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Board on Health Sciences Policy
September 29, 2011
John Howard, M.D.
National Institute for Occupational Safety and Health
Patriots Plaza 1
395 E. Street, S.W., Suite 9200
MS P12
Washington, DC 20201
Dear Dr. Howard:
At the request of the National Institute for Occupational Safety and
Health (NIOSH), the Institute of Medicine (IOM) appointed the ad hoc
Committee on Occupational Information and Electronic Health Records
(EHRs). The overarching charge to the committee was to examine the
rationale and feasibility of incorporating occupational information in
EHRs and to develop recommendations on next steps for NIOSH and
other partners to achieve this goal. More specifically, the committee was
asked to analyze the potential benefits of including occupational infor-
mation in EHRs, examine systems that are currently collecting these data
in their EHR in useful ways, and explore the technical challenges that
must be overcome in order to facilitate the incorporation of occupational
information in EHRs.
Implementation and use of EHRs have increased rapidly since pas-
sage of the 2009 Health Information Technology for Economic and Clin-
ical Health (HITECH) Act. The transition from paper to electronic
records offers the potential for providing clinicians with relevant and
necessary information about their patients’ occupations, as well as possi-
bilities for links to an array of clinical decision-support tools that could
improve the health care and safety of individuals. Additionally, the inclu-
sion of occupational information in EHRs offers a significant opportunity
to advance and expand public health surveillance in order to provide a
better understanding of occupational illness and injury. Each year in the
United States, more than 4,000 occupational fatalities and more than 3
1
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2 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
million occupational injuries occur along with more than 160,000 cases
of occupational illnesses (BLS, 2010b, 2011b). Advances in incorporat-
ing occupational information in EHRs could lead to more informed clini-
cal diagnosis and treatment plans as well as more effective policies,
interventions, and prevention strategies to improve the overall health of
the working population.
After gathering and reviewing the available evidence, the committee
concluded that occupational information could contribute to fully realiz-
ing the meaningful use of EHRs in improving individual and population
health care. The report examines the challenges that are inherent in this
important advance and makes recommendations (Box 1) focused on
moving forward the efforts to incorporate occupational information into
EHRs including feasibility studies, demonstration projects, and other
actions.
BOX 1
Recommendations
Initial Focus on Occupation, Industry, and Work-Relatedness Data Elements
Recommendation 1: Conduct Demonstration Projects to Assess the Collection
and Incorporation of Information on Occupation, Industry, and Work-Relatedness
in the EHR
NIOSH, in conjunction with other relevant organizations and initiatives, such as
the Public Health Data Standards Consortium and Integrating the Healthcare
Enterprise (IHE) International, should conduct demonstration projects involving
EHR vendors and health care provider organizations (diverse in the services
they provide, populations they serve, and geographic locations) to assess the
collection and incorporation of occupation, industry, and work-relatedness data
in the EHR at different points in the workflow (including at registration, with the
medical assistant, and with the clinician). Further, to examine the bidirectional
exchange of occupational data between administrative databases and clinical
components in the EHR, NIOSH in conjunction with IHE should conduct an
interoperability-testing event (e.g., Connectathon) to demonstrate this bidirec-
tional exchange of occupational information to establish proof of concept and,
as appropriate, examine challenges related to variable sources of data and
reconciliation of conflicting data.
Recommendation 2: Define the Requirements and Develop Information Mod-
els for Storing and Communicating Occupational Information
NIOSH, in conjunction with appropriate domain and informatics experts, should
develop new or enhance existing information models for storing occupational
information, beginning with occupation, industry, and work-relatedness data
and later focusing on employer and exposure data. The information models
should consider the various use cases in which the information could be used
and use the recommended coding standards. For example, NIOSH should
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3
LETTER REPORT
BOX 1 Continued
consider how best to use social history templates to collect a work history and
the problem list to document exposures and abnormal findings and diagnoses
with optional work-associated attributes for possible, probable, or definite
causes; exposures; and impact on work.
