Coproporphyrinogen Enzymes inhibited by lead Enzymes Fig. 15.1 Haem synthesis. 15_Smedley_Chap15.indd 327 1/2/2013 12:24:04 PM CHAPTER 15 Hematological disorders 328 Methaemoglobinaemia Methaemoglobinaemia arises when the ferrous iron moiety in haem is oxi- dized into the ferric form. The consequence is a decreased oxygen-carrying capacity of hem oglobin. It can be caused by a number of acute occupa- tional exposures. Causative agents \200 Ferricyanide \200 Bivalent copper \200 Chromates \200 Chlorat es \200 Quinones \200 Dyes with a high oxidation \200\223reduction potential \200 Nit rite, often used as a preservative, is one of the most common methaemoglobin-forming agents Aniline dye derivatives. Clinical features \200 Cyanosis \200 Dyspnoea \200 Headaches and dizziness \200 Mus cle weakness \200 Peripheral blood \201 lm shows mild anemia and erythrocyte abnormalit ies (Heinz bodies and punctate polychromasia). Individual susceptibility Hereditary methaemoglobin reductase de \201 ciency. Treatment Ac ute treatment is with methylene blue (methylthioninium chloride), administered by slow IV i nfusion. Management of acute poisoning is cov- ered in detail on b p. 808, Methaemoglobinae mia (acute treatment). (cid:2) Methylthioninium chloride may cause brisk haemolysis in thos e with glucose-6-phosphate dehydrogenase (G6PD) de \201 ciency. Relevant legislation Acute poisoning with a nitro-, chloro-, or amino- derivative of benzen e is reportable under RIDDOR . 15_Smedley_Chap15.indd 328 1/2/2013 12:24:05 PM HAEMOLYSIS 329 Haemolysis Haemolysis is the process of premature red blood cell destruction. Clinical features and treatment \200 Acute: haemoglobinuria, jaundice, and abdominal pain \200 methaemoglobinaemia and methaemoglobin uria \200 complicated by anuric renal failure \200 exchange blood transfusion is life-s aving in severe cases Chronic: anemia \200 reticulocytosis due to i red cell production is the hallmark of haemolysis. Exposures \200 Arsine gas: industries \200\224micro-electronics industry (semiconductor manufacture), metal smelting, plating, galvanizing, and soldering \200 effects occur with acute poisoning at exposures >3ppm for several hours, or >20ppm for <1h chronic low-level exposure can cause anemia with mild i bilirubin \200 diagnosis is based on history of exposure and i urinary arsenic Naphthalene: industries \200\224manufacture of plastics and dyestuffs, mothballs, biocides for the wood industry can precipitate haemolysis in individuals with G6PD de \201 ciency Rare occupational exposures associated with haemolysis include: potassium chlorate \200 pyrogallic acid \200 stibine gas (rare accidental exposure). Prevention Prevention is by substitution and exposure control. 15_Smedley_Chap15.indd 329 1/2/2013 12:24:05 PM CHAPTER 15 Hematological disorders 330 Hematological malignancies Leukaemias Exposures Two exposures have a well-established assoc iation with leukemia. \200 Ionizing radiation: leukaemogenesis is a late stochastic effec t of ionizing radiation (no dose threshold for the effect). The following have been noted i n excess among radiation workers: \200 acute myeloid leukemia (AML) \200 acute lymphobl astic leukemia (ALL) \200 chronic myeloid leukemia (CML) Benzene: AML. Other exposures (or job/industry used as a marker, but with the exact exposur e unclear) have been implicated with small increases in leukemia risk. Most studies have be en small, and in many there is a problem with confounding by benzene exposure. \200 Possi ble i leukemia risk: \200 1,3-butadiene \200 ethylene oxide. Clinical features Presents with a combination of anemia, bleeding, and infection. Compensat ion Acute non-lymphatic leukemia is prescribed (C7) for Industrial Injuries Disablement Ben e \201 t in those who are exposed to benzene. Lymphoproliferative disorders Exposures \200 Ionizing radiation: the following have been noted in excess among radiation workers, and are late stochastic effects: \200 multiple myeloma \200 non-Hodg kin \200\231s lymphoma. Clinical features Presents with anemia or local mass. Treatment and prognosis of hematologi cal malignancies Treatment is complex and beyond the scope of this book. However, the usual approach includes chemotherapy regimes +/ \200\223 radiotherapy +/ \200\223 bone marrow tr ansplant. The prognosis for treated acute leukaemias has improved signi \201 cantly in the past 10yrs. Prevention Prevention is through exposure control. See b p. 542, Ionizing Radi ation Regulations 1999. 