The advent of electronic dental records

Electronic health records (EHR) are widely used among medical practices and hospitals to share patient clinical information in a quick, accurate, secure, and efficient manner.

Expert outlines what dental hygienists should expect

by Lisa Wadsworth, RDH, DA, and Mike Uretz

Electronic health records (EHR) are widely used among medical practices and hospitals to share patient clinical information in a quick, accurate, secure, and efficient manner. This adoption didn't happen overnight -- it was 10 years in the making. Today, the dental industry finds itself at square one of the EHR-adoption process. Dental professionals have a lot of questions, especially hygienists who will probably be doing a lot of the "heavy lifting" in the selection, implementation, and day-to-day utilization of dental's version of EHR, electronic dental records (EDR). Lisa Wadsworth, RDH, DA, recently interviewed Mike Uretz, an EHR veteran who, for 10 years, helped individual medical practices, group practices, and hospitals migrate to this new technology and who is now focusing on assisting the dental industry.

Wadsworth Why should dental professionals, hygienists especially, embrace electronic dental records?
Uretz There are many reasons for a dental practice to adopt electronic health records (EHR), or more specifically, electronic dental records (EDR). For example, what hygienist wouldn't appreciate the ability to have all of their patient's medical history, including past dental procedures and medications, at their fingertips while the patient is in the chair?

Wadsworth That certainly would streamline the process of gathering medical history information.
Uretz Of course it would! Imagine – there's no longer a need to try to contact any of the patient's medical or dental providers for background information or to fill medical history information gaps during the visit. Another extremely important benefit is the ability to automatically check for any drug interactions. This is often very complex with older patients or those being treated for systemic conditions, such as high blood pressure or heart disease. Knowing this information and taking appropriate measures could reduce a practice's risk of a lawsuit.

Wadsworth Speaking as a hygienist, it would be nice to see all the meds a patient was taking without having to ask at every maintenance visit. As you know, sometimes patients can't remember all of the medications they are taking, let alone the doses. How does an EDR have the capability to keep the dental team up to date on a patient's medications?
Uretz It has become standard in medical EHRs to use what is known as e-prescribing. Basically, all the prescriptions a patient is given, no matter what the source, go through a clearinghouse to the pharmacy. In turn, these lists can be shared almost in real time with a practice's EHR when the patient's chart is opened. The system itself then can automatically check for any interactions with prescriptions that you are contemplating and update the overall medical list with your prescription. They are even adding the capability to check for compliance – in other words, to check if the patient actually picked up the meds at the pharmacy.

Wadsworth What is the difference between dental charting software and what you consider to be "true" electronic record software?
Uretz When we use the term "electronic dental records," we are not just talking about dental charting per se. I have talked to a number of practice owners who believe they have electronic dental records systems, when in reality they have a few components of what a complete EDR system would have. In addition to charting, a true electronic dental record system should be able capture the patient data in a discrete or structured format so it can be used for a number of clinical applications and patient analytics. What's more, a true EDR system should have advanced features such as treatment planning, specific protocols, electronic prescribing, clinical workflow, clinical alerts, and other integrated features that have become standard for EHR in the medical world. Hopefully, they will also have tools to analyze the treatments and outcomes of their entire patient population. It should be noted that the ability to import and export clinical data in a standard format will be essential in the future as we move toward sharing patient records between provider offices.

Wadsworth Could you clarify the federal incentive programs for acquiring EDR technology along with the term "meaningful use" we keep hearing?
Uretz This question is not only very timely, but it is near and dear to my heart, as I have been involved with this program for the past two years on a national and state level. What is most relevant to dental providers is the EHR incentive program that is administered under Medicaid. Here it is in a nutshell: If a dental provider sees at least 30% Medicaid patients, then the dental provider is eligible to receive up to $63,750 in federal reimbursements over a six-year period for acquiring and using EHR technology in a "meaningful" way. That's where the term "meaningful use" comes in. This refers to the use of certain criteria that the federal government has set for features and functionality mandated in the EHR. The main impetus for this program was to increase the quality of patient care through EHR technology as well as to capture and analyze clinical measures and outcomes to determine best practices.

Wadsworth Hygienists often spend more time communicating with patients than do the dentists. Therefore, should hygienists have a role in the acquisition, training, and implementation of EDR technology in their offices?
Uretz Absolutely. Each clinician who interacts with the patient during the visit will utilize the system and, because of this, it is important that each of them has input into the selection of the components of the system that will most affect them. The hygienist should be able to evaluate the EDR system based on how it serves the hygienist's needs from a feature and functionality standpoint as well as the ease of use of the system. Dental team buy-in is extremely important to ensure the long-term success of the EDR system. In terms of implementation, practice owners can get frustrated in the long term because they haven't been as involved in the training and implementation of the system as they should have been. It is essential for the hygienists to be engaged in this role, for many times there are modifications that can be made with the EDR system, and if the hygienist has input during this process, they get a more customized system that best suits their needs.

