| Submitted By: Genevieve Luensman
/ Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health
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| Data Element Information |
| Use Case Description(s) |
| Use Case Description |
Employment Status is a social determinant of health that can be indicative of job security and access to work benefits. It can be used to examine populations within a healthcare organization, for example to identify individuals who would benefit from community referrals or to identify and address related health disparities and mental health. For persons who are unemployed, this Employment Status component provides information regarding their efforts to participate in the labor force in a way that’s consistent with Bureau of Labor Statistics data. The Gravity Project plans to address employment (scheduled for late 2020; https://www.hl7.org/gravity/).
Employment Status is expected to be collected/reviewed/updated at or prior to registration for every adult. The use of a patient portal or in-office kiosk or tablet is expected to facilitate this process. In addition, the Occupational Data for Health (ODH) set of templates for Patient Work, including Employment Status and Retirement Data templates, is an option in the IHE Exchange of Personal Health Record Profile (XPHR), allowing the patient to enter the data in their personal health record and share it with care providers to reduce the burden of data collection in the clinical setting.
The Employment Status and Retirement Date templates also are included as part of the ODH set of templates for Patient Work that are an option in the HL7 Consolidated CDA (C-CDA) Templates for Clinical Notes, Social History section. Social History is required in the C-CDA Continuity of Care Document (CCD) and History and Physical Document. Social History is optional in the C-CDA Consultation Note, Discharge Summary, Transfer Summary, Referral Note, and Procedure Note.
The Employment Status and Retirement Date templates are similarly included within the optional ODH set of templates for Patient Work in the IHE profiles for: data query using FHIR (QEDm), CDA or FHIR for international patient summary (IPS), CDA for medical summary (XDS-MS), CDA for personal health record data (XPHR), CDA for emergency department referral data (EDR), and CDA for healthy weight (HW) data.
Leveraging these implementation guides and profiles with structured and standardized Employment Status and Retirement Date can improve the quality of care by providing a more complete picture of factors that may affect the patient’s health during referrals. The data entry burden also can be reduced by sharing the information across care providers using one of these standards.
Related website: Institute of Medicine. Incorporating Occupational Information in Electronic Health Records: Letter Report. Washington, DC. National Academies Press; 2011. https://www.nap.edu/catalog/13207/incorporating-occupational-information-in-electronic-health-records-letter-report
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| Estimate the breadth of applicability of the use case(s) for this data element
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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. Since work and health are interrelated, most of the 209,000 primary care physicians and many of the 120,000 certified physician assistants and 290,000 licensed nurse practitioners in the U.S. would potentially benefit from the capture, access, use, and exchange of Employment Status and Retirement Date. |
| Link to use case project page |
https://www.cdc.gov/niosh/topics/ehr/default.html |
| Use Case Description |
Combat Zone Period: Both those who have served in the military and civilian workers can have experienced working in a combat zone. Combat zones present unique health hazards, many of which can have long-term consequences. Retrospective studies have shown correlations between combat zone deployments and health concerns such as respiratory conditions, certain types of cancer, post-traumatic stress disorder, sleep disorders, and others.
Many people who have served in the military seek care first outside of the Veterans Health Administration system, but may neglect or be reluctant to mention their military service unless asked. This situation can lead to misdiagnoses and poor health outcomes. The American Academy of Nursing “Have You Ever Served?” initiative includes a question about deployment in a combat zone in recognition of the special health risks that can be raised. Examples from the American Academy of Nursing, “Have You Ever Served?” initiative (https://www.aannet.org/initiatives):
https://jamanetwork.com/channels/health-forum/fullarticle/2760455
https://www.chamberlain.edu/blog/nurses-must-ask-patients-ever-served-military
https://www.dhhs.nh.gov/veterans/documents/atq-part-3.pdf
Collecting self-reported dates of working in a combat zone can facilitate important conversations about possible related health concerns, potentially prompting referral to the Department of Veterans’ Affairs (VA) healthcare system. The HL7 Military Service History and Status reporting project, sponsored by the VHA, is extending this FHIR specification as part of a FHIR implementation guide to share service member data (https://confluence.hl7.org/display/CGP/Military+Service+History+and+Status+FHIR+Profiles+Project+Page).