15_Smedley_Chap15.indd 330 1/2/2013 12:24:05 PM 331 Chapter 16 Medically unexplained occupational disorders Post-con \202 ict illness in military personnel 332 Sick building syndrome 334 Karoshi : d eath from overwork 336 16_Smedley_Chap16.indd 331 1/2/2013 12:25:33 PM CHAPTER 16 Medically unexplained occupational 332 Post-con \202 ict illness in military personnel In the aftermath of every major con \202 ict over the past century, some returning personnel have complained of ill health. Some hav e symptoms of physical origin, others psychiatric disorder including post-traumatic stress disorder (PTSD). However, there is a third group characterized by vague and non-speci \201 c symptoms, for which (despite extensive investigation) no cause is found. Different names have been ascribed to this third group, including Agent Orange syndrome and Gulf War illne ss. These syndromes share many common features. There are also similarities with other medi - cally unexplained symptoms, including chronic fatigue syndrome, multiple chemical sensiti vity syndrome and neurasthenia. All groups have de \201 nitive health care needs. Gulf War illness Gulf War illness affecting the veterans of the Arabian Gulf Con \202 ict of 1991 has been extensively investigated, with over $300 million of funds from the US and UK governments. Despite extensive study into possible links with vaccinations, depleted ura nium exposure, oil well \201 res, and exposure to pesticides or other chemical agents; no de \201 nitive cause has been found. However, the following lessons have emerged, and are pertinent to other post-deployment conditions: \200 In general, military populations are healthier than civilians \200\224the healthy warrior effect More than a decade after deployment, some Gulf War veterans still suffer ill health. However, the same symptoms and groupings are seen in non-Gulf Veterans c ontrol groups. There appears to be no unique Gulf War syndrome Although the condition persists two decades after exposure and many veterans remain ill, in general they appear to be getting better gradually Gulf veterans are 2 or 3 times more likely to have symptom complexes including multi-focal pain, fatigue, cognitive or memory problems, and psychologi cal distress. Most of these individuals do not meet criteria for established psychiatric il lness Although there is a raised incidence of PTSD in Gulf War veterans as in other con \202 ict s, it is not elevated to the degree that could explain the overall increase in ill health. Common symptoms include tiredness, headaches, lack of concentration, memory loss, and numbn ess \200 Thorough medical examination including physical, physiological, and psychological testing have revealed no major abnormalities Reported health is worse the lower the rank and after retirement \200 In contrast to cont rol groups, Gulf War veterans report more of every hazard and recall exposure to more of th ese over time. Those who are in good health recall fewer exposures There is no evidence of an excess of malignancy, birth defects, or increased mortality. 16_Smedley_Chap16.indd 332 1/2/2013 12:25:33 PM POST-CONFLICT ILLNESS IN MILITARY PERSONNEL 333 Management of post-con \202 ict illness \200 A detailed history, examination, and invest igation should be taken to detect the presence of any organic disease. Treatment should be appropriate to the \201 ndings, and any patient with a known clinical disorder should be referred promptly to the appropriate 2 care consultant Enquiries about stress-related symptoms should be handled with care, to avoid any impressio n that the individual \200\231s symptoms are being dismissed as psychological. However, it is worthwhile exploring patient \200\231s beliefs with regard to the etiology of the condit ion If necessary, a follow-up appointment should be used to: discuss investigation results \200 give the physician an opportunity to review the litera ture \200 counsel the patient over any subjective concerns Within the UK, the Medical Ass essment Program provides a special- ized referral facility for investigation of any deploym ent-related problems in respect of the 1991 and 2003 Gulf Con \202 icts and subsequent ope ra- tions in Iraq and Afghanistan. All regular and reserve service men, serv- icewomen, and MOD civilians who participated in these operations are eligible to attend. Further information and guidance Ministry of Defense. Medical Assessment Program : Availabl e at: M http://www.mod.uk/ Post-con \202 ict illness in military personnel DefenceInternet/FactSheets/PersonnelFactsheets/MedicalAssessmentProgramme.htm 16_Smedley_Chap16.indd 333 1/2/2013 12:25:33 PM CHAPTER 16 Medically unexplained occupational 334 Sick building syndrome The term sick building syndrome (SBS) was \201 rst used in the mid -1980s to describe an ill-de \201 ned collection of symptoms that are typically reported b y workers located in the same building. Despite substantial research, the cause of the synd rome has not been fully explained. Epidemiology \200 More common in women \200 More common at lower end of the organizatio nal hierarchy. Reported symptoms Usually mild, but can lead to signi \201 cant impairment of performance: \200 Headache \200 Fatigue \200 