Wadsworth Can the EDR system help with communication between administrative and clinical team members?
Uretz Yes, and this is most apparent in optimizing the workflow within the practice. The EDR system can electronically hand off the patient between various touch points and pass along appropriate information between administrative and clinical status. Also, a good EDR system has a very robust internal messaging capability. It can also have a task management component. The claims processing between clinical and administrative becomes more streamlined and efficient because there is an ability to check insurance eligibility ahead of time, and also less manual intervention that enables claims to flow electronically from procedures performed in the operatory and on through the claims processing system.

Wadsworth How can EDRs facilitate communication among all clinical dental team members – dentist, hygienist, and assistant?
Uretz From a clinical workflow standpoint, a well-designed EDR can manage task lists, including the ability to alert for overdue tasks. In addition, the EDR system should allow a clean pass-off of information between the various members of the dental team. For example, when the hygienist has completed his or her portion of the exam and treatment, the system should be able to automatically alert the dentist, and when the dentist sees the patient, he or she should easily be able to bring up the patient records with one click. In the medical world, a number of EHR systems actually enable you to set up the workflow that your practice uses to have that as a base to work from – and the hope is that the dental vendors will embrace these types of features in their products. Another beneficial byproduct of this is the standardization of treatment and procedures within the practice.

Wadsworth Based on your experience in the medical profession, how long does it take a practice to get proficient with its EDR system? How much training does it take to flatten the learning curve?
Uretz As you can imagine, this really depends on a number of factors, including the level of buy-in that the dental team has regarding the new system, the willingness to use the system on a regular basis, and the resources that have been invested in the training process. An implementation can fail if the practice does not provide staff resources to the vendor during training. In terms of flattening the learning curve, it really depends upon the complexity of the system, along with the practice's desire to get up to speed as soon as possible.

Wadsworth There is a lot of discussion regarding effective collaboration between dentists and physicians to better manage a patient's overall health. Do you see EDRs as being a catalyst for increased collaboration?
Uretz Without a doubt! With more and more research linking oral health with systemic health and the simultaneous burgeoning growth of interoperability and health information exchange, dental and medical providers should be able to easily share information of patients they have in common. EDRs help facilitate this collaboration and team approach. The term "medical home" is becoming more popular and describes this multidisciplinary approach to managing a patient's health and wellness. This type of collaboration would be much more difficult, and perhaps more error-prone, if not for EDR technology.

Wadsworth It's often difficult to track whether the dentist has reviewed, signed off, and closed a patient's visit note. Is there some way to make sure that the dentist reviews and signs his or her notes on a daily basis?
Uretz Yes. With medical EHRs, an office manager can query the system to see what notes remain unsigned – and you can even automate the system so it places a list of unsigned notes on the doctor's desktop, along with other tasks, when the doctor signs in to the system. This should be able to be achieved in an EDR system as well. Of course, this level of accountability might bother some folks, especially when they are the ones signing your paycheck, but it certainly leads to a more efficient workflow.

Wadsworth When a patient leaves the general dental practice to see a specialist, it can become difficult to keep up with the patient's progress. Faxing information is very cumbersome and faxes are often lost or misplaced. How can EDR make this process more efficient and ensure we stay involved with the patient's care?
Uretz With EDRs, the manual faxing process is replaced by a more automated form of communication that refers a patient out from within the electronic chart at the click of a button. This sends an electronic fax to the referred provider, along with the appropriate information that is needed from the patient's chart. As interoperability and health information exchange become more standard, this information would then go right into the EDR system of the provider to whom you are referring. Conversely, even if the provider you referred to does not have an EDR system, any faxes the provider sends to you would go directly into the patient's chart so you wouldn't have to deal with any paper. Also, any and all communication you send out will be documented electronically.

Wadsworth How will the patient's information from the dental community be downloaded into the system?
Uretz This will happen via interoperability and health information exchanges (HIEs), which are like big routing systems through which information from various systems, general providers, and specialists passes. Already, standards are being adopted by EHR systems to facilitate this. It's similar to what happened in the financial industry. Years ago, if you wanted to get cash from an ATM, you had to go to your bank's ATM. But the industry developed standards so today you can withdraw cash from any ATM, as they are interconnected electronically. The financial industry had to develop messaging standards to make this happen. We all know that trying to communicate via faxes and back-and-forth telephone calls isn't very efficient at times.

