Why hospital EHRs struggle with occupational health

A hospital EHR keeps a patient’s medical history for care under one provider, where diagnosis codes and level of service are commonly structured for billing. Occupational health starts from something else: the worker, the exposures that worker faces, the employer who needs a fitness-to-work answer, and a confidentiality wall between the two. In our view, that difference in design, more than the quality of the software, is why hospital EHRs struggle with occupational health.

Hospital EHRs are strong tools for patient care. Friction starts when the same system must run surveillance by exposure group, give the employer an outcome without the diagnosis, and keep records for decades. Here is where the fit breaks, where a hospital EHR still belongs, and what to ask of any occupational health EHR.

What hospital EHRs are built to do

The Centers for Medicare & Medicaid Services (CMS) defines an EHR as an electronic version of a patient’s medical history, maintained by the provider over time, relevant to that person’s care “under a particular provider”.

A 2024 guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) notes that US guidance on EHRs has largely focused on adopting ONC-certified EHRs to meet meaningful use and Merit-Based Incentive Payment System (MIPS) criteria tied to Medicare reimbursement, while most occupational health clinics are exempt from MIPS. It also observes that EHRs commonly use structured data entry for diagnosis codes and level of service for billing.

National data standards now cover a patient’s work, too. ONC’s USCDI version 3 lists occupation and occupation industry as patient data elements, and NIOSH’s Occupational Data for Health model supports collecting standardized work information in EHRs. Studies have found capture uneven. In a study of a Canadian regional emergency department covering 49,365 patients seen between April 2015 and March 2016, occupation was not recorded for any patient with a work-related condition, even though the EHR had an occupation field. In a US study published in 2021 of 1,107 colorectal cancer survivors in two Kaiser Permanente regions, the employer was missing for over 95% of the cohort.

Those fields describe a patient’s job; they do not run an employer’s occupational health program. For the standard definitions, see our guide to EMR vs EHR in occupational health.

Five things occupational health needs that a patient chart was not designed to hold

ACOEM states that occupational clinicians need specialized EHRs to address privacy, data governance, interoperability and medical surveillance concerns specific to occupational health. Five gaps explain most of the friction.

Two roles in one clinic

An occupational health clinician often works in two roles: treating a worker’s injury or illness, and examining a worker on behalf of an employer. ACOEM notes that occupational clinicians serve multiple clients, including employees, employers, insurance carriers and other healthcare providers. It recommends that occupational EHRs account for the purpose of each encounter and distinguish administrative visits for an employer from visits as a treating provider.

ACOEM’s example is a note template with questions on pregnancy and family history, which should not be used for an administrative pre-placement exam: in the US, pregnancy questions raise discrimination concerns under laws the EEOC enforces, and family history is genetic information under GINA. An occupational EHR has to draw that line in its templates and encounter types.

A confidentiality wall that faces the employer and the hospital

In the US, the ADA regulations, which apply to covered employers (generally those with 15 or more employees), require medical information from employment entrance exams and employee exams to be kept on separate forms, in separate medical files, and treated as a confidential medical record (29 CFR 1630.14(b)(1) and (c)(1)). Supervisors and managers may be told about necessary work restrictions and accommodations.

For hospitals, the wall also runs inside the building, because their own staff can be their patients. In a 2011 informal discussion letter, EEOC staff wrote that keeping personal and occupational health information in a single electronic medical record, particularly one that lets anyone with access view everything in it, presents a real possibility of violating the ADA, GINA or both. Their example: a health professional treating an employee at the hospital where she works may not view medical information she provided to support an accommodation request. The letter is not an official Commission opinion. ACOEM adds the reverse case: fitness-for-duty drug testing should not be visible to community providers in their EHRs.

OSHA standards also limit what leaves the occupational record for the employer:

Under the respiratory protection standard, the written recommendation the employer obtains from the examining clinician contains only any limitations on respirator use (including whether the worker is medically able to use one), the need for follow-up evaluations, and a statement that the worker received a copy (paragraph (e)(6)(i)).
Under the respirable crystalline silica standard for general industry, the clinician’s written medical opinion for the employer is limited to the exam date, a statement that the exam met the standard, and any recommended limits on respirator use; recommended limits on silica exposure, or a recommendation to see a specialist, are added only with the worker’s written authorization (paragraph (i)(6)).
Under the bloodborne pathogens standard, all other findings or diagnoses remain confidential and stay out of the written opinion to the employer (paragraph (f)(5)(iii)).

The occupational record therefore needs two outputs: the full clinical record for health professionals, and a short opinion for the people who plan the work. Our article on employee health records vs personnel files covers the separation in the US, UK and EU.

Surveillance by exposure group, on a schedule

Occupational health surveillance starts with an exposure, not a visit. Under OSHA’s silica standard for general industry, for example, employers offer medical surveillance to each employee who will be exposed at or above the action level for 30 or more days a year, and repeat the exam at least every three years, or more often if the examining clinician recommends it (paragraphs (i)(1)(i) and (i)(3)).