Recommendation 3: Adopt Standard Occupational Classification (SOC) and
North American Industry Classification System (NAICS) Coding Standards for
Use in the EHR
NIOSH, with assistance from other federal agencies, organizations, and
stakeholders (e.g., Bureau of Labor Statistics, Census Bureau, Council of
State and Territorial Epidemiologists [CSTE], National Library of Medicine,
National Institute of Standards and Technology, National Uniform Billing
Committee, Health Level 7 International [HL7]), should recommend to the
Health Information Technology (IT) Standards Committee the adoption of SOC
and NAICS to code occupation and industry. Furthermore, NIOSH should de-
velop models for reporting health data from EHRs by occupation and industry
at different levels of granularity that are meaningful for clinical and public
health use.
Recommendation 4: Assess Feasibility of Autocoding Occupational Informa-
tion Collected in Clinical Settings
NIOSH should place high priority on completing the feasibility assessment of
autocoding the narrative information on occupation and, where available, indus-
try that currently is collected and recorded in certain clinical settings, such as
the Dartmouth-Hitchcock health care system, Kaiser Permanente, New York
State Occupational Health Clinic Network, Cambridge Health Alliance, and
hospitals participating in the National Electronic Injury Surveillance System.
Recommendation 5: Develop Meaningful Use Metrics and Performance Measures
Based on findings from the various demonstration projects and feasibility stu-
dies, NIOSH, with the assistance of relevant professional organizations and
the Health IT Policy Committee, should develop meaningful use metrics and
health care performance measures for including occupational information in
the meaningful use criteria, beginning with the incorporation of occupation,
industry, and work-relatedness data, and later expanding as deemed appro-
priate to include other data elements such as exposures and employer.
Recommendation 6: Convene a Workshop to Assess Ethical and Privacy Con-
cerns and Challenges Associated with Including Occupational Information in the
EHR
NIOSH should convene a workshop involving representatives of labor unions,
insurance organizations, health care professional organizations, workers’
compensation-related organizations (e.g., International Association of Industri-
al Accident Boards and Commissions, National Council on Compensation In-
surance), and EHR vendors to
Continued
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4 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
BOX 1 Continued
assess the implications for the patient and clinician of incorporating
work-relatedness in the EHR, with respect to workers’ compensation;
and
propose guidelines and policies for protecting the patient’s non-work-
related health information from inadvertent disclosure and to ensure
compliance with the Health Insurance Portability and Accountability
Act, workers’ compensation, and other privacy standards.
Enhance the Value and Use of Occupational Information in the EHR
Recommendation 7: Develop and Test Innovative Methods for the Collection
of Occupational Information for Linking to the EHR
NIOSH should initiate efforts in collaboration with large health care provider
organizations, health insurance organizations, EHR vendors, and other stake-
holders to develop and test methods for collecting occupational data from in-
novative sources. Specifically, NIOSH should evaluate collection methods that
involve
patient input through mechanisms such as web-based portals and
personal health records, and
other means such as health-related smart cards, health insurance
cards, and human resource systems.
Recommendation 8: Develop Clinical Decision-Support Logic, Education Ma-
terials and Return-to-Work Tools
NIOSH, relevant professional organizations, and EHR vendors should begin to
develop, test, and iteratively refine and expand
clinical decision-support tools for common occupational conditions
(e.g., work-related asthma);
tools and programs that could be easily accessed for education of pa-
tients and caregivers about occupational illnesses, injuries, and
workplace safety;
training modules for administrative staff to collect occupational infor-
mation in different care settings; and
tools to improve and standardize functional job assessment and re-
turn-to-work documentation in EHRs, including standards for the
transmission of these forms.
Recommendation 9: Develop and Assess Methods for Collecting Standardized
Exposure Data
NIOSH should continue to work with occupational and environmental health
clinics and other relevant stakeholders to develop and assess methods for
collecting standardized exposure data for work-related health conditions.
