DEVELOPING A WEB-BASED MIS SYSTEM FOR

OCCUPATIONAL HEALTH

Thomas M. Connolly, April MacPhail

University of the West of Scotland, High St, Paisley, Scotland, PA1 2BE, U.K.

David G. W. Scott

Sterling HealthCare, 28 Bannatyne St, Lanark, Scotland, ML11 7JR, U.K.

Keywords: Occupational Health, MIS, EHR, Interoperability, Security, Knowledge Transfer.

Abstract: Occupational Healthcare (OH) is about the promotion and maintenance of the physical, mental and social

well-being of employees. It aims to protect staff from workplace risks, but also to manage the effect of any

health issues on their work. Given the cost of absence through illness to both the organisation and the

individual, and given the government legislation that exists in this area, OH is of increasing importance to

organisations and many now outsource this service. This paper discusses how a Knowledge Transfer

Partnership (KTP) project between a university and an OH provider led to the development of a web-based

Management Information System (MIS) for Occupational Health that allows organisations to better manage

their OH provision and sickness absences. The system is currently being evaluated in a large public sector

organisation and early feedback is positive.

1 INTRODUCTION

Occupational Healthcare (OH) is about the

promotion and maintenance of the physical, mental

and social well-being of employees. It aims to

protect staff from workplace risks, but also to

manage the effect of any health issues on their work.

OH is of increasing importance to companies. For

example, in the UK each week (HSE, 2005):

 one million workers take time off because of

sickness and most return to work within days;

but

 around 17,000 people reach their sixth week of

statutory sick pay; and

 at this point, almost one in five people will stay

off sick and eventually leave work.

Work is essential to health, well-being and self-

esteem. When ill health causes long-term sickness

absence, a downward spiral of depression, social

isolation and delayed recovery make returning to

work less likely. Reducing long-term sickness

absence helps maintain a healthy and productive

business and safeguards jobs.

While there is UK and European legislation that

makes it the responsibility of companies to ensure

the health and safety of their staff, it is also in the

companies’ best interests to look after the staff’s

health and well-being. For example, the 2008

Confederation of Business Industry (CBI) report, as

cited by Leaker (2008), found the direct cost of

absence in 2007 was £13.2 billion, around £517 for

each employee and that indirect costs added another

£263 for each employee. When these indirect costs

are added to the direct costs, the CBI estimates the

UK lost £19.9 billion to absence in 2007. In their

absence management survey report for 2009, the

Chartered Institute of Personnel and Development

(CIPD) estimated that the average cost of absence

per employee per year was £692 (£784 for public

sector employees) (CIPD, 2009) and that 7.4

working days were lost for every member of staff

per year (9.7 days for public sector organizations

and 9.4 days for non-profit organizations). Given

these statistics, it is not surprising that the market for

outsourced Occupational Health has grown in recent

years. MBD has estimated that the UK market for

OH provision grew by 34% in the period between

2003 and 2007 to a value of £394 million (MBD,

2009). In 2007, an estimated 53% of UK

occupational health services were outsourced to

private companies and MBD forecast that the UK

Connolly T., MacPhail A. and G. W. Scott D.

DEVELOPING A WEB-BASED MIS SYSTEM FOR OCCUPATIONAL HEALTH.

DOI: 10.5220/0002792100810088

In Proceedings of the 6th International Conference on Web Information Systems and Technology (WEBIST 2010), page

ISBN: 978-989-674-025-2

market for OH provision will increase by 16%

between 2007 and 2012.

One approach to managing sickness absence has

been outsourcing to “Day-one” reporting systems,

which require employees who are unwell to call a

telephone number manned by OH professionals and

provide details of what is wrong with them and how

long they expect to be off. This enables the

employer to manage absence more effectively, for

instance, by arranging cover where necessary. The

service can also help employers to identify any

sickness patterns or recurring health problems with

staff. This paper discusses an alternative approach

that provides companies with an online information

system to help them manage their occupational

health requirements. In the next section, we examine

issues around the management of Electronic Health

Records (EHRs) and in Section 3 present the

requirements that have been gathered from client

companies and the key design decision for the

platform around EHRs and security. The final

section briefly provides some feedback obtained

from a first installation of the product at a large

public sector organisation in the UK.

2 PREVIOUS RESEARCH

A basic challenge of software systems in modern

medical informatics is their use of (open) standards

for communication allowing different types of

clinical applications to interact (Eichelberg et al.,

2005). Although the initial version of the platform

will be closed (ie. there will be no transfer of

information into or out of the system from or to

another external system), the company were keen

that the system would be extensible in the future.

