Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
TABLE OF CONTENTS PREFACE EXECUTIVE SUMMARY Backgrounc' . . -'nc Ings Recommendations AL NATIONAL INFORMATION SYSTEM FOR OCCUPATIONAL AND ENVIRONMENTAL HEALTH Background Finclings DISCUSSION OF EXISTING INFORMATION SYSTEMS Poison Control Centers Cancer Information Service ............. Comments RECOMMENDATIONS ORGANIZATIONAL ASPECTS OF THE OCCUPATIONAL AND ENVIRONMENTAL MEDICAL INFORMATION SYSTEM . . . Costs CONCLUSIONS ..... 1 1 4 10 ........ 11 13 21 22 23 APPENDIX IX
PREFACE The explosion of scientific and technical information has stretched the ability of physicians to obtain ancJ absorb it in a timely and systematic fashion. Today's practitioners must keep up with an expanding biomedical research base along with a plethora of new drugs, medical devices, and treatment regimens. While the task is formidable, it is also exciting--especially when the knowledge base being tapped is accessible, familiar, and quickly applicable to the physician's practice. It becomes more difficult and demanding when the knowledge base is unavailable, hard to access, somewhat foreign, and perceived as being irrelevant to the physician's practice. For hard pressed primary care physicians (those who see large numbers of patients), the task of keeping up with information about occupational and environmental (O-E) exposures, and associated hazards and treatments becomes exceedingly burdensome both in time and effort. This information is difficult to obtain; when it exists at all, it is scattered throughout numerous databases. The information is certainly unfamiliar to most primary care x
physicians, who have had lithe formal education in the field. (The 1988 results of the Association of American Colleges medical student graduation questionnaire showed that 1.2 percent took an elective in preventive medicine and 1.0 percent in occupational medicine.) And, at least in the past, it may have been perceived as having lithe application to the primary care physician's practice. Thus, the essential part of the proposed information system is the person trained in accessing the needed information from available data bases, in interpreting the vagaries of risk assessment technologies and the actual limitations of data, in understanding physician needs for information, and in communicating information over the telephone. There are only about one thousand board-certified occupational medicine physicians in the United States. The subcommittee estimated 10 million workers are injured and 125,000 occupational related illnesses reported each year. The lager estimate was presumed conservatively low, and may actually be over 1,000,000. [Note that patients exposed to environmental sources of these hazardous substances have not been estimated, and would add greatly to the physician's patient load]. Accordingly, each board-certified physician would have an allotted patient load of 10,000 occupationally injured and 1,250 occupationally ill patients each year. Thus, the board-certifiecl occupational medicine physicians presently available in the United States cannot handle this load of patients with work-related injuries and illnesses. Furthermore, these certified physicians cannot serve as the O-E information resource for primary care physicians (and other non-board-certifiecl physicians) who will see the majority of these types of patients for the first time. tt is unreasonable to expect the present board-certified physicians to accept the burdensome task of supplying O-E information for diagnosis/treatment to all physicians xl i
with lithe or no training who need this type of consultation. Added to these statistical estimates of patient load are those exposed to hazardous environmental sources outside the workplace. The report recommends a means for quicker access by primary health care providers, to occupational and environmental information on hazardous chemicals as a way to enhance medical care to the hundreds of thousands of patients who are exposed, and concerned. every year. The information system described herein is intended to facilitate the accurate diagnosis and treatment of diseases attributed to exposure to chemicals and agents at work or from the environment. The essential part of the proposed information system would be the staff; the ideal approach would be for a physician seeing patients to call a physician at the information center who knows ways to discover the information requested. Most important is understanding the physician-caller's information needs and how these needs might be met quickly and accurately. Times are changing. The expanding use and knowledge of the risks of chemical and physical agents in workplaces, homes, public buildings, and consumer products are now accompanied by laws that make information about their use available to the public. Workers have a right to know about the chemicals used on the job and how these substances threaten their health. Community residents can now obtain information about accidental releases, chemical inventories, and the emission of toxic substances into their air, water, and soil. And it is no longer uncommon for neighborhood residents to demand answers from public health officials and other medical experts about proposals to site incinerators and xll