Dizziness \200 Nausea \200 Eye soreness and dryn ess \200 Upper respiratory tract (nose, throat) symptoms \200 Skin rash/redness \200 Generalized pruritis \200 i Rate of respiratory infections. Possible causative factors Many causal factors have been proposed. Among the factors listed here, some have been associated with SBS in epidemiological studies. Most have a plausible link to some of the common symptoms, but none have been proven to be the cause of the synd rome at low-level exposure. Physical and environmental factors \200 Humidity: either excessively high (encouraging mo ld formation), or excessively low (leading to drying of the mucous membranes) Excessively high temperature \200 Air conditioning: associated with microbial contaminati on, exotoxins produced by contaminating organisms, biocides Poor lighting \200 Nuisance dusts. Chemicals \200 Formaldehyde is ubiquitous in of \201 ce environments due to \200\230off-gassing \200\231 from furniture, carpet adhesive a nd other \201 xtures made of particle board Volatile organic compounds (VOCs): many are known irritants at high exposure levels. Some have low odor thresholds, thus contributing to the perception of poor air quality (irrespective of actual health effects) Nitrogen dioxide \200 Cigarette smoke: passive smoking may have been a factor in the past , but smoking in public buildings is no longer permissible by law in the UK. 16_Smedley_Chap16.indd 334 1/2/2013 12:25:33 PM SICK BUILDING SYNDROME 335 Bio-aerosols Airborne particles comprising or contaminated with bacteria, fungi, or mites. Psychosocial factors \200 Low control over work \200 Insuf \201 cient or excessive dem ands \200 Low job satisfaction \200 Poor support. The syndrome is likely to have a mult ifactorial etiology with contributions from more than one of the factors listed here. Mecha nisms are unclear, but might include allergic (immune-mediated) or non-allergic (non-speci \201 c in \202 ammatory or directly toxic) reactions. Management \200 Optimize physical environment attention to standards of lighting, temperature, humidity \200 allow adequate personal sp ace to work \200 regular cleaning to minimize nuisance dust Address known risk factors for stress (see b p. 134, Organizational psychosocial factors): \200 promote good industrial relations and communication \200 in crease control \200\224demand ratio where possible Investigate speci \201 c issues, e.g. odors. Further information and guidance HSE (1995). How to Deal with sick building syndrome , HSG1 32. HSE, Sudbury. 16_Smedley_Chap16.indd 335 1/2/2013 12:25:33 PM CHAPTER 16 Medically unexplained occupational 336 Karoshi : death from overwork The concept of \200\230 karoshi \200\231 or death from overwork originates in Japan and re fers to sudden death in workers believed to have been caused by very long working hours. Th ere is limited research evidence to support this belief, at least in those suffering acute myocardial infarction (MI). The family of a worker whose death has been accepted by the Worker \200\231s Compensation B ureau (part of Japan \200\231s Ministry of Labor) as being due to karoshi is eligible for c ompensation. These deaths may be due to a number of conditions as listed here. Karoshi is not a concept widely recognized in the West. However, there are overlaps between the beliefs that sudden death may be due to over- work and the increasing body of research that suggests a link between work demands and cardiovascular mortality. Epidemiology Japan \200\231s Ministry of Labor compensates about 20 \200\22360 deaths from karo- shi each year. Some authors estimate that up to 10,000 deaths in the 20 \200\22359-yr -old age group may be due to karoshi . Robust estimates of incidence are lacking. Two Japan ese case-control studies have shown increased odds ratios for acute MI in workers working > 11h/day or >60h/ wk, respectively. Causes of death \200 Subarachnoid hemorrhage \200 Ce rebral infarction \200 Cerebral hemorrhage \200 Heart failure \200 Myocardial infarct ion. Relevant legislation In an effort to prevent Karoshi, the Japanese government issued guidan ce in 2002 that employees should not work more than 45h overtime per month. 