The option to collect Combat Zone Period is expected to be made available to adults at or prior to registration. Subsequently, the opportunity to review and update is to be presented as appropriate. The use of a patient portal or in-office kiosk or tablet is expected to facilitate this process. In addition, the Occupational Data for Health (ODH) set of templates for Patient Work, including a Combat Zone Period template, is an option in the IHE Exchange of Personal Health Record Profile (XPHR), allowing the patient to enter the data in their personal health record and share it with care providers to reduce the burden of data collection in the clinical setting.
The Combat Zone Period template is included as part of the ODH set of templates for Patient Work that is an option in the HL7 Consolidated CDA (C-CDA) Templates for Clinical Notes, Social History section. Social History is required in the C-CDA Continuity of Care Document (CCD) and History and Physical Document. Social History is optional in the C-CDA Consultation Note, Discharge Summary, Transfer Summary, Referral Note, and Procedure Note.
The Employment Status and Retirement Date templates are similarly included within the optional ODH set of templates for Patient Work The Combat Zone Period template is similarly included as part of the ODH set of templates for Patient Work that is an option in the IHE profiles for: data query using FHIR (QEDm), CDA or FHIR for international patient summary (IPS), CDA for medical summary (XDS-MS), CDA for personal health record data (XPHR), CDA for emergency department referral data (EDR), and CDA for healthy weight (HW) data.
Leveraging these implementation guides and profiles with structured and standardized Combat Zone Period can improve the quality of care by providing a more complete picture of factors that may affect the patient’s health and supporting referrals. The data entry burden can be reduced by sharing the information across care providers using one of these standards and by using the XPHR profile to share information from a personal health record to a care provider.
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| Estimate the breadth of applicability of the use case(s) for this data element
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According to the 2019 American Community Survey (https://data.census.gov/cedsci/table?q=S2101&tid=ACSST1Y2019.S2101) there are 17.4 million veterans living in the U.S. and it has been documented that many veterans seek care outside of the VHA. This information suggests that most of the 209,000 primary care providers and many of the 120,000 certified physician assistants and 290,000 licensed nurse practitioners in the U.S. would potentially benefit from the capture, access, use, and exchange of Combat Zone Period data. |
| Link to use case project page |
https://www.cdc.gov/niosh/topics/ehr/default.html |
| Healthcare Aims |
- Improving patient experience of care (quality and/or satisfaction)
- Improving the health of populations
- Improving provider experience of care
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| Maturity of Use and Technical Specifications for Data Element |
| Applicable Standard(s) |
An information model of the Patient Work data elements, called Occupational Data for Health (ODH), has been published ( https://doi.org/10.1093/jamia/ocaa070) and the data are represented in the Federal Health Information Model (FHIM; https://fhim.org/). An HL7 informative EHR-S Functional Profile has been published (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=498). A Guide to Collection of Occupational Data for Health (ODH) is in preparation.
Logical Observation Identifiers Names and Codes (LOINC; https://loinc.org/) codes are available for each Patient Work Data Element, including Employment Status.
The ODH code set (https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.327) provides a value set for Employment Status as well as other Patient Work Data Elements (https://phinvads.cdc.gov/vads/SearchValueSets_search.action?searchOptions.searchText=ODH). The PHIN VADS ODH Hot Topics section provides downloadable files with Preferred Concept Names and Easy Read Descriptions for Employment Status values (https://phinvads.cdc.gov/vads/SearchVocab.action).
