Electronic medical record for audiological monitoring of occupational noise exposure

ABSTRACT

Purpose:  to develop and implement an electronic medical record for managing audiological assessments of workers exposed to occupational noise at a university.

Methods:  a computer system - the Electronic Audiology Record Program (PPVA, in Portuguese) - was developed with Microsoft Access for a university hospital’s audiology service, encompassing functional, occupational, and audiological information. After a testing period, the system was implemented in the service.

Results:  the PPVA is a personalized system that registers employees, audiological exams, clinical history, and risks for hearing loss induced by high sound pressure levels. It also generates reports indicating audiological monitoring frequency.

Conclusion:  the PPVA proved to meet the service’s needs, adequately. Its implementation improved the usability, efficiency, and quality of the service user records. Hence, it is a potential health surveillance tool, indicating that this type of instrument can benefit occupational hearing loss prevention programs.

Keywords:
Electronic Health Records; Health Information Management; Occupational Health; Database

RESUMO

Objetivos:  desenvolver e implementar um prontuário virtual para gerenciamento das avaliações audiológicas de trabalhadores expostos ao ruído ocupacional de uma universidade.

Métodos:  foi desenvolvido um sistema informatizado para um serviço de audiologia de um hospital universitário de São Paulo, o Programa de Prontuários Virtuais de Audiologia (PPVA), utilizando o programa Microsoft Access, onde foram incluídas informações funcionais, ocupacionais e audiológicas. Após período de testes, o sistema foi implementado no serviço.

Resultados:  o PPVA é um sistema personalizado, no qual é possível realizar o cadastro de funcionários, exames audiológicos, histórico clínico e de riscos para perda auditiva induzida por níveis de pressão sonora elevados, além da geração de relatórios indicando a periodicidade para o monitoramento audiológico.

Conclusão:  o PPVA mostrou-se adequado para atender às demandas do serviço. Sua implementação trouxe melhorias na usabilidade, eficiência e qualidade do registro dos usuários do serviço, sendo também uma potencial ferramenta de vigilância em saúde, indicando que este tipo de ferramenta pode trazer benefícios para um programa de prevenção de perdas auditivas ocupacionais.

Descritores:
Registros Eletrônicos de Saúde; Gestão da Informação em Saúde; Saúde do Trabalhador; Base de Dados

INTRODUCTION

Prolonged exposure to noise at high levels can cause hearing and non-hearing damage^1,2. Hearing changes are initially imperceptible, but after a few years of noise exposure without using proper hearing protection, the first symptoms begin to appear, possibly causing permanent hearing loss³.

This type of hearing loss is considered a public health problem. Approximately 250 million people worldwide have hearing loss greater than 25 dBHL caused by noise, with occupational noise accounting for 16% of disabling hearing loss in adults (hearing thresholds above 40 dBHL in the better ear). It is worth noting that this clinical condition impacts the quality of life of affected individuals and reduces the economically active population^4,5.

Annex II of the Brazilian Regulatory Norm 7 (NR-7) - which addresses occupational medical control of exposure to high sound pressure levels - uses the term hearing loss induced by high sound pressure levels (PAINPSE, in Portuguese) to define hearing loss resulting from noise exposure, also known as noise-induced hearing loss (NIHL)⁶. This is the second most common type of sensorineural hearing loss in adults, behind only age-related hearing loss. It is irreversible but preventable with protective and monitoring measures, making them mandatory in all work activities in which employees are exposed to high and constant noise levels^6,7.

The high prevalence of NIHL has been associated with increased industrialization, coupled with the low capacity of government institutions to monitor adequate preventive measures against noise, such as efficient prevention programs and deficient data collection systems. Noise exposure mainly affects workers in the transportation, agriculture, manufacturing, and construction sectors or facilities in these sectors^4,8,9.

Therefore, efforts should be made to improve and enhance communication between workers and services, seeking access to possible factors that interfere with the dynamics of the health-disease process and that increase or decrease the risk of illness. Thus, there is a need for initiatives involving the entire work and health process, with permanent and continuous monitoring systems as part of occupational health, triggering actions to reduce and eliminate existing risks^10,11.

In addition to monitoring the audiometric exam, health agencies strongly recommend using and constantly updating databases, since they help identify the employees’ audiological profile, monitor the prevalence of cases suggestive of NIHL, support educational and surveillance actions, and identify employees who need audiological assessment. However, there are few options for electronic medical records in audiology, and most of them do not manage such data and/or require payment to keep them operating in the service¹².

Thus, an electronic medical record for managing audiological assessments of workers exposed to occupational noise at a university has been developed and implemented, aiming to verify whether this type of tool can contribute to occupational hearing loss prevention programs.

METHODS

The research was developed in the outpatient audiology service of a public hospital in São Paulo, with approval from the Ethics Committee of the Medicine School at the University of São Paulo, SP, Brazil, under number 058/08 (CAAE 0068.0.198.000-08).

The university hospital’s audiology service has been active since 2002, providing audiological care for all the university’s employees. This service’s activity results in numerous and extensive physical records due to both the number of employees monitored and the longevity of such monitoring.

