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EXECUTIVE SUMMARY Background The 1988 Institute of Medicine Committee on the Rote of the Primary Care Physician in Occupational and Environmental Medicine addressed several problems related to occupational and environmental factors. One of several recommendations made by that committee was the need to improve information sources available to the physician confronted with patients suspected of having occupational or environmental (O-E) disease. Subsequently, the Institute formed the Committee on Enhancing the Practice of Occupational and Environmental Medicine which then appointed an Information Systems Subcommittee to evaluate the requirements and design of a national information system for O-E health. The commidee's charge to this subcommittee was to examine the O-E information needs of primary care physicians and to develop a set of objectives and criteria for a national system to facilitate their access to a "single" information resource; to enhance the availability and visibility of a A second subcommittee, the Subcommittee on Physician Shortage, was formed to address the issue of ///ness From the Environment: Meeting the Growing Neec! for C/inica/ Services (in press).

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responsive, peer-reviewed knowledge base of clinically relevant information to improve clinical practice; and to form firm links between established local clinical networks (hospital, private, group practice, academically based, and others) and a single information resource with the goal to improve practice. In the Preface, mention was mace of several important existing information systems that have O-E resource material that could be used by physicians. However, physicians cannot take the time to learn the unique accessing features of each of these systems. Moreover, none of those examined by the subcommittee met the functional criteria or objectives of the mode! system described. Several of the poison control centers (PCCs) were reviewed with special attention paid to those which provide O-E medical information. The national network of cancer information centers was also examined as a mode' of system organization and administration, as were selected state information systems. Findings Physicians seeing patients with suspected O-E disease must obtain a quick response regarding causers) of the disease; accurate diagnosis; and appropriate therapy: therefore, a physician-talking-to-physician source of information is envisioned. As mentioned previously, these physicians cannot take time to learn the detailed access procedures for these databases. There are professional organizations and a diversity of resources where the neecled information can be obtained if one knows how to access the various databases and has the time to do so. However, there is no single, organized, national O-E information system dedicated to serving the needs of medical practitioners whose patients would 2

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benefit from the information in this area of medicine. This is a neglected area of medicine; with better information and better recognition of O-E related illness, the national incidence reports might surpass that for breast cancer, for example. The committee has envisioned a national information system that will focus upon furnishing the breadth of knowledge for hazardous substance information essential to primary care physicians in the practice of O-E medicine. In its broader extensions, the proposed system wit! be an information resource to industry's medical staff; first responders in accidents, spills, or other emergencies; and perhaps, in the future, to the public as suggested by the committee. Physicians may need to know a specific technical fact about a hazardous substance, the risk of exposure causing illness or injury, or whether a patient's clinical manifestations could be related to exposure in the workplace and or environment. Physicians frequently need expert advice about diagnostic methods and plans for medical management of persons exposed to hazardous substances. The information needed also includes hazardous substances produced by local industry, geographical patterns of relevant clinical illness, state and local governments' case reporting requirements, and other legal makers. To be most useful, an O-E medical information system must serve principally the physicians, and state and local health care providers. As the system develops, its services should be expanded to emergency first responders situations, emergency program planners, and then to the public. A national information resource meeting these requirements must have available a staff of experts in O-E medicine, industrial hygiene, epidemiology, pharmacology, toxicology, biostatistics, risk assessment, law, and education. 3

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Furthermore, to be effective, the subcommittee stipulated that such a national O-E medical information system must be simple and quick to use (in emergency situations this is important, but it is important also as a time saver for primary care physicians), the information furnished must be easily accessible 24 hours per day, and it must be credible and reliable. The system would collect and assess data about the incidence and prevalence of clinical cases involving exposure to hazardous substances, and would maintain records to serve as useful tools for epidemiological studies and public health planning at national, state, and local levels. Recommendations Based on the findings of the subcommittee, the committee recommends that Congress authorize and appropriate funds within a governmental agency's budget to establish a two-component national O-E medical information system: a network of multi- disciplinary regional information centers, whose services would be available over a toll-free telephone line; and a national center, whose primary role would be to coordinate, oversee, provide quality assurance, and administer the regional centers. The geographically dispersed regional centers would provide the following: information to physicians, industry, and first responders; medical information to primary care providers on the best available estimates of health risks due to hazardous exposures; medical advice for clinical treatment in emergency or nonemergency instances; and resources for clinical data acquisition. The national coordinating center would establish the need and award the regional contracts, provide training, build and share information resources. conduct quality 4