Interoperability standard formats for all of the Patient Work Data Elements are published as aligned HL7 CDA, V2, and FHIR ODH templates as well as an IHE CDA profile ODH template. Related References:
HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes; Occupational Data for Health, Release 1 – US Realm; STU. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=522
IHE Patient Care Coordination (PCC) Technical Framework Supplement: CDA Content Modules, Revision 2.6 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc
HL7 FHIR Release 4.0.1 Profile: Occupational Data for Health (ODH), Release 1.0 STU. http://hl7.org/fhir/us/odh/STU1/
HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516 . Chapter 2C, Tables, Tables 0954-0959 provide the Patient Work Data Element component value sets. Chapter 3, Patient Administration, sections 3.4.15 and 3.4.18 describe the Patient Work Data Elements Employment Status and Combat Zone Period as Occupational Health (OH) segments; Retirement Date is included in the PD-1 segment.
https://doi.org/10.1093/jamia/ocaa070
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| Additional Specifications |
IHE Patient Care Coordination (PCC) Technical Framework Supplement to Volume 1, CDA Occupational Data Options, Revision 1.1 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc. This adds the Occupational Data for Health (ODH) template of all Patient Work Data Elements as an option to three profiles in the PCC Technical Framework: Cross-Enterprise Sharing of Medical Summaries (XDS-MS), Exchange of Personal Health Record (XPHR), Emergency Department Referral (EDR).
IHE Patient Care Coordination (PCC) Technical Framework Supplement: Query for Existing Data for Mobile (QEDm), Revision 2.2 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc. (ODH template for all Patient Work Data Elements is an option)
IHE Patient Care Coordination (PCC) Technical Framework Supplement: International Patient Summary (IPS), Revision 1.1 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#pcc. (ODH template for all Patient Work Data Elements is an option)
IHE Quality, Research and Public Health Technical Framework Supplement: Healthy Weight (HW), Revision 2.3 – Trial Implementation. https://www.ihe.net/resources/technical_frameworks/#qrph. (ODH template for all Patient Work Data Elements is an option)
HL7 Version 2.9 Messaging Standard – An Application Protocol for Electronic Data Exchange in Healthcare Environments, Normative. 2019 Dec. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=516. Patient Work segments and Retirement Date are included as options in: Chapter 3, Patient Administration, 13 ADT/ACK message events; Chapter 4, Orders, 1 OMG, 4 OML and 1 OMI message events; Chapter 7, Observations, 7 ORU, 2 OUL, and 1 OPU message event. |
| Current Use |
In limited use in test environments only |
| Supporting Artifacts |
ODH interoperability templates for Patient Work have been used to demonstrate exchange at HIMSS Interoperability Showcases annually since 2016 and the PHI Conference Interoperability Showcases in 2016 and 2018 using the IHE Healthy Weight (HW) profile. These transactions and demonstrations have involved four personal health records, one interface engine, one public health representative, one provider portal, and one EHR. One personal health record and the interface engine used production environments; the others used test environments. For three 2020 NACCHO 360X Interoperability Demonstrations, Patient Work was exchanged using the QEDm (FHIR) and CCD (CDA) formats.
Related websites:
“Health and Fitness,” Interoperability Showcase. Health Information Management and Systems Society (HIMSS) Annual Conference. Feb 19-24, 2017. Video at https://www.youtube.com/watch?v=ZxRx1UECUkg&list=PLFB222C2B798A2877&t=0s&index=22
“Value-Based Care,” Interoperability Showcase. Health Information Management and Systems Society (HIMSS) Annual Conference. Las Vegas, NV. 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. Health Information Management and Systems Society (HIMSS) Annual Conference. Orlando, FL. 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
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| Extent of exchange
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4 |
| Supporting Artifacts |
ODH interoperability templates for Patient Work have been tested at IHE Connectathons and demonstrated at annual HIMSS and bi-annual PHI Conference Interoperability Showcases since 2016 using the IHE Healthy Weight (HW) profile. The 2020 NACCHO 360X Interoperability Demonstrations used the FHIR QEDm and CDA CCD standards. These transactions and demonstrations have involved four personal health records, one interface engine, one public health representative, one provider portal, and one EHR. One personal health record and the interface engine used production environments; the others used test environments.