Hence, the service’s needs were initially surveyed to develop the project.

The quantity and volume of the service's medical records were identified through a retrospective survey of audiological assessments based on the physical medical records of workers referred by the Specialized Safety Engineering and Occupational Medicine Services (SESMT, in Portuguese). They were recorded in Microsoft Excel, collecting the following information: the employee's full name, occupational number, hospital registration number, and date of birth. In this stage, 3,300 employees were registered.

Then, a computer system of electronic medical records was created with the information necessary to successfully implement the university's hearing loss prevention program - obtained through meetings with the occupational health team. The university hospital’s Electronic Medical Records Program (PPVA, in Portuguese) used the 2109 Microsoft Office 365, specifically Microsoft Access, and the available macros and VBA (Visual Basic for Applications) code. This platform was chosen for its accessibility, capacity to accommodate data, and low cost. The system was developed by an undergraduate speech-language-hearing student, incorporating all the information and needs of the service. The program is based on Annex II of NR-7⁶ and complies with the requirements of the hospital where the service is located. Hence, it included additional information about the employees.

After developing the PPVA, initial tests verified whether the electronic medical record was functioning properly and contained all the information necessary for the service, validated by the service's audiologists. Then, the employees' records were included in the system. Although it was not part of the study's objectives, a descriptive statistical analysis (percentages, mean, and standard deviation) of the data included in the PPVA was performed to exemplify how the system can assist in data handling and audiological procedures.

The criteria for including medical records in the system were active employees at the institution and complete audiological assessment data in the physical medical records.

RESULTS

Developing the electronic medical record

As previously mentioned, the PPVA was developed to meet the service’s needs. The PPVA included the main information required for the hearing loss prevention program: registration and occupational data, clinical and occupational history, and audiometric test results. These data include the reason for the test (whether pre-employment, periodic, post-employment, change of position, or return to work), occupational data (position, job description), exposure to physical (noise) and chemical agents, use of hearing protection devices (earmuffs or foam and/or silicone earplugs), previous illnesses, auditory and vestibular complaints, risk factors for NIHL, and audiological monitoring.

The PPVA screens were divided according to the distribution of information to facilitate registration and report.

The opening screen contains the user's login and password, designed to limit access to data and reports. After entering their login and password, users are redirected to the PPVA home screen (Figure 1), which shows all the system's resources: employee registration, exam history, clinical history, risk history for PAINPSE, and reports, indicating which employees had or should have their hearing monitored.

Figure 1
Home screen of the Electronic Audiology Record Program

The employee registration screen (Figure 2) contains data for employee identification. After filling it in, they can also register additional information from the medical history survey and audiological examination by clicking on the corresponding screens.

Figure 2
Employee registration screen

The exam screen (Figure 3) first shows employee identification data, such as their name, hospital registration, and date of birth. Exams can be uploaded below these fields, following the guidelines established in Annex II of NR-7⁶.

Figure 3
Exam registration screen in the Electronic Audiology Record Program

Users can select one of the following options in “reason for examination”: pre-employment, periodic, return to work, change in occupational risks, and post-employment. In “exam result” and “curve/notch type”, they can select either “hearing within normal limits” or one of the options corresponding to the type, degree, and configuration of hearing loss. In “conclusion of Annex II of NR-7”, they can select the interpretation of the audiometric examination result, with the options: “within acceptable limits”, “suggestive of PAINPSE”, “suggestive of PAINPSE triggering” or “suggestive of PAINPSE worsening”. They can also select the procedure: “referral to otorhinolaryngology”, “notification to the SESMT”, or “return in one year” and enter the estimated return date.

Patients with more than one exam registered in the service can simply click on “New” to add the other exams. The “Search employee” button, available on all registration screens, easily shows a medical record by searching for the patient’s name.

The clinical history screen (Figure 4) also shows employee identification data, such as their name, hospital registration, and date of birth.

The user can enter data about the employee's general health and hearing below these fields. Employees with more than one medical history can simply click on “New” to add another record with this information.

Figure 4
Clinical history screen in the Electronic Audiology Record Program

The “Risks for PAINPSE” screen (Figure 5) also displays employee identification data, such as their name, hospital registration, and date of birth. Information about occupational and extra-occupational risks for PAINPSE can be registered below these fields. Employees with more than one medical history survey can simply click on “New” to add another record with this information.

Figure 5
Screen of occupational and extra-occupational history of risk for hearing loss induced by high sound pressure levels from the Electronic Audiology Record Program

Lastly, the “Report” screen organizes the exams by date (Figure 6). This function is extremely important, as it helps monitor exams and identify whether the adequate frequency of audiological monitoring is being met, complying with legal requirements and the hearing loss prevention program. Moreover, a PDF file can be generated with these data (Figure 7) to be forwarded to the SESMT.

Figure 6
Screen for selecting exam dates in the Electronic Audiology Record Program

Figure 7
Exam report screen organized by date in the Electronic Audiology Record Program

It is worth noting that after testing and before feeding and implementing the PPVA, four training sessions were held with the service residents, including information on how the program works and its importance to the service. They will be responsible for maintaining the PPVA records in the long term. One of those training sessions has been video-recorded and is available for consultation and training future residents. Short videos were also created for quick consultation, available on a drive at the audiology service.