16_Smedley_Chap16.indd 336 1/2/2013 12:25:33 PM Section 3 Occupational health practice 17 Operational issues 18 Ethics 19 Policies 20 Sickness absence, rehabilitation, and retire ment 21 Principles of risk assessment and risk 339 359 365 393 management 22 Health surveillance 415 423 17_Smedley_Chap17.indd 337 1/2/2013 1:26:43 PM This page intentionally left blank 339 Chapter 17 Operational issues General principles of OH services 340 The OH team 342 Models of OH services 344 Managing OH records 1: electronic record systems and security 348 Managing OH records 2: security, transfer, and archiving of records 350 Quality and audit in OH practice 1: general principles 352 Quality and audit in OH practice 2: systems and tools 354 Guidelines in Occupational health 356 17_Smedley_Chap17.indd 339 1/2/2013 1:26:43 PM CHAPTER 17 Operational issues 340 General principles of occupational health services Aims Occupational medicine is preventati ve medicine practiced in the work- place; promoting health and fostering wellness within th e workforce. Although services must be reactive to unforeseen problems, the aim is to proac tively prevent work-related ill-health wherever possible. OH is concerned with the interaction between work and health, and is concerned with the health and welfare of four (overlapping) groups: \200 The workforce as a group or population \200 Individual workers or prospective employees \200 The employ er \200\231s customers or clients (product or service safety) \200 The local population ( environmental issues). 2 The population perspective is central to understanding OH practice . Status of occupational health advice In health and safety law, the ultimate responsibility for protecting the health and welfare of employees and the public rests with the employer. Managers may choose whether to take and how to implement OH advice. Therefore, rather than instructing the employer, the OH professional seeks to in \202 uence key decision-makers ( management and trade unions) regard- ing health and safety issues. This is best achieved by seeking \200\230buy-in \200\231 from the top of the organization downwards. The approach will be most effec- tive if the OH professional is well respected by all parties. (cid:2) O H professionals should remain impartial (preserving good relation- ships even if managers i gnore advice), but should ensure that the respon- sibility for accepting risk has been take n at an appropriately high level in the organization. Impartiality OH professionals advise both employee(s) and the employer. This fundamental di fference between occupational medicine and other spe- cialties, in which the health profess ional is primarily responsible for pro- viding care, is often misunderstood. In an environm ent where employer, employees, and their representatives may be adversarial, the OH profes- sional must remain impartial to be effective. 2 This dual responsibility must be understoo d and respected by all. Its importance in effective OH practice cannot be overemphasized. Trade unions \200 Trade union support can be crucial in developing OH services \200 Tra de unions have a legitimate interest in their members \200\231 welfare \200 The principle s of medical con \201 dentiality hold whether or not a union representative is involved in issues concerning individual members. 17_Smedley_Chap17.indd 340 1/2/2013 1:26:43 PM GENERAL PRINCIPLES OF OCCUPATIONAL HEALTH SERVICES 341 Traditionally, OH activities have been classi \201 ed under two main headings: \200 The effect of work on health \200 The effect of health on work. The effect of work on health: preventing work-related illness 2 Occupational illness is prevented by a proactive cycle o f risk assess- ment, risk reduction, and review. \200 The classical occupational diseases of the industrial age are becoming less common in the developed world due to improved heal th and safety practice, increasing mechanization, and reduced exposure to hazards. However, these diseases remain in developing countries \200 Work-related illnesses still represen t a signi \201 cant proportion of sickness absence in developed countries The workplace is often one of a number of interacting factors. Many musculoskeletal or ment al health problems are multifactorial and may have a substantial psychosocial component. It can be dif \201 cult to disentangle the contribution of workplace and non-work factors \200 Occupational demands may aggravate or sustain existing illness. The effect of health on work: \201 tness for work 2 The important underpinning principle is that most work is \200\230healthy \200\231, and is a positive aspect of overall health and wellbeing. Advice about \201 tness for work can be divided conceptually as follows. Context \200 Pre-employment or pre-placement \200 Intra-employment: following an episode of ill health \200 following a change to job or exposures \200 fol lowing/during long term sickness absence \200 to inform the management of short term sick ness absence. Timescale \200 Short-term: temporary rehabilitation program with the \201 nite endpoint of achieving a return to normal work (hours and tasks) \200 Long-term: permanent adjustm ents to hours or tasks Context and timescale are not mutually exclusive, but are important dimensions in a conceptual framework for \201 tness for work. This frame- work emphasizes the important hierarchy of advice, the broad aims of which are: \200 To maximize the pot ential for maintaining gainful employment \200 To minimize any health risks to the employ ee \200 To view iIl-health retirement as a last resort after all options for maintaining employment have been explored. 