There are a number of standards bodies in the

medical informatics area. Health Level 7 (HL7) is a

not-for-profit organisation, accredited by ANSI as a

Standards Developing Organizations (SDO) whose

specifications pertain to all aspects of clinical and

administrative data in health services. Its current

Version 3 defines (XML) messages based on a

common object-oriented Reference Information

Model (RIM) and a Clinical Document Architecture

(CDA) based on XML to specify the encoding,

structure and semantics of clinical documents for

exchange (Hooda, Dogdu, and Sunderraman, 2004).

The HL7 RIM has the following base classes

(HL7, 2009):

• Act: represents actions that have happened, are

happening, or are scheduled to happen.

• Entity: represents physical things or beings such

as persons, places, or devices.

• Role: represents the role that Entities play as

they participate in a healthcare act.

• RoleLink: represents a connection between two

Roles.

• Participation: represents the association between

a Role and an Act (for example, the context of

an Act, such as who performed it, for whom it

was performed, or where it was performed).

• ActRelationship: represents the association

between two Acts (for example, the relationship

between an order for a blood test and the result

of a blood test).

Most of these classes have subclasses that further

refine the class. For each base class in RIM, the

subclasses form a hierarchy rooted in the base class.

For example, the class LivingSubject is a subclass of

Entity, and the class Person is a subclass of

LivingSubject. Part of the RIM is shown in Figure 1.

The CDA specification states that the content of

the document consists of a mandatory textual part

(which ensures the contents are in a human readable

format) and optional structured parts (for software

processing). Different CDA levels allow for

different levels of granularity of presented clinical

information. At the simplest, level, Level One, a

document is represented through a structured header

and a body; at Level Two, sections of clinical

processes and activities have been separated by

markups; and Level Three finally provides basic

medical concepts using codification schemes such as

SNOMED (Systematized Nomenclature of

Medicine) and LOINC (Logical Observation

Identifiers Names and Codes) to represent concepts.

CDA documents are validated against the XML

schema for that level (Blobel, Engel, and Pharow,

2006).

Unlike other standards, HL7 CDA does not

specify services or protocols that are used to

exchange a document. From the perspective of HL7

messages, a CDA document is just a multimedia

object than can be exchanged as a MIME package.

openEHR (www.openehr.org) is an open

standards specification that describes the

management and storage, retrieval and exchange of

health data in Electronic Health Records (EHRs).

The primary focus of openEHR is not the exchange

of data between EHR-systems; this is the primary

focus of message standards such as HL7 and

ISO13606 (discussed shortly). openEHR has

produced a number of specifications that focus on

both the content/structure of EHRs and the

underlying technology. openEHR uses a two-level

model for EHRs: the first level, the reference model

provides a general framework in which any clinical

WEBIST 2010 - 6th International Conference on Web Information Systems and Technologies

Figure 1: HL7 Reference Information Model.

information can be safely stored and exchanged; the

second level, provides rules for how specific clinical

concepts are to be used in the health record. These

rules (or archetypes) represent the clinicians’ agreed

requirements for data sharing. The reference model

specifies the overall structure of the EHR, how

contextual information is recorded, how clinical

information is organized and safely managed (Bott,

2004). Each EHR consists of a number of

compositions, which are used to capture information

around an event, such as a lab test result or a GP

appointment. The EHR can also organize these

compositions into a set of optional folders, typically

used to group events around an episode of care

Electronic Health Record Communication

(EHRCom) European Standard (EN 13606) is

another EHR specification from the technical

committee on Health Informatics of the European

Committee for Standardization (CEN/TC 251).

EHRCom is based on the older pre-standard (ENV

13606) and many concepts have been adopted from

openEHR. The standard defines an architecture for

communicating part or all of the EHRs of a single

patient, making sure that (a) the original clinical

meaning intended by the author of the record is

preserved and (b) the confidentiality of the data as

intended by the author and the patient is not

breached (Begoyan, 2008). It does not specify the

internal structure or database design/schema of the

EHR. EHRCom consists of:

 The Reference Model – a generic model for

communicating part of an EHR between

heterogeneous systems;

 Archetype Interchange Specification –

constraint-based approach for defining clinical

business objects that are built from the

Reference Model (adopted from openEHR);

 Reference Archetypes and Term Lists – an

initial set of inter-reference model conversion

archetypes (mapping to openEHR and to the

HL7 V3);

Security Features – measures and models to

share the access control, consent and

auditability of EHR communications;

 Interface Specification – message and service

interfaces to enable EHR and archetype

communication.

DEVELOPING A WEB-BASED MIS SYSTEM FOR OCCUPATIONAL HEALTH

Figure 2: EN13606 Reference Model.