Entering employee data into the system

As the service’s needs were surveyed, the researchers identified the quantity and volume of service records, divided into active and inactive employees - of the 3,300 employees, 1,881 were active. The physical records of the inactive employees were filed, and eight duplicate records of the active employees were reorganized. After testing and training, part of the records of the active employees (144 records) were digitized.

The following profile was found in the 114 medical records in the system: mean age of 55.93 years (SD: 8.35 years), mostly having worked at the university for 15 or more years (84.72%). In the medical history survey, 77.08% reported occupational noise exposure, and 84.68% of them had performed the same activity with noise exposure for 15 or more years. Of those exposed to noise, 42.85% reported having contact with chemical products sporadically during the workday, and 41.86% used hearing protection devices during the entire noise exposure time. Regarding audiological complaints, 27.02% of those exposed to noise reported not hearing well, 39.53% reported tinnitus, and 38.37% reported dizziness.

DISCUSSION

Computerization in health is a global trend, with quick scientific development to store, retrieve, and use biomedical information, data, and knowledge for problem-solving and decision-making¹³. Such characteristics are present in the PPVA, demonstrating its relevance as a health information and research tool, assisting in the excellence of the service provided in a hearing loss prevention program.

To develop a database, it is necessary to plan the usability, efficiency, and quality of user records. It is also essential to develop the system in advance, with the participation of health professionals responsible for the service in which the electronic medical record will be implemented^14-17. These steps were completed in the present research, as the initial PPVA prototype was based on contributions from the service's audiology, who validated the system's fields according to the needs.

As a result, the following benefits are being consolidated with the research, during the implementation of the PPVA: agility in accessing employee data, providing comprehensive and continuous care; more legible and qualified information, tending to eliminate redundancies and data loss; relevant data for clinical decision-making, promoting qualified care management; handling duplicate physical medical records, avoiding the loss and/or confusion of patient data^18,19.

Another relevant point is the high cost associated with healthcare computerization, identified as one of the main reasons for failure in implementing electronic medical records¹⁸. This issue does not apply to PPVA, as it was developed on a platform consistent with a program licensed by Microsoft, previously installed on the hospital's computers, not requiring additional costs to develop and maintain the active program.

The literature also discusses training professionals to use technology, emphasizing that health professionals spend more time on documentation than on care and when faced with complex electronic medical records, they tend to abandon their use^15,16,20. Therefore, the service's audiologists and residents were periodically consulted and trained with the tool during the project to implement it in the service's daily routine.

The PPVA was designed for a university hospital’s audiology service, meeting its needs and aligning it with the outpatient clinic’s routine. Thus, the program was compatible with the reality of the services provided at the site, making it easier for professionals to accept it and minimizing their abandoning the database^17,21,22.

Electronic medical records, such as PPVA, provide an extensive source of data that allows longitudinal comparisons, cohort studies, quality assessment with large sample sizes, and health surveillance. The data also makes it possible to plan actions and implement policies to reduce and eliminate the risks of NIHL^15,17,23.

Data security and confidentiality pose another challenge to implementing electronic medical records. Therefore, to meet these requirements, the data stored in the system must be secured (besides the login and password), protecting it in accordance with current legislation.

The PPVA implementation process is not immediate, and its maximum potential may not be achieved soon. Implementing and consolidating new technology at work is an evolutionary process, requiring time and often adjustments¹⁹.

This research developed and implemented the PPVA and collected the service’s physical medical records, demonstrating its magnitude and complexity and the need to develop and maintain a database for a successful hearing loss prevention program. At this stage, the records were organized into active and inactive employees, then obtaining a profile of the employees served by the service after entering the medical records in the database. This type of analysis shows the importance of electronic medical records to prepare reports with demographic, occupational, and other data - important indicators in longitudinal health programs.

One of the study objectives was to demonstrate the feasibility of developing and implementing such a tool in services with a limited budget but requiring and desiring a customized audiological monitoring system to support the hearing loss prevention program. Hence, a customized computerized system can be developed and implemented by assessing the service’s needs and executing the step-by-step process presented here, with a relatively simple and accessible platform. It can improve the quality of the program and generate indicators to help continuously reassess the quality of the service.

CONCLUSION

A customized electronic medical record was developed to manage audiological assessments of workers exposed to noise at a university, meeting the service’s needs at a low cost. This electronic medical record was validated by professionals from the service where it was implemented. It is expected that the PPVA will contribute to record usability, efficiency, and quality and serve as a health surveillance tool.

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• A study conducted at the Medical School of the Universidade de São Paulo, São Paulo, São Paulo, Brazil.
• Financial support: Nothing to declare
• Data sharing statement: Individual data of unidentified participants will not be shared.

Data availability

Data sharing statement: Individual data of unidentified participants will not be shared.

Publication Dates

• Publication in this collection
  23 Sept 2024
• Date of issue
  2024

History

• Received
  22 Apr 2024
• Reviewed
  12 June 2024
• Accepted
  31 July 2024