NIOSH should explore the feasibility of
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5
LETTER REPORT
BOX 1 Continued
listing possible or probable exposures in the problem list or elsewhere
in the EHR;
linking occupational information in the EHR to online occupational,
toxicological, and hazardous materials databases, such as the Occu-
pational Information Network (O*NET), the Association of Occupa-
tional and Environmental Clinics, and Haz-Map, to enhance diagnosis
and treatment of work-related illnesses and injuries; and
automatically generating codes for exposures based on narrative text
entries.
Recommendation 10: Assess the Impact of Incorporating Occupational Infor-
mation in the EHR on Meaningful Use Goals
NIOSH, in conjunction with relevant stakeholders (e.g., Public Health Data
Standards Consortium, CSTE, Association of State and Territorial Health Offi-
cials), should
develop measures and conduct periodic studies to assess the impact
of integrating occupational information in EHRs, and
estimate the economic impact of EHR-facilitated return-to-work prac-
tices for both work-related and non-work-related conditions.
I would like to thank NIOSH and its staff members for supporting
this study and for the information they provided to the IOM committee in
the course of its work. Appreciation also is due to the IOM committee
and staff members for their work in planning the information-gathering
workshop that was held in June 2011 and in developing the report and its
recommendations. I hope that NIOSH will find this report helpful as it
continues to work toward incorporating occupational information in
EHRs.
Sincerely,
David H. Wegman, Chair
Committee on Occupational Information
and Electronic Health Records
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6 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
STUDY PROCESS
In early 2011, NIOSH requested that the IOM conduct a study to ex-
amine the rationale and feasibility of incorporating occupational1 infor-
mation into EHRs and to develop recommendations on next steps for
NIOSH and other partners to achieve this goal (see Box 2). This letter
report and its recommendations contribute to a larger effort to ensure
widespread adoption and meaningful use of EHRs in health care, which
has been prompted by incentives that were created by the HITECH Act
of 2009.
This study was conducted by the 11-member ad hoc IOM Committee
on Occupational Information and Electronic Health Records. The com-
mittee included members with expertise in occupational medicine, elec-
tronic health records, primary care, public health, biomedical
informatics, information technology, and epidemiology (see Appendix C
for committee biosketches).
Over the course of the study, the committee held three meetings to
gather and review available information, plan and conduct a public
workshop, and draft and refine this report’s recommendations. The
committee’s second meeting included a public information-gathering
workshop, held June 2, 2011, in Washington, DC (see Appendix A for
the workshop agenda and Appendix B for a list of registered attendees).
The workshop provided the committee with insights from experts in pri-
mary care, occupational medicine, public health surveillance, and infor-
mation technology. Presentations and discussion focused on the potential
benefits and challenges of including occupational information in EHRs
to improve health care delivery and public health surveillance, the extent
to which and the manner in which this information is currently being
recorded in EHRs, and technical considerations related to standardizing
and maximizing the value of the data. Additional information on occupa-
tional morbidity and mortality, as well as on EHRs and meaningful use,
was collected in a literature search and reviewed by the committee to
inform its deliberations.
1
Throughout this report, “occupational” is used broadly to describe attributes related to
one’s occupation (e.g., secretary), industry (e.g., mining), employer (e.g., Ford), and
work environment (e.g., exposure to asbestos). Occupational illness, injury, and fatalities
are used to denote morbidity and mortality related to employment and work environment.
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7
LETTER REPORT
BOX 2
Statement of Task
At the request of the National Institute for Occupational Safety and Health
(NIOSH), the Institute of Medicine (IOM) will conduct a study to examine the ra-
tionale and feasibility of incorporating work history information into patient elec-
tronic health records. NIOSH seeks to ensure meaningful use of occupational
information in electronic health records by 2015. This will require the agency’s
demonstration of feasibility by 2013.
An ad hoc committee will plan and hold data-gathering meetings, including a
public workshop; conduct analysis; hold deliberations; and prepare a letter report
with findings and recommendations that will address the following issues:
Significance—What are the potential benefits to individual and public
health of incorporating occupational information in electronic health
records?
Current environment—Are there current systems which incorporate work
history into the record in a manner which supports clinical decision mak-
ing and public health reporting activities?