17_Smedley_Chap17.indd 341 1/2/2013 1:26:43 PM CHAPTER 17 Operational issues 342 The occupational health team Roles and overlap \200 Occupational health is a multidiscipl inary specialty \200 Each professional group has different expertise and may have differe nt approaches in \202 uenced by background and training However, there is substantial commonality of experience between professional groups, and potential overlap between roles \200 There is no \201 xed or t ypical con \201 guration for an OH team. \200 Provided role de \201 nitions are clear, and overlaps and gaps are managed sensitively, any model can be successful. The occupational health team The make-up of the OH team is likely to be in \202 uenced by; \200 The model of service delivery (see b p. 344, Models of OH services) The service requirements of client organization(s) \200 Prevailing hazards, and the knowl edge to assess them \200 Availability of manpower in the various OH professions \200 Lo cal, historical or industry precedent \200 Individual personalities and attributes \200 Legal requirements \200 The prevailing OH market. Occupational physician \200 In a small OH service the occupational physician (OHP) may ac t as part-time medical support to a nurse-led service In other services the OHP may be the service manager, with overall responsibility for occupational health and (sometimes) safety An OHP \200\231s clinical work includes sickness absence assessments, health surveillance, and giving advice on adjustments and rehabilitation for ill, injured, or disabled workers In the broader clinical context, workplace visits, advice on risk management, attendance at safety meetings, meetings with managers and trade unions, and pol icy writing may be undertaken Some OHPs have a managerial function. They manage an occupational health service, provide c linical governance, set overall strategy, policy, and procedures for others to follow. This role may cross national boundaries and involve the management of health professionals from varying backgrounds All OHPs should have input to audit and quality assurance. Occupational health nurse \200 Occupational health nurses (OHNs) may work in isolation in single-handed services, or within a larger occupational health service \200 Trained OHNs, often called occupational health advisers (OHAs), may be involved in an extended range of professional activities, including pre-employment and sickness absence assessments, health surveillance 17_Smedley_Chap17.indd 342 1/2/2013 1:26:43 PM THE OCCUPATIONAL HEALTH TEAM 343 (e.g. screening audiometry, skin inspections), drug and alcohol screening, workplace monito ring (e.g. noise, chemicals), advisory role in risk management, health promotion, counselin g, and \201 rst aid training Some OHNs have a managerial role and lead OH departments \200 Some nurses in industry may have had no formal training in occupational health and can be professionally isolated. Suc h nurses may \201 ll a limited role, providing a treatment room service, immunizations, a nd basic (non-statutory) health and pre-employment screening. Occupational hygienist \200 Specialists in assessing and monitoring workplace exposures. Their role is described in detail in b p. 598, Role and function of occupational hygienists Relatively few organizations employ a full-time occupational hygienist \200 Many hygienis ts work in consultancies or as independent contractors. Counselor \200 Many occupational health services provide in-house staff counseling or hav e contracted with an employee assistance program (EAP) that employs counselors and occupati onal psychologists While some counselors may be quali \201 ed psychologists, this is not an occupational requirement. Ergonomist \200 Specializes in \201 tting the task to the human, and may be involved in assessing and advising on processes, products, and work systems Ideally an ergonomist \200\231s advice should be sought at the process or plant design stage in an effort to design out potential problems As with occupational hygienists, ergonomists are generally found in large organizations or working on a consultancy basis. Case manager \200 Case managers are employed by some OH services to manage sickness absence. They can come from various health professional backgrounds Their role focuses on identifying and overcoming, in conjunction with the ill or injured em ployee and their employer, barriers to an early, sustained return to work Their approach to sickness absence follows a non-medical model. Other occupational health team members \200 Health and safety adviser or manager \200 F ire safety specialist \200 Manual handling adviser \200 Physical therapist \200 Healt h promotion specialist \200 Business/ \201 nance adviser \200 Clerical support (includ ing specialist medical secretaries) \200 Screening technicians (non-medically quali \201 ed) \200 Environment specialists. 