https://product-registry.ihe.net/PR/pr/search.seam?integrationProfileOption=424&integrationProfile=372&domain=9&date=ANY|1601300810685|1601300810685
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| Potential Challenges |
| Restrictions on Standardization (e.g. proprietary code) |
None |
| Restrictions on Use (e.g. licensing, user fees) |
None |
| Privacy and Security Concerns |
The Data Elements in the Patient Work Data Class are intended to be a part of the medical record and protected as such. |
| Estimate of Overall Burden |
We estimate that it will take approximately 600 hours to implement all of the Patient Work Data Elements (Job, Usual Work, Employment Status and Retirement Date, and Combat Zone Period) as described in the HL7 EHR-S Work and Health Functional Profile and A Guide for Collection of Occupational Data for Health (ODH, aka Patient Work. NIOSH, in preparation). The functional profile suggests system features to manage the information (including rendering, storing, etc.) so that it will be most useful and accessible to the care provider at the right time.
Initially, data collection will likely occur primarily via patient self-entry, e.g., during preregistration in their patient portal or via a kiosk on arrival in the clinic. Based on user testing of a Patient Work collection prototype, initial entry of all Patient Work Data Elements (Job, Usual Work, Employment Status and Retirement Date, and Combat Zone Period) takes 5-30 minutes. As with other 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.
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| Other Implementation Challenges |
None |
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Submitted by nedragarrett_CDC on
CDC comments on Employment Status
CDCs requests the inclusion of Employment Status in USCDIv6.
Justification: Employment Status is a social determinant of health that can be indicative of job security and access to work benefits. This data element captures whether a person is: employed, not in the labor force, or unemployed.
The National Institute for Occupational Safety and Health (NIOSH) collaborated with the National Association of Community Health Centers (NACHC) to support collection of Employment Status data among patients seen by three large Health Center Controlled Networks (HCCNs). Two of the HCCNs used an Epic EHR, and one used athenahealth. Among 34,777 unique patients seen in affiliated community health centers, Employment Status was recorded for 26,221 (75.4%). Notably, there was a 10% increase in collection of this variable across the three-year project period, an indicator of increasing buy-in among implementing partners.
NIOSH EHR webpage: How Work Information and Electronic Health Records Works | EHRs | CDC
Employment Status is an artifact in the HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.1 - STU 2.1.1: 10.0.9 ODH Employment Status Example: observation-odh-employment-status-ecr-eve-everywoman
Employment Status is a social determinant of health that can be indicative of job security and access to work benefits. It can be used to examine populations within a healthcare organization, for example to identify individuals who would benefit from community referrals or to identify and address related health disparities and mental health. For persons who are unemployed, this Employment Status component provides information regarding their efforts to participate in the labor force in a way that’s consistent with Bureau of Labor Statistics data. The Gravity Project addresses employment in their Employment Status domain; https://www.hl7.org/gravity
Employment status has been shown to provide insight into factors that contribute to health disparities, be an important social determinant of health, impact mental health, and provide a measure of job security. (Journal of the American Medical Informatics Association, Volume 27, Issue 7, July 2020, Pages 1072–1083,https://doi.org/10.1093/jamia/ocaa070)
Employment status is associated with access to healthcare— more than half of U.S. adults have healthcare through an employer or a union. (Keisler‐Starkey K, Bunch LN. Health Insurance Coverage in the United States: 2019. US Census Bureau; 2020. Health Insurance Coverage in the United States: 2019 (census.gov).
Unemployment is associated with physical and mental health problems that worsen as the duration of unemployment increases (Silver SR, Li J, Quay B. Visual representation of work as a social determinant of health: Augmenting Silver et al., Employment status, unemployment duration, and health-related metrics among US adults of prime working age. Am J Ind Med. 2022 Aug;65(8):697-698. https://doi.org/10.1002/ajim.23398).