That logic depends on data a patient chart does not normally hold: who belongs to which exposure group, when each exam falls due, and workplace monitoring results, which OSHA classes as exposure records, separate from medical records (29 CFR 1910.1020(c)(5)). ACOEM adds that most medical surveillance programs examine workers case by case and do not routinely aggregate data across a panel of workers or over time, and it notes that longitudinal analysis in an occupational EHR could uncover trends by worksite, job title, job task, shift or chemical exposure.

Records that belong to the employment, for decades

OSHA’s records standard covers the medical and exposure records of employees exposed to toxic substances or harmful physical agents (paragraph (b)(1)). Unless a specific standard sets another period, those medical records are kept for at least the duration of employment plus 30 years, with limited exceptions, and exposure records generally for at least 30 years (paragraph (d)(1)). An employer that ceases business must transfer the records to the successor employer (paragraph (h)(1)). The clock follows the employment, not the last clinical visit. See how long to keep occupational health records for US, Great Britain and EU periods, and OSHA employee medical records for access rights.

Many sites, many employers

CMS describes an EHR as holding the information relevant to a person’s care “under a particular provider”. In our view, where an employer runs clinics on several sites or in several countries, and contractors employed by other companies work alongside its own staff, one provider’s chart is not enough. ACOEM notes that occupational EHRs carved out of general-purpose EHRs designed for office-based practices or healthcare systems, or built as home-grown databases, are typically not scalable across an organization’s workforce. The record has to follow each worker across sites, rotations and contracts. See contractor health records for who is responsible on shared sites.

Where the hospital EHR still belongs

Treating a work injury is clinical care, and it belongs in the clinical record. ACOEM supports exchanging occupational data with other health systems when the exchange follows employee protection laws and uses clear user access controls. One of its illustrative cases shows the cost of the opposite extreme: a complete firewall between an occupational EHR and a general EHR in the same health system meant a drug interaction was not flagged.

In our view, the answer is a separate occupational health record that shares only what is needed with clinical systems, rather than a module inside the patient chart or no connection at all. Hospitals covered by OSHA’s bloodborne pathogens standard are employers too: records of their own exposed staff stay confidential, are not disclosed without the worker’s express written consent except as the standard or other law requires, and are kept for at least employment plus 30 years (paragraph (h)(1)).

Hospital EHR vs occupational health record: side by side

Question	Hospital EHR	Occupational health record
Who is the record about?	A patient of the health system	A worker, employee or contractor, across sites and employers
Who is the client?	The patient	The worker, and also employers, insurers and other providers, depending on the visit
What leaves the record?	Clinical information shared with other providers	A limited opinion or fitness-to-work outcome for the employer; the medical basis stays confidential
What does it hold besides care?	Orders, results, billing codes	Exposure groups, workplace monitoring results, surveillance schedules, fitness-to-work decisions

Questions to ask before running occupational health in a clinical EHR

#	Question	Why it matters
1	Is there one record per worker that follows them across sites, contracts and employers?	Transfers and contractor work should not split the history
2	Can each encounter be marked as treatment or as an exam for the employer, with different templates?	ACOEM recommends distinguishing the two roles
3	Can managers see restrictions and fitness-to-work outcomes without medical details?	ADA regulations keep medical files separate and confidential in the US
4	Are hospital clinicians outside occupational health kept out of employment-related medical information?	An EEOC staff letter says a single record anyone with access can view risks violating the ADA or GINA
5	Can surveillance be scheduled by exposure group, with due dates and alerts?	OSHA standards set exam triggers and frequencies by exposure
6	Will records stay available for decades and survive a migration or a change of owner?	Exposed employees’ medical records run to employment plus 30 years in the US
7	Is every access logged, by role?	Shows who opened a record and when

MyC was built for this side of the table. On the MyC platform, each worker keeps one health record across sites, rotations and decades, employees and contractors alike. Surveillance is scheduled per worker from their exposure group, with due dates and expiry alerts. The outcome, such as fitness-to-work, is shared with HR, HSE and managers while the medical basis stays confidential; access is based on role, and every access is logged. Older records can be imported before each site switches on. Our occupational health EHR page compares EMR, EHR and occupational health EHR side by side, and the page for medical services providers covers care delivered across client sites.

Questions

Can a hospital EHR be used for occupational health?

It can hold the clinical care, but it was designed for patient care under one provider. Occupational health also needs exposure groups, surveillance schedules, limited opinions for the employer and decades-long records tied to employment.

Should employee health records sit in the same EHR as patient records?

The ADA regulations do not name a particular system, but they require medical information from employee exams to be kept in separate, confidential medical files. A 2011 EEOC staff letter added that a single record that anyone with access can view presents a real possibility of violating the ADA, GINA or both. Ask legal counsel about a specific setup.

Do hospital EHRs record a patient’s occupation?

The standards allow it. USCDI version 3 lists occupation and occupation industry, and NIOSH’s Occupational Data for Health model supports collecting standardized work information in EHRs. Studies have found occupation and employer fields often empty, and these fields describe a job, not an employer’s surveillance program.

To see one record per worker across every site, book a demo.

Sources

Written by Lisa Bardet, VP Marketing at MyC. Every factual claim in this article is checked against primary sources, such as regulations, regulators and peer-reviewed studies, in three passes before publication, and the sources are listed above.

This article is general information for employers and occupational health teams. It is not legal or medical advice for a specific situation.

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