17_Smedley_Chap17.indd 343 1/2/2013 1:26:43 PM CHAPTER 17 Operational issues 344 Models of OH services Models of OH provision are in \202 uenced by many changing factors, includ- ing legal requirements, the economy, the nature of risks, and political pri- oritie s (see Table 17.1). \200 In 1998 the World Health Organization de \201 ned the purpose o f OH services as the \200\230promotion of health and maintenance of workability \200\231 \200 In Scotland the Healthy Working Lives and Health Works strategies \200\230maximize t he functional capacity (physical, mental, social, spiritual) of the working age population \200\231, and help the unemployed \201 nd work \200 In The Netherlands, the political i nitiative to move the responsibility for sickness absence bene \201 ts to employers led to models that were focused on the evaluation and control of sickness absence. In the UK it h as been proposed that employers should commission a functional capacity assessment after 4w ks sickness absence. Factors that in \202 uence occupational health service models \200 Legal: in some countr ies the model may be prescribed (e.g. Germany, Italy, Austria) Risks and type of industry: treatment and primary care will be included in countries or loc ations with poor access to health services. The services that are needed by an of \201 ce population in a large city will require a different skill mix to those in a steel foundry o r shipyard \200 Priorities of the service purchaser: these may include health surveillanc e, sickness absence control and rehabilitation, and workplace health promotion depending on priorities and pro \201 tability Resources and manpower availability: in some countries the discipline of OH nursing is not well developed or recognized; in others there may be few OH physicians Extent of multidisciplinary working: services may be monodisciplinary (e.g. a doctor or nur se working independently) or, more commonly, two disciplines, when a team consists of OH ph ysicians and nurses \200 Internal services: OH professionals are employed by the enterpri se \200 External contracted services: the enterprise buys in services from a commercial provider or local group service Government-funded services: for small and medium enterprises, self-employed, home workers, micro-enterprises, the unemployed, e.g. in Scotland. Rationale for occupational health models OH delivery requires a multidisciplinary effort, w ith close co-operation between health and safety, occupational hygiene, ergonomics or other specialists, human resources, and legal advisers. Where the OH pro- fessionals are not an integral part of a multidisciplinary team, it will be necessary to liaise with these other disciplines. OH services, which do not have close operational links with other professional s, are more likely to undertake inappropriate health checks and health surveillance. Much O H provision is determined by the perceptions of the enterprise or 17_Smedley_Chap17.indd 344 1/2/2013 1:26:44 PM MODELS OF OH SERVICES 345 Table 17.1 Advantages and disadvantages of the different models Model Advantages Disadvantages Single OHP or OHN Autonomy Dif \201 cult to maintain clinical competence and establish clinical governance OHP and OHN Team work Appropriate use of resources May do more health examinations than necessary Issues about adequacy of the risk assessment process In-house OH service Understanding of the organization \200\231s needs Knowledge of other members of the extende d OH team Can become institutionalized and inward looking; loss of independence (actual or perceived) Group OH service: providing services to a number of enterprises May have critical mass of resource and experience of different sectors More likely to have quality assurance processes if in a contracting situation with large commercial enterprises May experience shareholder pressure for pro \201 t maximization, which can distort advice given to organizations May not be multidisciplinary, and have blind spots in provision Multidisciplinary service Potentially the best model, if well integrated and there is good teamwork Should be able to give the most appropriate advice to a client organization, i.e. advice not subject to the bias of a dominant professional group Dif \201 cult for SMEs, micro-enterprises, and home workers to access such services unless provided within the public sector employing organization. An organization that has \201 nancial problems is more likely to focus on the control of sickness absence, while a pro \201 table organization (with low ab sence) may invest more in health improvement. 