Employment status is the “screening” question for Industry and Occupation – collection of employment status provides more efficient and accurate Industry and Occupation data. It would reduce the burden on collection of Industry and Occupation data, as those who have never worked would not need to be asked about their Industry and Occupation.
Formally collecting employment status—and coding this information in the EHR is gaining attention as an important data set for health care. (Weiss, E., Uy, R.Work: An Important Social Driver of Health – NACHC. https://www.nachc.org/work-an-important-social-driver-of-health/).
The Bureau of Labor Statistics reported as of August 2024, 62.7% of persons aged 16 and older were participating in the labor force, whereas the unemployment rate measured 4.2% or 7.1 million. Since work and health are interrelated, most of the 989,320 physicians and many of the 258,230 licensed nurse practitioners and the 236,516 psychologists in the U.S. would potentially benefit from the capture, access, use, and exchange of Employment Status. Knowing about a patient's work could help clinicians recognize the relationship between work and health.
Having standardized employment status data available at the population level will support public health research and policy. Employment status is a social determinant of health and a health equity indicator, particularly because healthcare access and other health-related needs vary greatly by employment status. Stable employment helps provide workers with the ability to live in healthier neighborhoods, secure quality education and childcare services for their children, and buy nutritious food (rwjf.org).
https://www.bls.gov/news.release/pdf/empsit.pdf.
https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/state-of-the-health-workforce-report-2023.pdf
Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social determinants of risk and outcomes for cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2015;132(9):873–98. doi:10.1161/CIR.0000000000000228
Occupational Data for Health Value Sets:
Employment Status is a codeable concept with a 0..1 cardinality. The binding is required to the HL7 value set: employmentStatusODH
Examples of use within EHRs or other Health IT: Findings from the NIOSH/NACHC collaborative resulted in 2 Health Center Controlled Networks (HCCN)s using the Epic EHR; 1 HCCN using the athenahealth EHR to collect Employment Status data.
Use of proprietary code does not prohibit its inclusion in USCDI, but a higher barrier to adoption such as this would require a more substantial justification of the use case and value to nationwide interoperable exchange. The value sets are not proprietary. Another example of challenges related to standardization is a lack of clear consensus about how to represent or exchange this data element, or where there are different and/or conflicting uses by different stakeholders. Currently there are duplicate value sets for Employment Status. These duplications will be corrected in 2024 ODH vocabulary update.
Licensing or user fees may impact either inclusion in Level 2 or addition to next version, especially if fees are significant relative to the impact on nationwide interoperable exchange. An example is payment of licensing fees to use a standard.
There are no licensing or user fees. Privacy and/or security concerns must be addressed here. These concerns may invoke existing privacy and security regulations or restrictions such as HIPAA or 42 CFR Part 2. If a new data class/element is not specifically covered by these, this must be stated clearly, not assumed to be not applicable.
No privacy concerns.
How hard has it been, or would it be to access and exchange the data element?
The collection of Employment Status is common practice within the healthcare workflow. Anticipated burden stems from the integration of a standardized value set to allow interoperable exchange. The Employment Status value set is very small and is anticipated to be an easy lift to integrate within existing health IT systems.
Is the data element only available in a system external to an EHR, such as a lab reporting system?
No, it is widely available and freely accessible.
Does the data element value need to be calculated by the patient or provider, or can it be automatically retrieved or calculated by the system in a production environment?
At current, the data element needs to be selected by the registration, patient or provider.
Does accessing or collecting the data element require significant time on the part of patient or provider, or does it require an interruption in normal workflow to collect?
No.
Does support for the data element require significant developer time to implement in EHR systems?
The value sets are available for immediate use.
Answers to these questions may be unknown to the submitter and additional information would be needed from industry or may be discovered as part of the ONC consideration process.
The only barrier foreseen is replacing the exiting Employment Status value sets, or free text box with a standardized value set based collection capacity.
USCDI-ONDEC-Submission-Form-Prep-Sheet - Employment Status USCDI v6.docx