The EHR Reference Model defines the core

classes shown in Table 1, which closely align with

those in the openEHR Reference Model, and the

corresponding class diagram is shown in Figure 2.

As there is more than one standard, it is still

difficult to achieve interoperability. To address this

document sharing problem, an industry initiative

called Integrating the Healthcare Enterprise (IHE)

specified the Cross Enterprise Document Sharing

(XDS) Profile. The basic idea of IHE XDS is to

store healthcare documents in an ebXML registry/

repository architecture to facilitate their sharing. IHE

XDS is not concerned with document content; it

only specifies metadata to facilitate the discovery of

documents (IHE, 2009).

3 STERLING HEALTHCARE

AND STERLINGCONNECT

Sterling HealthCare is a Scottish SME that provides

an extensive range of Occupational Health,

physiotherapy and training services to match each

client’s requirements. Highly qualified OH medical

staff advise on a range of medical issues including

legislation compliance, monitoring employee health

through workplace audits and health “surveillance”,

and promoting good health at work. Sterling

HealthCare has 12.5% of the market in Scotland and

their physiotherapy division, Physicare, trade with

the majority of Local Authorities in Scotland. The

physiotherapy division also provides throughout the

UK clinics, moving and handling training and

assessment services to other public and private

WEBIST 2010 - 6th International Conference on Web Information Systems and Technologies

Table 1: EHR Reference Model.

EHR

Hierarchy

component

Description Examples

EHR_Extract

Top-level container of part or all of

the EHR of a single subject of care,

for communication between a

Provider and a Recipient.

Folder

High level organisation within an

EHR, with divisions related to care

rovided for a single condition, by

a clinical team or institution, or

over a fixed time period such as an

episode of care.

Diabetes care;

Gartnavel

Hospital, GP

Folder.

Composition

Set of information committed to

one EHR by one agent, as a result

of a single clinical encounter or

record documentation session.

Progress note;

laboratory test

results form;

referral letter;

clinic visit;

Section

EHR data within a Composition

that belongs under one clinical

heading, usually reflecting flow of

information gathering during a

clinical encounter, or structured for

the benefit of future human

readership.

Past history;

family history;

allergy

information.

Entry

Information recorded in an EHR as

a result of, for example, one

clinical action, one observation,

one clinical interpretation.

A symptom;

one test result;

a diagnosis;

lood pressure

measurement.

Cluster

Means of organising nested multi-

art data structures such as time

series, and to represent the columns

of a table.

Audiogram

results.

Element

The leaf node of the EHR

hierarchy, containing a single data

value.

Systolic blood

ressure; heart

rate; drug

name.

sector clients.

The company identified an opportunity to expand

its business activities but was restricted by the

limitations of the manual systems they currently had

in place. The development of a bespoke web

delivery platform (SterlingConnect) would allow

Sterling HealthCare’s clients to manage employee

absences, make OH referrals, and generally have

access to statistical information on OH data. The

platform would also allow Sterling HealthCare staff

to access and process information from any location,

thereby significantly reducing the level of

administrative staff input.

However, the company did not have the technical

knowledge to develop the system and approached a

local university to help. With funding from the UK

Technology Strategy Board through KTP

(Knowledge Transfer Partnership), the company and

the university have collaborated to develop the

system. KTP is one of Europe’s leading programmes

combining graduate recruitment with knowledge

exchange. Its benefits are proven across a range of

measures, whether company development and

profitability, knowledge exchange between

universities and business, or job creation. During the

2007/08 financial year, almost £95 million was

committed by the UK Government to new KTP

Partnerships in the form of grant support and

company contributions. At the year-end the portfolio

comprised over 1,000 individual projects, facilitating

the exchange of knowledge between the UK

knowledge base and companies across the spectrum

of size and business sector. Latest information

shows that, on average, the business benefits that

can be expected from a single KTP project are (TSB,

2008):

 an increase of over £222,000 in annual profits

before tax;

 creation of three new jobs;

 an increase in the skills of existing staff.

A Partnership works by employing one or more

high calibre ‘Associates’ (recent graduates), to

transfer the knowledge the company is seeking into

the business. Each Associate works in the company

on a project that is core to the strategic direction of

the business. Through contact with businesses, the

knowledge base partner (academic institution) gains

relevant and improved understanding of the

challenges companies encounter which, in turn,

stimulates business-relevant teaching material and

new research themes. KTPs are an important

funding mechanism in the UK and have direct

benefits to both industry and academia, as shown in

Table 2.