Technical issues—What are the perceived technical barriers to incorpo-
rating work history information into the patient’s electronic health
record? What are the barriers to using current systems of coding indus-
try and occupation? What are alternatives to current methods? How
would the technical issues be best addressed by electronic health
record system vendors and researchers?
Next steps—What steps are needed to advance this effort? What efforts
by NIOSH in conjunction with government and non-governmental part-
ners are needed?
BACKGROUND
Occupational Morbidity and Mortality
Employed Americans spend almost half of their waking hours at
work (BLS, 2011a). The nature of the work environment and work tasks
can have a significant impact on workers’ health and even on the health
of family members. Physical, chemical, radiological, biological, and er-
gonomic hazards can cause injury and illness, as can organizational
attributes of the workplace, such as stress and other psychosocial factors.
The work environment can also influence personal lifestyle choices.
Health care professionals need to understand their patients’ work envi-
ronment in order to diagnose and treat certain illnesses and injuries and
to recommend medical restrictions or work environment modifications
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8 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
that will help them recover and prevent additional harm. Identification
and documentation of work-related health problems by health care pro-
fessionals can also lead to interventions that protect other workers at risk.
Work demands can contribute to common health problems not gen-
erally associated with employment. For example, Church and colleagues
(2011) suggested that decreasing energy expenditures at work over the
last 50 years could explain a significant portion of Americans’ increase
in body weight. On the other hand, the workplace can offer health pro-
motion and disease prevention benefits, including wellness programs
(e.g., stress reduction classes, smoking cessation programs) and facilities
(e.g., exercise rooms). These types of programs have been demonstrated
to be successful when interventions for behavior change occur in the
workplace (Okechukwu et al., 2009; Sorensen et al., 2009, 2010).
U.S. estimates of the annual number of nonfatal injuries at work
range from 3.1 million to 5.5 million (BLS, 2010b; Schulte, 2005; Smith
et al., 2005), with more than 3 million of these leading to at least a partial
day out of work (Smith et al., 2005). The Bureau of Labor Statistics
(BLS) reported 4,547 deaths in 2010 due to occupational injury (BLS,
2011b).2 BLS (2010b) estimates the annual number of acute occupational
illnesses to be about 166,000.
Steenland and colleagues (2003) estimate more than 55,000 U.S. oc-
cupational deaths per year, including 6,200 from injuries and 49,000
from known occupational illnesses, making occupational causes the na-
tion’s eighth leading cause of death. An estimated 15 percent of asthma
deaths, 14 percent of deaths due to chronic obstructive pulmonary dis-
ease, and 2.4 to 4.8 percent of all cancer deaths are attributable to occu-
pational exposures (Steenland et al., 2003).
The costs of occupational injuries, illnesses, and deaths are high. In
2008, employers paid $78.9 billion in workers’ compensation premiums
(Sengupta et al., 2010). The overall costs to workers and their employers,
when taking into account direct health care costs and indirect costs, such
as lost productivity, range from $128 billion to $170 billion per year
(Schulte, 2005; Thomsen et al., 2007).
The current surveillance systems for occupational health, including
BLS and workers’ compensation databases, do not fully capture the im-
pact of occupational injuries and illnesses (GAO, 2009). The BLS Sur-
vey of Occupational Injuries and Illnesses (SOII) derives its non-fatal
2
The Census of Fatal Occupational Injuries, conducted by the BLS, integrates data
from 25 sources (e.g., death certificates, government agency administrative reports, the
Current Population Survey) to estimate mortality due to occupational injury.
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9
LETTER REPORT
workplace injury and illness data from a sample of Occupational Safety
and Health Administration (OSHA) logs kept by employers, which ena-
ble estimates across states. The SOII undercounts occupational injuries
and illnesses for several reasons, including scope (e.g., these estimates do
not cover self-employed workers, federal government employees, and
others) and delayed recognition of cases, including those with long laten-
cy periods (Boden et al., 2010; GAO, 2009; Hilaski, 1981; Oleinick and
Zaidman, 2010; Rosenman et al., 2006). Less severe conditions, requir-
ing workers to miss less than a week of work, also have a lower probabil-
ity of being recorded (Boden et al., 2010).