17_Smedley_Chap17.indd 345 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 346 Current and future developments Recent years have seen the decline of large within-company models and a growth of alternative models including contracted-in services. Many coun- trie s have strategies to address the lack of access to competent OH advice for many workers and employers in the SME sector (<250 employees). Across the world, OH services for this secto r are very variable, and are generally inadequate. This has led to parallel developments in the coun- tries of the UK. In Scotland the Healthy Working Lives service provides free Occ upational health, safety and rehabilitation telephone advice to the employed and unemployed , access to a workplace visit and advice, and third-level access to OH advice. One of the most highly developed models of OH provision is in Finland, which has a network of regional centers and high levels of coverage of the workforce. 17_Smedley_Chap17.indd 346 1/2/2013 1:26:44 PM This page intentionally left blank CHAPTER 17 Operational issues 348 Managing occupational health records 1: electronic record systems and security Electronic r ecords Most occupational health services are now computerized. Their security is critical t o the continued success of the OH service. \200 Although IT security can be viewed in the narrow sense of hardware theft, protecting data is arguably more important Just as access to written OH records should be restricted, so data on an IT system must be protected. This is particularly important where the OH service uses an organization-wide IT system Medical information is deemed to be especially sensitive data by the Data Protection Act 1998, and particular care is required to protect it \200 Staff should be trained on information security and how to report any security breaches Data security should be audited and any breaches or suspected breaches of security investigated Where management reports are e-mailed these should be encrypted (this is NHS policy) and se nt in portable document format (pdf) to reduce the likelihood of the report being altered w ithout the originator \200\231s permission. Physical security Threats to the physical security of computer hardware may arise from theft, \201 re, \202 ood, power surges, or accidental damage All IT hardware (monitors, printers, CPUs) should be security marked and kept on an asset register An uninterruptible power supply should be provided \200 Building security should be at a level proportionate to local crime levels and the likely impact of loss of IT equipment on the OH service. This may include th e provision of alarm systems, \202 oodlighting, security patrols, etc. Particular care is needed when dealing with portable data storage devices such as data pens, detachable hard drives, lap tops and note books, or personal dig ital assistant (PDAs). Such devices are easily lost or stolen, and their contents should be protected using high quality encryption. Software security \200 Loss, corruption, theft, or unauthorized access to data should be guarded against Data should be backed up to a remote server on a daily basis, or saved on a detachable hard drive and stored in a \201 reproof safe. Small operations may be able to use CDs or other IT storage media to back up \201 les. Ideally, these should b e stored in a separate building Data back-ups should be checked for integrity, in case the back-up data is itself corrupt 17_Smedley_Chap17.indd 348 1/2/2013 1:26:44 PM MANAGING OCCUPATIONAL HEALTH RECORDS 1 349 All data should be password protected and the passwords should be regularly updated Passwords should not be written down, nor should computer user names or passwords be shared All computers should be locked when not in use \200 Computer users should log off any net work application after use. This is especially important where the computer is shared with others \200 Computer monitor privacy screen \201 lters should be used to keep con \201 dential data secure and prevent others viewing the screen \200\231s contents, e.g. clinic appointment lists Networked IT systems should have varying access levels, de \201 ned by operational need IT systems should provide an audit trail to identify unauthorized access, or attempts to access sensitive OH data. (Often the greatest threat to data securit y comes from within an organization) \200 IT support staff, whether in-house or contracte d to an OH department, should be asked to sign a con \201 dentiality agreement \200 Increasingly, s mart cards (an identi \201 cation card which carries an integrated computer circuit capable of holding personal data), are being employed to record health and safety data. Such cards require several layers of security to restrict access t o data and to prevent unauthorized changes to existing electronic records Systems that allow remote working via the Internet should employ the highest possible security. (cid:2) E-mail systems, where used for