3.1 Participatory Design

While Sterling HealthCare had extensive knowledge

of the OH market and their clients and staff, it was

critical that all stakeholders who would use the

system should have input into the specification of

the system requirements. Moreover, it was important

for both the company and clients that there was early

sight of the platform being developed to ensure it

met the desired requirements. As a result, it was

decided at a very early stage in the project that the

development of the platform would be underpinned

by Participatory Design principles with users and

other stakeholders playing a prominent role in all the

stages relating to design, development and

evaluation. The benefits of Participative Design are

that it can provide better project control, better

communication, more satisfied users and

participants, lessens the need for costly corrective

action post implementation and can provide more

innovative and creative solutions than might have

otherwise been possible (Kensing and Blomberg,

DEVELOPING A WEB-BASED MIS SYSTEM FOR OCCUPATIONAL HEALTH

Table 2: Benefits of industry/academia collaboration through KTP (adapted from Edwards, 2005).

Benefits Industry Academia

Knowledge Transfer

Acquire new knowledge and expertise Better understanding of industrial requirements and business

imperatives

Enhanced performance

Increased profitability through new

products, services and processes

Up-to-date research and teaching materials and more

relevant curriculum

Essential resource Use of high calibre personnel Increased staff

Additional finances Subsidised funding (67% for SMEs) Supplements core funding

Dissemination Publicity and promotion Learned publications

Additional opportunities

Access to wider university facilities and

potential for an on-going relationship

Student placements/projects; potential for on-going

relationship; pump-prime new research themes

1998; Cherry and Macredie, 1999).

The requirements led to the identification of the

following main subsystems: Client, Patient and

Appointments subsystem; Referral subsystem;

Occupational Health Reports subsystem; Human

Resources subsystem; security subsystem;

Electronic Health Records subsystem. The main

functionality revolves around authorised personnel

(eg. line managers and HR staff) being able to refer

their staff for an OH service.

A number of different types of referrals were to

be supported including:

 Absence Management

 Pre-Employment Screening

 HAVS (Hand Arm Vibration Screening):

 Audiometric Testing

 Respiratory

 Musculoskeletal

 Vehicle-related (LGV; PCV; Fork Lift Driver;

Taxi Driver)

 Working at Heights

 Working with Lead/Asbestos.

The system maintains information on the

availability of OH professionals and OH clinics and

schedules an appointment for the referred employee

with a suitable OH professional at an appropriate

clinic (which may be within the organisation’s

premises or external to the organisation). The system

generates an email/appointment letter for the

employee. Following the consultation, the system

may schedule another appointment if the OH

professional requests it. The system generates a

letter for the employee providing a report from the

consultation, as prepared by the OH professional.

OH reports are available online for line

managers/HR to view. In addition, managers/HR are

able to view all current and historical reports/health

surveillance results on each employee, view

statistical data regarding departmental utilisation of

OH services, view OH service adherence to

performance targets, among other data. The system

will provide reminders when some action is due (eg.

an employee is due for an annual health check).

Moreover, in the UK it is a legal duty of employers

to report certain injuries/illnesses under RIDDOR

(Reporting of Injuries, Diseases and Dangerous

Occurrences Regulations) (HSE, 2008) and the

system provides advice to line managers/HR when

this occurs.

3.2 Electronic Health Records (EHR)

The storage and retrieval of EHRs was a key

component of the system and an appropriate EHR

standard had to be selected. There is some

harmonisation between the EHR standards we

examined in Section 2 (for example, the openEHR

Reference Model uses the CEN 13606 Reference

Model, which in turn is used in HL7 CDA) and

further harmonisation is likely. As a result, it was

decided to model the health records after EN 13606

and, when communication with external systems is

eventually required, to use HL7 V3 Messaging

3.3 Security

Clearly given the sensitivity of the data being stored,

security was of paramount importance in the design

of the system. Again, many of the standards

discussed in the previous section address security to

some degree. The openEHR approach to security is

based on the following two premises as proposed by

the British Medical Association (Anderson, 1996):

 Informed consent: patients have a right to

expect that personal information will not be

passed on to another party unless they agree.

 Relevance of access: people should only have

access to the patient’s health record if it can be

established that they are currently engaged in

provision of care for the patient, at the current

time.

In particular, privacy settings can be set on selected

parts of the EHR, not just the whole entity. There are

a number of policy principles in openEHR such as

WEBIST 2010 - 6th International Conference on Web Information Systems and Technologies

(Beale and Heard, 2008):

 Indelibility: Health record information cannot

be deleted; logical deletion is achieved by

marking the data in such a way as to make it

appear deleted.

