Data Element
Job Supervisory Level or Pay Grade
Description

A coded term that indicates the responsibilities of a person’s job for directing work and managing personnel, as reported by the person. Pay grade is used for a military position, since it distinguishes between officers and enlisted service members and conveys similar meaning across all branches of service.
Submitted By: Nedra Garrett / CDC
Data Element Information
Rationale for Separate Consideration The concept of Job encompasses multiple unique, independent data elements and so should be its own Data Class.
Use Case Description(s)
Use Case Description --Support public health electronic case reporting (eCR), analyses, and response by providing more timely and complete information for public health activities. Used to understand and quantify occupation (and industry)-related exposures and risks. Could reduce or eliminate the need for limited-use questions, such as ‘Are you a healthcare worker’ or ‘Are you a food handler’. Provides information for public health reporting, investigation, and response. approximately one-half of nationally-notifiable conditions would be supported by Job information.

Example 1: locate infectious disease outbreaks and intervene to prevent further illness. Job Industry would identify types of businesses associated with high rates of SARS-CoV-2 infection, e.g., meatpacking and poultry processing. Employer Name and Address would facilitate contact tracing. Job Occupation and Industry could support vaccination monitoring among essential workers.

Example 2: analyze work-related conditions such as silicosis and pesticide poisoning, to identify Industry sectors and Employers for whom interventions are needed to mitigate risk.

eCR program anticipates publication of new IGs (CDA/FHIR) that include ODH Job in Fall 2021 and will be working with EHR vendors to implement in 2022.

Some related references:

--Making EHR Data More Available for Research and Public Health (MedMorph): https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html

--Outbreak of Silicosis among Engineered Stone Countertop Workers in Four States: https://blogs.cdc.gov/nioshscience-blog/2019/10/29/silicosis-countertop/

--NIOSH Data and Statistics Gateway: https://www.cdc.gov/niosh/data/default.html

--Work-Related Lung Disease Surveillance System (e(WoRLD)): https://wwwn.cdc.gov/eworld

--Crystalline Silica (silicosis): https://www.cdc.gov/niosh/topics/silica/default.html

--Barry V, Dasgupta S, Weller DL, et al. Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity — United States, December 14, 2020–May 1, 2021. MMWR Morb Mortal Wkly Rep 2021;70:818–824. http://dx.doi.org/10.15585/mmwr.mm7022e1

--Bonwitt J, Deya RW, Currie DW, et al. COVID-19 Surveillance and Investigations in Workplaces — Seattle & King County, Washington, June 15–November 15, 2020. MMWR Morb Mortal Wkly Rep 2021;70:916–921. http://dx.doi.org/10.15585/mmwr.mm7025a3
Estimate the breadth of applicability of the use case(s) for this data element Job data are important for public health infectious disease case reporting in all state, local, tribal, territorial jurisdictions and in data shared with CDC. For example, All US States and Washington, DC are funded through CDC’s Division of HIV Prevention, Division of TB Elimination, and Division of STD Prevention flagship Notice of Funding Actions to perform surveillance activities, including collection of these data for surveillance purposes.

Thirty states currently require health care providers to report selected occupational illnesses to a state agency.
Link to use case project page https://www.cdc.gov/ecr/index.html
Supporting Attachments Healthcare Surveillance for Pandemic Response_eCR_Showcase.pdf
EPICJuly 2021 -- ehr letter.sent (002) (1).docx
LTR.Tripathi.23.Sep_.2021_0.pdf
Use Case Description 1) Collect and use data that address “conditions in the places where people … work … that affect a wide range of health and quality-of life-risks and outcomes,", i.e., work as a social determinant of health (SDOH; https://www.cdc.gov/socialdeterminants/index.htm). Work and health are inextricably related, regardless of whether a condition is work-related: in the U.S., workers spend more than half their waking hours at work.

--Example: A person has a job as a customer service specialist (Job Occupation) at a newspaper publisher and printing business (Job Industry). She sees her primary care provider for respiratory issues. The care provider sees the job information, which prompts them to ask if she works near the newspaper printing operation. She reports that she moved to an office adjacent to the printing operation three months ago. The care provider provides an electronic referral to an occupational medicine specialist who can evaluate whether workplace exposures are causing the patient’s respiratory symptoms.

2) Inform diagnosis and management of illness and injury, management of health in the work environment. Also leverage history built over time: some work-related health conditions can manifest after a long latency.

3) Improve the quality of care by exchange of medical information (transitions of care, referrals, patient summaries, etc.) to provide a more complete and computable picture of factors that may affect the patient’s health. This will also reduce the need for data reentry.

