glimpse of how automation has changed the retail sector in terms of scalability and efficiency. Perhaps the “art of medicine” is a barrier to more productive, efficient and smarter medicine. Standards in information exchange have existed since 1989, but recent interfaces have evolved more rapidly thanks to increases in standardization of regional and state health information exchanges.

History of Health Information Exchanges

Major urban centers in Canada and Australia were the first to successfully implement HIE’s. The success of these early networks was linked to an integration with primary care EHR systems already in place. Health Level 7 (HL7) represents the first health language standardization system in the United States, beginning with a meeting at the University of Pennsylvania in 1987. HL7 has been successful in replacing antiquated interactions like faxing, mail and direct provider communication, which often represent duplication and inefficiency. Process interoperability increases human understanding across networks health systems to integrate and communicate. Standardization will ultimately impact how effective that communication functions in the same way that grammar standards foster better communication. The United States National Health Information Network (NHIN) sets the standards that foster this delivery of communication between health networks. HL7 is now on it’s third version which was published in 2004. The goals of HL7 are to increase interoperability, develop coherent standards, educate the industry on standardization and collaborate with other sanctioning bodies like ANSI and ISO who are also concerned with process improvement.

In the United States one of the earliest HIE’s started in Portland Maine. HealthInfoNet is a public-private partnership and is believed to be the largest statewide HIE. The goals of the network are to improve patient safety, enhance the quality of clinical care, increase efficiency, reduce service duplication, identify public threats more quickly and expand patient record access. The four founding groups the Maine Health Access Foundation, Maine CDC, The Maine Quality Forum and Maine Health Information Center (Onpoint Health Data) began their efforts in 2004.

In Tennessee Regional Health Information Organizations (RHIO’s) initiated in Memphis and the Tri Cities region. Carespark, a 501(3)c, in the Tri Cities region was considered a direct project where clinicians interact directly with each other using Carespark’s HL7 compliant system as an intermediary to translate the data bi-directionally. Veterans Affairs (VA) clinics also played a crucial role in the early stages of building this network. In the delta the midsouth eHealth Alliance is a RHIO connecting Memphis hospitals like Baptist Memorial (5 sites), Methodist Systems, Lebonheur Healthcare, Memphis Children’s Clinic, St. Francis Health System, St Jude, The Regional Medical Center and UT Medical. These regional networks allow practitioners to share medical records, lab values medicines and other reports in a more efficient manner.

Seventeen US communities have been designated as Beacon Communities across the United States based on their development of HIE’s. These communities’ health focus varies based on the patient population and prevalence of chronic disease states i.e. cvd, diabetes, asthma. The communities focus on specific and measurable improvements in quality, safety and efficiency due to health information exchange improvements. The closest geographical Beacon community to Tennessee, in Byhalia, Mis

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