 Audit trailing: All changes made to the EHR

including content objects as well as the EHR

status and access control objects are audit-

trailed with user identity, timestamp, reason,

optionally digital signature and relevant version

information.

 Anonymity: The content of the EHR is separated

from demographic information so that theft of

the EHR provides no direct information on the

identity of the patient.

 Access control lists: access should be both

relevant and time-limited (ie. during the current

period of care and possibly for some period

afterwards). An access control list can be

defined for the EHR indicating both identified

individuals and categories of users, possibly

using role types or particular staff groups. A

gate-keeper should control access to the EHR

access control settings. All changes to the list

are audit-trailed as for normal data.

 Privacy: patients can mark parts (compositions)

in the EHR as having one of a number of levels

of privacy.

Other security policy principles not directly

specified by openEHR but which should be included

in an EHR deployment are:

 Access Logging: Read accesses to EHR data

should be logged.

 Non-repudiation: Allow digital signing of

changes to the record. Communications (EHR

Extracts) can also be digitally signed.

 Certification: a mechanism should be provided

to allow a level of trust to be formally

associated with user signing keys.

The requirements around security, privacy,

confidentiality and accountability in HL7 are

extensive and include (Kratz, n.d.):

 Authentication: use of Digital Signatures.

 Authorization/Access Control: use of Digital

Signature, Access Control Lists.

 Integrity: use of Encryption, Digital Signatures,

Check Values.

 Confidentiality: use of Encryption, Key Escrow.

 Accountability: use of Audit Trails, Logs, and

Receipts.

 Non-repudiation: use of Encryption, Digital

Signatures.

Much of what openEHR and HL7 specify are

relevant to our system. For our (session-oriented)

application we have used SSL, SPKM, HTTP-S and

Digital Certificates. Each user has a specified

username/password and has access to a limited set of

data (eg. line managers can only access data for staff

they manage) and employees can restrict what parts

of an EHR line managers have access to. Every

record access is controlled through an access control

list and all access (including reading data) is

recorded in an audit log. No record is ever deleted

and all time-based information is maintained so that

accurate records are always available. For example,

if a medical report is prepared for an employee

called Ann Smith who subsequently marries and

changes her name to Ann Jones, at some time in the

future when the medical report is viewed again, the

original name will be shown.

3.4 Implementation

The system has been implemented in Microsoft

ASP.NET 3.5 and a centralized SQL Server 2008

database. The system is fully database driven and to

allow different clients to use different terminologies

all labels, identifiers, text and messages are taken

from the database. Similarly, all questions (eg. pre-

employment questions) are taken from the database

so that each client can modify the questions that are

asked. In effect, each web page is fully generated

dynamically at runtime. Reports are generated in

Crystal Reports. For illustration, a screen shots from

the Referral subsystem is provided in Figure 3.

Availability and reliability were key considerations

and an external hosting company was selected that

could satisfy the availability and reliability

requirements and provide an appropriate Service

Level Agreement.

Figure 3: Status of Referrals for Line Manager.

DEVELOPING A WEB-BASED MIS SYSTEM FOR OCCUPATIONAL HEALTH

4 CONCLUSIONS

This paper has discussed the development of a web-

based Occupational Health system and, in particular,

examining the choice of standard for storing

Electronic Health Records (EHRs). The first version

of the system has been fully tested by one of the

large Councils within Scotland with over 1,000 staff

and has been well received by all users. We

attributed the positive feedback to the use of a

Participatory Design methodology as outlined at the

start of Section 3. The main comments were around

the administration options and reports, which were

quite limited in this first version. For example, HR

wanted to be able to modify line management

arrangements (for example, an existing line manager

may leave the organisation and the staff have to be

assigned to a new line manager). In addition, the

organisation would like to be able to customise the

form data (eg. static text for labels, questions in a

pre-employment questionnaire) stored in the

database (at present, this is carried out by Sterling

HealthCare technical staff prior to installation).

Encouragingly, there have been very little comments

on the main functionality and no major bugs have

been detected. A second version of the system has

been provided with extended reporting and the

system is now in full use at the Council. It is

anticipated that the system will be rolled out to other

Councils in the UK during the first half of 2010.

The next phase is to complete the full

implementation and add enhanced administration

functions. Thereafter, an iPhone service will be

added to allow OH professionals to dictate their

findings following a consultation and for the

dictation to be stored within the employee’s EHR in

the database.

ACKNOWLEDGEMENTS

This project received financial support from the

Knowledge Transfer Partnerships programme

(KTP). KTP aims to help businesses to improve their

competitiveness and productivity through the better

use of knowledge, technology and skills that reside

within the UK Knowledge Base. KTP is funded by

the Technology Strategy Board.

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