hazardous waste treatment facilities or about the possible effects of a newly discovered dump site. This growing interest in the effects of toxic substances on the environment and on public health along with the new righI-to-know laws will challenge physicians whose patients will want answers about risks to their own and their family's health. Most physicians are ilI-prepared to answer these questions, to course' their patients about occupational and environmental risk, and to diagnose illnesses probably related to workplace or community exposure to toxic substances. A whole report might be prepared showing the trends in occurrences of spills of hazardous substances. It is beyond the scope or the charge of this committee to assemble data on the numbers of incidents that occur each year that might result in human exposure to hazardous substances. In 198S, the Institute of Medicine reported on the role of the primary care physician in occupational and environmental medicine. The report identified a critical need for a credible and accessible source of information in occupational and environmental medicine for primary care physicians. The report recommended that such an information center be able to meet the clinical and nonclinical needs of physicians whose patients have occupational or environmental health problems. The present report reflects the deliberations of a second fOM committee which convened a subcommittee on information systems to explore how the original commiNee's recommendation for an occupational and environmental information resource might reasonably be implemented. The subcommittee, having broad representation from physicians in practice, explored the functional requirements for such an information resource. Further, it examined several information systems, but gave . . . x///
detail on only two existing models -- poison control centers and the Cancer Information Service. The report concludes with a proposal for an occupational and environmental information system that the subcommittee believes would meet the needs of physicians and the affected public. If funded, implemented, and successfully marketed, this information system will be a vital element in the health care community's response to a growing public health issue, and it will provide an effective and efficient link between busy practitioners, a multi-clisciplinary team of occupational and environmental specialists, and public health officials. To prepare the present report, the subcommittee began with the premise from the 1988 report: "Improved information sources are needed. The most practical 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 all necessary clinically pertinent information." The study group sough! to identify currently available organizations or facilities that could provide the single-access point to information. In an effort to identify such organizations, a mad! questionnaire was considered, but abandoned. An in- depth interview and detailed questioning over the telephone subsequently led to an invitation to representatives from selected information dissemination organizations to participate in two workshops. These two workshops were held with representatives from selected organizations to discuss the information resources furnished by each of them and to evaluate the application of these resources to meeting the needs of the practicing physician. There were several practicing physicians present at both workshops. At the first XIV
workshop, a representative was invited from each of the following organizations: National Library of Medicine, discussing the MEDical Literature Analysis and Retrieval System (MEDLARS, including TOXN ET, ELVILLE, PDQ, and the Chemical Substances Information Network); National Oceanic and Atmospheric Administration, discussing the Computer Aided Management Emergency Operations; Environmental Protection Agency, discussing the Toxic Release Inventory Program and the program for Emergency Response Preparedness for information focal communities about hazardous chemical releases; Chemical Manufacturers Association's Community Awareness and Emergency Response program and CHEMTRAK; Association of State and Territorial Health Officials, State and Territorial Health Risk Assessors and their linkages with the public health officials in state and local governments; American Association of Poison Control Centers, discussing the requirements for establishing one of the several certified poison control centers in the nation. At the second workshop, the participants discussed the capabilities of existing organizations identifiecl in the first workshop to respond to primary care physicians' questions about O-E health hazards. Questions included: Who are the principal users? Are any of the presently known existing organizations structured to respond to physicians' questions? What are the perceived future needs for O-E information available to primary care physicians? Attendees at the workshop included the following: three practicing primary care physicians, and representatives from the hospital emergency rooms, the Association of Occupational and Environmental Health Clinics, the Hazard Evaluation System and Information Service (California) and the Association of State and Territorial Health Risk Assessors; medical staff from two state public health offices; physicians from a California Local Emergency Prepareciness Committee; a physician xv
from industry representing the Chemical Manufacturers Association; and representatives from several Poison Control Centers. The study group identified the characteristics of an information system specifically designed to enhance the practice of physicians seeing patients who have O-E concerns or who might have an O-E disease. In making this report, the study group has drawn broadly from existing information systems, from users of the different types of systems mentioned above, and from potential users of a physician-oriented system specifically desianed to enhance the practice of O-E medicine. - In summary, none of the information systems mentioned in this report fulfilled the requirements set forth by the study group to furnish the information about O-E health hazards directly to the primary care physician. "Information system" is perhaps a misleading term. The system proposed herein could better be characterized as a physician-talking-to-a-physician, where one of the physicians would be part of an information center. The lager physician would have training and skills in accessing the information from hazardous substance databases, and in the interpretation and communication of information about exposure hazards and about health risks. The lOM Committee is indebted to the members of the Information Systems Subcommittee for producing this report, and to the many individuals who contributed to its efforts. Special thanks go to Dr. Daniel Masys who graciously produced the subcommittee's first draft. Al i