A key factor that contributes to underreporting of occupational mor-
bidity, particularly illnesses, is that reporting relies on the health care
professional’s recognition of a health condition as work related.3 Many
such connections are overlooked or misdiagnosed (Landrigan and Baker,
1991; Steenland et al., 2003) and thus go unreported or are misclassified.
This is especially true for chronic conditions and diseases with a long
latency period, such as many types of cancer (Ruser, 2008; Souza et al.,
2010a).
For any number of reasons, patients may not suggest to their clini-
cian that an injury or illness may be work related. They may not be
aware that they could be eligible for workers’ compensation or the bene-
fits may be too small to warrant the time and effort to report a minor
problem (Azaroff et al., 2002; Fan et al., 2006). They may fear employer
retaliation or stigma if they report health problems (Azaroff et al., 2002;
Boden and Ozonoff, 2008; Boden et al., 2010; Fan et al., 2006). Employ-
ers that offer incentives based on the length of time without injuries may
create incentives not to report (Azaroff et al., 2002). Employers also have
incentives to avoid reporting: high injury rates may result in a loss of
business, more frequent OSHA inspections, or high workers’ compensa-
tion insurance rates (Azaroff et al., 2002; Boden et al., 2010).
EHR Use and Incentives for Meaningful Use
The transition to EHRs is moving ahead rapidly. Health care provid-
er organizations (primary care and specialist physician offices, hospitals,
health systems, specialty clinics, and community and public health clin-
ics) are in the midst of adopting new EHR systems, and health care pro-
3
Throughout this report, “work related” is used to denote caused by or aggravated by
work (WHO Expert Committee, 1985).
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10 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
fessionals and staff are establishing habits of working with the new sys-
tems. The percentage of office-based physicians with basic EHR capabil-
ity rose from 11 percent in 2006 to an estimated 21 percent in 2009
(ONC, 2010). In 2008, 8 percent of U.S. hospitals reported having basic
EHR capability (ONC, 2010).
Driving EHR development and providing financial incentives for
implementation is the HITECH Act of 2009. The Act provides funds to
the Office of the National Coordinator for Health Information Technolo-
gy (ONC) to promote the implementation of health information technol-
ogy and an estimated $27 billion for the Centers for Medicare and
Medicaid Services (CMS) to use as incentive payments for physician’s
offices and hospitals to support adoption of EHRs4 (CMS, 2010b). The
incentives require that providers use a certified EHR product and fulfill a
set of objectives that demonstrate “meaningful use” of EHRs.5 ONC has
detailed a set of certification criteria for EHRs that stipulate the technical
capabilities required to ensure data security, confidentiality, interopera-
bility, and capability to perform specific functions. Its EHR certification
process is conducted by private-sector organizations approved as ONC-
Authorized Testing and Certification Bodies (HHS, 2010). Hospitals that
are not using certified EHRs according to meaningful use criteria by
2015 will face reduced reimbursements.
Several of the Stage 1 objectives are particularly relevant to the in-
clusion of occupational information in EHRs, including the requirement
that electronic records “maintain up-to-date problem list of current and
active diagnoses,” “use certified EHR technology to identify patient-
specific education resources and provide those resources to the patient, if
appropriate,” and have the “capability to submit electronic data on re-
portable (as required by state or local law) lab results to public health
agencies and actual submission in accordance with applicable law and
practice” (CMS, 2010c).
4
Health care professionals who do not see Medicare or Medicaid patients are not
eligible for the CMS incentives (CMS, 2010a).
5
ONC expects to implement the meaningful use requirements in three stages (42 CFR
412, 413, 422, and 495). The first stage was released in July 2010 (45 CFR 170) and
focuses on EHR functionality, including data capture. For Stage 1, the maximum incen-
tive per eligible health care provider is $18,000; for hospitals, the base incentive payment
is $2 million (CMS, 2010a). Although the timelines are somewhat flexible, Stage 2 im-
plementation is anticipated for 2013 (CMS, 2011) and is expected to focus on structured
health information exchange (42 CFR 412, 413, 422, and 495). Stage 3 implementation is
anticipated for 2015 (CMS, 2011) and is expected to focus on patient-centered health
information exchange and clinical decision support (42 CFR 412, 413, 422, and 495).