--Example: Job supports collection of self-reported military service information, which can (1) prompt important conversations between a care provider and patient, and (2) can be used to facilitate referrals to the VA and support data-sharing. The HL7 Military Service History and Status FHIR profiles project, sponsored by the VA, is harmonizing with the ODH FHIR IG (and supports additional requirements; https://confluence.hl7.org/display/CGP/Military+Service+History+and+Status+FHIR+Profiles+Project+Page ).

--Example: Leverage Job Occupation and Job Industry to identify agricultural workers (farmworkers) per HRSA UDS reporting requirements. (https://bphc.hrsa.gov/datareporting/reporting/index.html ).

4) Reduce burden by supporting patient-entry/review/update at or prior to registration for adults, e.g., via a patient portal, in-office kiosk or tablet, sharing from a personal health record (PHR). Also for some children per locality: e.g., an area where children may work on a family farm or in a family business.

5) Contribute, potentially, to patient matching algorithms.

6) Standardize Job Occupation, which may already be collected:

--Example: Obstetricians are required to ask a pregnant woman about her current job at the first visit.

--Example: Primary care medical homes (PCMH) are required to record [job] occupation to provide comprehensive care in the primary care setting.
Estimate the breadth of applicability of the use case(s) for this data element In 2018, approximately 75% of adults age 18 and older had worked in the past 12 months and on average approximately 60% of adults in the U.S. currently are working. Only 5% of adults report that they have never worked. Since work and health are interrelated, most providers involved in direct patient care would potentially benefit from the capture, access, use, and exchange of Job information. Includes:

--209,000 primary care physicians

--many of the 120,000 certified physician assistants and 290,000 licensed nurse practitioners

--many of the 415,000 specialty physicians who are also primarily involved in direct patient care, e.g., those who care for injuries and are faced with return-to-work decisions, such as emergency medicine specialists, orthopedists, physiatrists; those who care for patients with chronic diseases caused by occupational exposures, such as pulmonologists, neurologists, nephrologists, and oncologists.
Link to use case project page https://doi.org/10.17226/13207
Supporting Attachments LTR.Tripathi.23.Sep_.2021.pdf
Use Case Description Collect and use data to reduce health disparities, e.g., patient care aides have lower healthcare access and utilization than clerical workers. 90% of patient care aides are women, and more than half are racial or ethnic minority workers.

--Example: Use linked demographic and standardized job information to tailor resources and information to a patient population. A Federally-Qualified Health Center collected Current Job Occupation as text during registration for one year (more than 27,000 patients). The text data were extracted and coded by public health (not needed with standardized vocabulary), then analyzed with demographic information. Many patients primarily spoke Portuguese and of those patients most of the women were maids or hotel housekeepers and many of the men were construction or maintenance painters. The Health Center updated their intranet site with educational materials, in Portuguese, for painters about lead exposure and for housekeepers about ergonomic hazards and exposure to cleaning agents. This was so popular that they developed additional materials for more of their working patients, including those who speak Spanish. The painters can also be identified for annual blood-lead-level screening. (https://apha.confex.com/apha/141am/webprogram/Paper288596.html ).



Select References:

--Wipfli B, Wild S, Richardson DM. Work as a Social Determinant of Health—a Necessary Foundation for Occupational Health and Safety. 2021. J Occup Environ Med, published ahead of print. https://journals.lww.com/joem/Citation/9000/Work_as_a_Social_Determinant_of_Health__A.97775.aspx

--Selden TM and Berdahl TA. COVID-19 and Racial/Ethnic Disparities in Health Risk, Employment, and Household Composition. Health Affairs. 2020. 39:9,1624-1632. https://doi.org/10.1377/hlthaff.2020.00897

--Artiga S, Rae M, et al. COVID-19 Risks and Impacts Among Health Care Workers by Race/Ethnicity. KFF. 2020 Nov 11. https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-risks-impacts-health-care-workers-race-ethnicity/

Estimate the breadth of applicability of the use case(s) for this data element In 2018, approximately 75% of adults age 18 and older had worked in the past 12 months and on average approximately 60% of adults in the U.S. currently are working. Only 5% of adults report that they have never worked. Since work and health are interrelated, most providers involved in direct patient care would potentially benefit from the capture, access, use, and exchange of Job information. Includes:

--209,000 primary care physicians

--many of the 120,000 certified physician assistants and 290,000 licensed nurse practitioners

--many of the 415,000 specialty physicians who are also primarily involved in direct patient care, e.g., those who care for injuries and are faced with return-to-work decisions, such as emergency medicine specialists, orthopedists, physiatrists; those who care for patients with chronic diseases caused by occupational exposures, such as pulmonologists, neurologists, nephrologists, and oncologists.
Link to use case project page https://doi.org/10.17226/13207
Supporting Attachments LTR.Tripathi.23.Sep_.2021_1.pdf
Use Case Description Facilitate access to clinical decision support, e.g., through use of CQL, and reuse of the data for examination of populations, especially those who are underserved.