medical communications, should be secure and encrypt ed. Beware of similar e-mail addresses lest the wrong person receives the e-mail. Computer viruses \200 All IT systems should employ virus protection software to prevent computer viruses from compromising system operations Virus software must be kept up to date \200 IT systems that connect to the Internet are e specially vulnerable to infection with computer viruses, and this can lead to service loss for extended periods IT security by introducing viruses, and should be forbidden. Unauthorized use or installation of pirated software may compromise IT policy It is advisable for OH departments to have a written IT policy that covers the us e of computer technology. This should cover the security issues outlined here as well as ac cess to and use of stored data. 17_Smedley_Chap17.indd 349 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 350 Managing occupational health records 2: security, transfer, and archiving of records There are both legal and ethical issues around the security, transfer, and archiving of medical r ecords. The General Medical Council (GMC), the Faculty of Occupational Medicine, the Britis h Medical Association (BMA), and the Department of Health have all issued guidance on con \201 dential- ity. Concerns around con \201 dentiality are a recurring issue in occupation al medicine. OH professionals need to be aware of the many ways in which con \201 dentiali ty may be compromised. Security of occupational health records \200 All contacts between an employee and an OH s ervice should be recorded in the employee \200\231s OH record The medical records should be securely stored in a lockable cabinet or room or on a secure IT system Access to OH records should be restricted to OH staff \200 All OH staff should sign a con \201 dentiality agreement \200 It is unethical to allow access to OH records to non-OH staff, such as personnel managers. Transfer of occupational health records \200 Companies may outsource OH services, change OH provider, or go out of business. Independent occupational physicians may retire or chang e jobs. In all these cases, OH records will need to be transferred to an individual or orga nization that is in a position to maintain them for the appropriate period (this may be 50y rs after the last entry in the records in some cases, e.g. ionizing radiation records) The Faculty of Occupational Medicine publication Guidance on Ethics for Occupational Physic ians provides guidance on the transfer of OH records When it is proposed that OH records are to be transferred, employees should be informed and given the opportunity to request that their OH notes be ar chived, rather than transferred Where an organization closes, it may be appropriate to issue the OH records to the individu al or (with their consent) their GP. In some situations, statutory records may be offered t o the HSE for retention (again with the employee \200\231s consent). Archiving \200 Employees leave, are dismissed, or retire, and over time the number of ina ctive OH records held by an OH service will increase. Inactive \201 les occupy valuable s torage space. They can make it dif \201 cult for administration staff to locate current OH notes. As a result, all OH services need to have in place a standard operating procedure f or archiving OH records Archives may be held on or off site, but it is important that archiving medical records does not compromise medical con \201 dentiality 17_Smedley_Chap17.indd 350 1/2/2013 1:26:44 PM MANAGING OCCUPATIONAL HEALTH RECORDS 2 351 Readily accessible records detailing the location of all archived notes should be maintaine d. The location of records should be tracked to avoid the loss or mis \201 ling of records OH notes may need to be abstracted at a later date from an archive for a number of reasons, e.g. legal action, audit, or re-employment. Relevant legislation and guidance \200 GMC. Con \201 dentiality 2009: Disclosing informa tion for insurance, employment and similar purposes . Available at: M http://www.gmc-uk. org/Con \201 dentiali ty_disclosing_info_insurance_2009.pdf_27493823.pdf Faculty of Occupational Medicine (2006). Guidance on Ethics for Occupational Physicians , 6th edn. FOM, London. Revision to articles 3.37 \200\2233.40 of Guidance on Ethics for Occupational Physicians . Available at: M http://www.fom.ac.uk/wp-content/ uploads/m_gmcconf_ethicsrev1. pdf British Medical Association. Con \201 dentiality and disclosure of health information toolkit . Available at: M http://bma.org.uk/practical-support- at-work/ethics/c on \201 dentiality-tool-kit Department of Health. (2003). Con \201 dentiality: NHS Code of Practice . Available at: M http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidan ce/DH_4069253 17_Smedley_Chap17.indd 351 1/2/2013 1:26:44 PM CHAPTER 17 Operational issues 352