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11
LETTER REPORT
BENEFITS OF INCORPORATING OCCUPATIONAL
INFORMATION IN THE EHR
As part of its statement of task, the committee was asked to respond
to the question: What are the potential benefits to individual and public
health of incorporating occupational information in electronic health
records? The committee organized its response around the five health
care outcomes and policy priorities used to categorize the Stage 1 “mea-
ningful use” objectives (CMS, 2010c):
1. Improve the quality, safety, and efficiency of care and reduce
health disparities.
2. Engage patients and families in their health care.
3. Improve care coordination.
4. Improve population and public health.
5. Ensure adequate privacy and security protections for personal
health information.
In responding to the second part of the task on technical feasibility,
the committee decided to examine the individual occupational data ele-
ments that are commonly used in occupational health data collection and
are considered the most useful for clinical and public health purposes—
occupation, industry, work-relatedness, employer, and exposures. The
committee also explored the steps, such as information modeling, that
need to occur to provide detailed specifications for each of the data ele-
ments. These data elements are defined and described in depth later in
the report, but they are introduced here to provide context for the follow-
ing section, which outlines a number of potential benefits of incorporat-
ing occupational information in EHRs.
Improve Quality, Safety, and Efficiency of Care
and Reduce Health Disparities
Providing occupational information to the clinician could increase
the likelihood of arriving at a correct diagnosis and improve the man-
agement, treatment, and return to work of patients, regardless of the eti-
ology of their health condition. Several examples of the potential benefits
were presented and discussed at the IOM’s June 2011 workshop (Box 3).
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48 OCCUPATIONAL INFORMATION IN ELECTRONIC HEALTH RECORDS
dors, and other stakeholders to develop and test methods for collect-
ing occupational data from innovative sources. Specifically, NIOSH
should evaluate collection methods that involve
patient input through mechanisms such as web-based portals
and PHRs, and
other means such as health-related smart cards, health insur-
ance cards, and human resource systems.
Recommendation 8: Develop Clinical Decision-Support Logic,
Education Materials, and Return-to-Work Tools
NIOSH, relevant professional organizations, and EHR vendors
should begin to develop, test, and iteratively refine and expand
clinical decision-support tools for common occupational
conditions (e.g., work-related asthma);
tools and programs that could be easily accessed for educa-
tion of patients and caregivers about occupational illnesses,
injuries, and workplace safety;
training modules for administrative staff to collect occupa-
tional information in different care settings; and
tools to improve and standardize functional job assessment
and return-to-work documentation in EHRs, including stan-
dards for the transmission of these forms.
Recommendation 9: Develop and Assess Methods for Collecting
Standardized Exposure Data
NIOSH should continue to work with occupational and environmen-
tal health clinics and other relevant stakeholders to develop and as-
sess methods for collecting standardized exposure data for work-
related health conditions. NIOSH should explore the feasibility of
listing possible or probable exposures in the problem list or
elsewhere in the EHR;
linking occupational information in the EHR to online occu-
pational, toxicological, and hazardous materials databases,
such as O*NET, AOEC, and Haz-Map, to enhance diagnosis
and treatment of work-related illnesses and injuries; and
automatically generating codes for exposures based on narra-
tive text entries.
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49
LETTER REPORT
Recommendation 10: Assess the Impact of Incorporating Occu-
pational Information in the EHR on Meaningful Use Goals
NIOSH, in conjunction with relevant stakeholders (e.g., Public
Health Data Standards Consortium, CSTE, Association of State and
Territorial Health Officials), should
develop measures and conduct periodic studies to assess the
impact of integrating occupational information in EHRs, and
estimate the economic impact of EHR-facilitated return-to-
work practices for both work-related and non-work-related
conditions.
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