With the new millennium at hand, all of us in occupational health have a unique opportunity to take firm grasp on both preventing and managing occupationally-related injury and disease. As the traditional workplace, high level exposure-related health hazards diminish in most workplaces, we still face formidable challenges. These include low level exposures to a variety of chemical, biological, physical and biomechanical concerns. Researchers are also starting to address previously unexplored disease potential such as immunotoxicity and endocrine disruptors. OSHA's draft Proposed Ergonomic Program Standard released just prior to Thanksgiving, 1999 provides a prime example of the many considerations necessary to assure that medical management follows a written program along with appropriate medical restrictions and medical treatment protocols. Medical specialty organizations are publishing (with many now available through the Internet) practice parameters, based on both consensus and/or scientific literature.
Health care in general continues to undergo significant change especially quality of care, evidence-based practice requirements and cost containment. Occupational injuries and illnesses has been the target of cost shifting. Frequently non-occupational care has been claimed under workers compensation in some instances as the result of higher provider reimbursement and the absence of patient deductibles or co-payments. Computerized medicine is also impacting the delivery of all care and now occupational health services. Providers, payers and others are being "linked" through intra and internet applications. This linking phenomenon has allowed immediate scheduling, restriction designation, use of protocols, forms and decision-making criteria as well as access to important references and even electronic billing. It can also allow immediate red-flagging of specific diagnoses, costs, disabilities or potential "problem" providers to enable targeted, cost-effective case management.
All these changes produce both concerns and opportunities. One challenge is to identify approaches by disorder or body part for:
Diagnosis;
Treatment;
Rehabilitation;
Medical/Work Restrictions;
Worker Placement;
Work-Relatedness (Causation) Determination.
Higher quality and more efficient occupational health care should be delivered with enhanced knowledge and standardization of appropriate practice approaches. The American College of Occupational and Environmental Medicine took a giant step forward in developing and publishing practice guidelines in 1997. The parameters provided a first step towards assisting providers and hopefully businesses with some understanding of the basic approach that should be taken when medically managing some of the key health problems in workers. However, these guides as well as other guides developed by other medical specialties do not frequently provide necessary specifics, such as the evaluation criteria for nerve conduction testing when diagnosing carpal tunnel syndrome. But the ACOEM guides utilized excellent summary charts and algorithms, which go a long way towards achieving those goals. The practice guidelines also provide basic understanding of many important concepts such as causation determination as part of work-relatedness assessments. The references are comprehensive and the source and strength of the evidence basis for recommendations are provided as well.
