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assurance programs, collect and analyze regional incidence and prevalence data, be alert to recognize cases that represent significant sentinel events, serve as first alert response centers for (episodic) toxic events, and make timely reportings to state and local public health agencies and governments. Provisions must be included to publicize actively and broadly the availability of the services of this O-E medical information system in the health care sectors. The intent of this publicity would be to increase the awareness about the merits of the system among primary care physicians and other health officials; so that these services will be recognized, and used widely to enhance patient care and to promote personal health across the nation. Funding must provide for growth and expansion of this service. The need for O-E medical information will increase as public and health care providers' awareness about the risks of exposure to hazardous substances grows. The mode! multi-disciplinary information system envisioned by the subcommittee would be the focal point to meet the broad national needs of physicians for O-E medical information. A NATIONAL INFORMATION SYSTEM FOR OCCUPATIONAL AND ENVIRONMENTAL HEALTH Background The vast and growing body of knowledge in the life sciences presents a formidable challenge to health professionals. The technical complexity and volume of facts needed to identify and manage many health problems often far outstrip any individual's ability to 5

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remember or use them effectively. This is particularly evident in the diagnosis and management of O-E exposures that induce illness or injury. In instances where the number of disease-causing agents are large, the specific agent in a clinical case of exposure is often uncertain, the health risks difficult to quantify, and the illness sometimes insidious, delayed, confounded by co- existing medical conditions, or simply overlooked. Compared to baker understood diseases, illness or injury resulting from hazardous exposures often bring with them additional requirements for information about treatment, clinical referrals, consultation, compensation, reporting requirements, and involvement of social and support agencies. A 1988 Institute of Medicine Committee looked at the Role of the Primary Care Physician in Occupational and Environmental Medicine and concluded that improved medical information resources are essential to progress in iclentifying and managing illness from toxic exposure: "The most practice/ way to assist the primary care practitioner to function effectively and knowledgeably when confronted with a patient suspected of having an occupational or environmental disease is to have a single-access point for necessary clinically pertinent information. This single-access point should become the central source through which all appropriate clinical and nonclinical services available to the practitioner could be elicited. The development of such an access point for health care providers needs to be designed so that a single telephone call will satisfy the practitioner's need to access the full range of information necessary to address the patient's problem.~" 6

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Though the principal audience of such an information system undoubtedly would be occupational physicians, emergency medical staff, and primary care providers, an increasingly educated public will demand more information about the risks posed by both environmental and work- related exposures. In addition, legislation, such as the Emergency Planning and Community Right-to-Know Act (TitIe It' of 1986 Superfund Amendments and Reauthorization Act), specifically mandates that information about industrial hazards and the environmental release of chemicals must be made publicly available. To determine the functional requirements for an O-E medical information system, the subcommittee met with general medical practitioners and other potential users including representatives of organizations that currently provide information services relevant to O-E medicine. Also, the subcommittee examined in detail several existing information dissemination programs, but none of them met the criteria to serve as a mode' for the national system envlslonec . Findings Since the objective of the committee was to enhance the practice of O-E medicine, nothing in this report should be construed as a critique of the inadequacies of any existing information system or that any should be supplanted by the system proposed. The members of both the Committee and subcommittee preparing this report agreed that the envisioned medical information system described must be accessible, credible and reliable, simple to use, available at all hours of the clay, and capable of rapidly providing a timely response. These objectives must be diligently sought in the design and in the clevelopment of the recommended information 7

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resource, because, at present, they cannot be met by a single database, computer program, or compilation of printed material. it is particularly important that the medical information developed and disseminated for use in making patient care decisions meet the highest standards. These high standards should be designed to establish credibility -- the perception of users that the information is authoritative, and trustworthy -- which will determine the ultimate success of the system. Equally important, utmost confidentiality in the information system records must be maintained to insure the security of proprietary and confidential physician-patient information. The system should provide easy access to users; should save physicians time in obtaining the needed information, and should not overwhelm or burden the physician. This criterion might be met by a 24-hour, toll- free, 800 number. Timeliness also is an important consideration. To be an attractive resource for health professionals, the system's response time must be equal or better than that of a phone consultation with a physician's colleague. Response time is a especially important in emergency situations; sometimes decisions about whether to evacuate an area must be made within a maker of minutes. Information about hazardous exposures, should be available in three categories: Specific technical information as reported in the literature; for example, the symptoms or adverse health effects associated with hazardous exposures, the exposure levels likely to cause health effects, or the particular hazardous agents known to cause particular signs or symptoms by laboratory findings or physical examinations Oral 8

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answers given at the time of inquiry can be supplemented by written documents distributed by mail, facsimile, or electronic mail. Risk assessment - interpretation and judoement of pertinent information for example, what is the best judgement of risk to human health given the circumstances as described during the inquiry; what is the likelihood of a resulting illness or injury due to the exposure; what courses of action or treatment might be pursued to reduce the risk or eliminate it; what is the relative risk [risks compared to another, perhaps more familiar hazardous exposure]? Referrals for additional help; for example, specialized O-E health services, occupational health clinics, social support services, rehabilitation or specialized treatment centers, or state or federal government agencies. Realizing inquiries for information will come from broad sectors of the medical community, the subcommittee decided the information system should provide for graded responses. Many inquiries wit! be simple, and perhaps can be adequately addressed by trained nonprofessional staff using concise information sources such as brief fact sheets. Other inquiries will require more complicated technical, administrative, or legal information best obtained from experience and judgement of professional staff. Thus, heterogeneity of information requests could be met with an effective triage procedure, with experts in all of the disciplines relevant to O-E illness or injury available for more complex inquiries. Because of liability concerns, tape recording or other ways to validate the accuracy of information communi 9