--Example 1: Work Schedule use: identify patients with diabetes who are on a rotating shift with nights and provide them with appropriate educational materials about managing their diet and blood glucose levels as their shifts change (https://cds.ahrq.gov/cdsconnect/artifact/occupational-factors-impacting-diabetes ).

--Example 2: Job Occupation and Job Industry use to identify patients who need certain vaccinations, screening for exposure to health hazards, and/or screening for early signs of work-related disease, such as chest radiographs for workers in industries with potential for silica exposure.

--Example 3: Job Occupation use (based on the ODH value set) to access lists of tasks, activities, and work contexts available via O*NET OnLine (https://www.onetonline.org/ ).

--Example 4: Job Occupation and/or Job Industry use to identify persons in high-risks types of work. In response to a recommendation from the National Transportation Safety Board (NTSB), two EHR vendors have devised clinical decision support tools for “the evaluation of nontraumatic loss of consciousness episodes or for a diagnosis of epilepsy that will notify providers of the patient’s [job] occupation, such as commercial driver; and remind them to address the occupational and driving Status of the patient” (https://data.ntsb.gov/carol-mainpublic/sr-details/H-18-021 ).

--Example 5: Work Classification and Supervisory Level or Pay Grade uses to support understanding of a patient’s work. Supervisory Level or Pay Grade distinguishes officer versus enlisted position for certain military occupations. Work Classification can be an indicator of access to benefits and financial stability (e.g., self-employed) or can prompt consideration of important voluntary work, such as volunteer firefighter.
Estimate the breadth of applicability of the use case(s) for this data element In 2018, approximately 75% of adults age 18 and older had worked in the past 12 months and on average approximately 60% of adults in the U.S. currently are working. Only 5% of adults report that they have never worked. Since work and health are interrelated, most providers involved in direct patient care would potentially benefit from the capture, access, use, and exchange of Job information. Includes:

--209,000 primary care physicians

--many of the 120,000 certified physician assistants and 290,000 licensed nurse practitioners

--many of the 415,000 specialty physicians who are also primarily involved in direct patient care, e.g., those who care for injuries and are faced with return-to-work decisions, such as emergency medicine specialists, orthopedists, physiatrists; those who care for patients with chronic diseases caused by occupational exposures, such as pulmonologists, neurologists, nephrologists, and oncologists.
Link to use case project page https://journals.lww.com/joem/Fulltext/2017/11000/Recognition_of_the_Relationship_Between_Patients_.25.aspx
Supporting Attachments LTR.Tripathi.23.Sep_.2021_2.pdf
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Occupational Data for Health (Value Set -Job Supervisory Level or Pay Grade (ODH))
https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7613
Additional Specifications HL7 CDA® R2.1 IG: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, R1.1 – US Realm. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522 (Modular template for non-breaking insertion of Job (and/or other ODH sections) for any CDA IG social history section)

HL7 FHIR R4.0.1 Profile: Occupational Data for Health (ODH), R1, STU 1.1. http://hl7.org/fhir/us/odh/STU1.1 (Modular template for non-breaking insertion of Job (and/or other ODH profiles) for any FHIR IG social history section)

Public health case reporting IGs including Job:

--HL7 CDA R2 IG Public Health Case Report – the Electronic Initial Case Report (eICR), R1, STU R2 – US Realm. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=436 (also STU R3, to be published late 2021 and implemented starting in 2022)

--HL7 FHIR R4 IG: Electronic Case Reporting (eCR) – US Realm, R1, STU 1. http://hl7.org/fhir/us/ecr/history.html (also R2, to be published late 2021 and implemented starting in 2022)

IHE Patient Care Coordination (PCC) Technical Framework (TF) Supplement: CDA Content Modules, Revision 2.7 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc (Modular template for non-breaking insertion of Job (and/or other ODH sections) for any CDA profile social history section)

CDC/NIOSH. “A Guide to the Collection of Occupational Data for Health.” https://www.cdc.gov/niosh/topics/ehr/default.html

HL7 EHRS-FM R2: Functional Profile; Work and Health, R1 – US Realm. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498

Marovich S, Luensman GB, Wallace B, Storey E. Opportunities at the intersection of work and health: Developing the occupational data for health information model. J Am Med Inform Assoc. 2020 Jul 1;27(7):1072-1083. https://doi.org/10.1093/jamia/ocaa070

Additional IHE PCC TF Supplements including Job https://www.ihe.net/resources/technical_frameworks/#pcc :

--IHE PCC TF Supplement to Volume 1, CDA Occupational Data Options, Revision 1.1 – Trial Implementation adds Job (and other ODH sections) to:

(a) Cross-Enterprise Sharing of Medical Summaries (XDS-MS)

(b) Exchange of Personal Health Record (XPHR)

(c) Emergency Department Referral (EDR) profiles

--IHE PCC TF Supplement: Query for Existing Data for Mobile (QEDm), Revision 2.2 – Trial Implementation

--IHE PCC TF Supplement: International Patient Summary (IPS), Revision 1.1 – Trial Implementation

Federal Health Information Model (FHIM), Person Domain. https://fhim.org/

IHE Quality, Research and Public Health (QRPH) TF Supplement: Healthy Weight (HW), Revision 2.4 – Trial Implementation (includes Job) https://www.ihe.net/resources/technical_frameworks/#qrph

HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. (includes Job) http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516. Job is pre-adopted in:

--HL7 Version 2.6 IG: Early Hearing Detection and Intervention (EHDI) Results, R1, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=344

--HL7 Version 2.6 IG: Critical Congenital Heart Defects (CCHD) Pulse Oximetry Screening Results, R1, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=366
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Testing and demonstrations for HIMSS Interoperability Showcases 2016-2019 and the PHI Conference Interoperability Showcases in 2016 and 2018 used the IHE Healthy Weight (HW) profile. Involved 3 personal health records, 1 integration engine, 1 public health representative, 1 provider portal, and 1 EHR using a test environment. Deployed in interface engine production product.

Three 2020 NACCHO 360X Interoperability Demonstrations, using the IHE QEDm (FHIR) and CCD (CDA) formats. A PHR and public health representative used a test environment.

Testing and demonstration for HIMSS Interoperability Showcase 2021, 1 EHR implemented.

Related References:

--“Health and Fitness” Interoperability Showcase. Health Information Management and Systems Society (HIMSS) Annual Conference. Feb 19-24, 2017. Video available at https://www.youtube.com/watch?v=ZxRx1UECUkg&list=PLFB222C2B798A2877&t=0s&index=22

--“Value-Based Care” Interoperability Showcase. HIMSS Annual Conference. Mar 5-8, 2018. Video available at https://www.youtube.com/watch?v=JH4Y4pV3mw8&t=0s&index=7&list=PLGFNwETCTdKlvMmCk0XjXksTDMW57kxUx

--“Patient-Centered Interoperability” Interoperability Showcase. HIMSS Annual Conference. Feb 11-15, 2019. Video available at https://www.youtube.com/watch?v=0ZCyjHG8Kpo&t=584s
https://www.cdc.gov/niosh/topics/ehr/default.html
Opioid Abuse and Prevention NACCHO_2020.pdf
Immunization Scenario NACCHO_2020.pdf
eCaseReporting Use Case NACCHO_2020.pdf
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts Testing and demonstration for HIMSS and NACCHO 360X Interoperability Showcases has involved 3 personal health records, 1 interface engine, 1 public health representative, 1 provider portal, and 2 EHRs.

Job will be included in the upcoming (fall 2021) public health case reporting (eCR) CDA R3 and FHIR R2 IGs, which CDC will be working with EHR vendors to implement in 2022.

A project to pilot collection and use in health centers will begin Oct 2021.
https://product-registry.ihe.net/PR/pr/search.seam?integrationProfileOption=424&integrationProfile=372&domain=9&date=ANY|1601300810685|1601300810685
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) The value sets for Occupation and Industry suggested in some interoperability standards are the CDC_Census2010 category value sets. However, the new ODH Occupation and Industry value sets assist with self-selection of coded entries that provide detail to support patient care. Crosswalks from ODH to CDC_Census2010 codes are available in the PHIN VADS Hot Topics section. A non-breaking “translation” in CDA or “slice” in FHIR can be used to transmit either or both ODH or CDC_Census2010 values; all relevant HL7 interoperability IGs and IHE interoperability content profiles are being updated accordingly. The translation is in the upcoming public health IGs.
Restrictions on Use (e.g. licensing, user fees) none
Privacy and Security Concerns Job is intended to be a part of the medical record and protected as such.
Estimate of Overall Burden We estimate that it will take approximately 300 hours to implement Job as described in the HL7 EHRS Work and Health Functional Profile and “A Guide for Collection of Occupational Data for Health (ODH).”

Initially, data collection will likely occur primarily via patient self-entry. Based on usability testing of a data collection prototype, initial entry of all ODH (Job, Usual Work, Employment Status and Retirement Date, and Combat Zone Period) takes 5-30 minutes. As with other EHR data classes, such as medications and family history, the opportunity to review previously entered information will be key to reducing the collection burden. Leveraging interoperability standards will also help to minimize the collection burden by sharing the information across systems.
Other Implementation Challenges The ODH value sets for Occupation and Industry are large, in order to provide recognizable terms. However, keyword text searches can be used to facilitate selection as described in the NIOSH “A Guide to Collection of Occupational Data for Health (ODH).”
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

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