Wadsworth Can we use this system to reduce rejections for payment from dental insurance companies? For example: the dental practice recommends scaling and root planing. The insurance company does not agree that the procedure is necessary. We have to write back and explain that the patient is a diabetic and would benefit overall from this treatment. The claim gets paid. Therefore, would it be possible for the system to "red flag" patients who have complex medical histories and have the treatment accepted to fit a protocol that is beneficial for the patient?
Uretz That depends on the system, but the technology is available to get preauthorization and eligibility from the insurance company directly from the patient's electronic chart. Also, it is possible in some cases to automatically pull the procedures needed from predefined protocols within the system and then, in turn, these are electronically provided for preauthorization and eligibility.

Wadsworth I heard that there are some EHR companies in the medical field that offer their solutions free to the medical practice. Is this true, and will that happen in dental as well?
Uretz As they say, "There is no such thing as a free lunch." There have been some EHR companies in the medical world that have web-based models in which the system is essentially free, and revenue for the company is supposedly generated by advertising on the screens. However, they have not been very successful. It is very distracting to have ads pop up when you're trying to read a patient's chart or address a specific clinical issue. Also, to be successful in the EDR business, it takes a continual investment to keep up with all the innovations, and a few dollars from advertising money doesn't necessarily provide the kind of capital needed on a continuing basis to have a best-of-breed EDR. So, if we start seeing these "free" models in dentistry, then you really need to look very closely at the company providing the services.

Wadsworth The hygienist's role is to be the periodontal detective for the practice. Periodontal disease is the main cause for tooth loss in adults. What information will the EDRs be able to provide to assist with patient evaluations?
Uretz In terms of evaluations and diagnosing issues, a good EDR system should give you the ability to provide templates for various exams and evaluations, so that pertinent information is not missed. The better systems have libraries of evidence-based templates that have been put together by clinicians with the ability to customize the template depending on the needs of the hygienist. In the case of periodontal disease, the EDR could incorporate a checklist that corresponds with the "Comprehensive Periodontal Therapy Statement" from the American Academy of Periodontology.

Wadsworth One last question, Mike. The communication that hygienists have with their patients consists of home care instruction, explaining charting and pocket depths, and discussing periodontal disease and intervention protocols. How will EDRs support this level of patient education and hopefully improve compliance?
Uretz This is a perfect application of EDR technology. It should be possible, based on a diagnosis and treatment, to have the system automatically present patient education materials (i.e., videos, charts, graphs, images, etc.) to the patient during the hygienist encounter. In addition to presenting this information at point-of-care, the system should be able to print these materials out upon check-out. One area of growth is patient web portals, where patients can log in to a browser, sign on to the EDR system, and receive patient education materials that have been specifically loaded into their accounts. This is especially helpful when patients forget the patient education they received in the office. Now, they would have the capability at any time to review the patient education that was prescribed to them. RDH


Consider reading:A team approach to electronic dental records
Consider reading:Digital patient communication portals and practice profitability
Consider viewing:Electronic health records can improve patient care

Lisa Wadsworth, RDH,DA, owns Lisa C. Wadsworth, Inc, a company focused on consulting and personal coaching for the dental community. With more than 3 decades of experience in the implant and periodontal arena, she began her career as a dental assistant, progressed to certification in Implant surgical assisting, and lastly a degree in dental hygiene. Ms. Wadsworth has received Fellowship status with the Association of Dental Implant Auxiliaries; served as a dental hygiene educator for OraPharma, and is recognized by Philips/Sonicare as a Key Opinion Leader. She is a member of the Speaking Consulting Network and lectures nationally on implant dentistry, periodontal protocols, professional development, and ergonomics. She can be reached at (215) 262-6168 or via the Web site at lisawadsworth.com.

Mike Uretz is a 30-year technology veteran and nationally-recognized electronic health records (EHR) expert. Mike has helped hundreds of individual practices and multiclinic groups properly evaluate and select their EHR solutions and structure and negotiate contracts while providing management and oversight for their implementations. In addition, Mike has been a member of the EHR Certification Commission for Health Information Technology and is a member of ADA's dental software interoperability workgroup. Mike is now applying his wealth of knowledge and experience to the dental industry to introduce dentists to EDR software best practices, and to help them avoid the pitfalls experienced by other health care professionals. Mike is also the founder and editorial director of DentalSoftwareAdvisor.com, a trusted and objective online resource on all matters related to dental software. He can be contacted at MikeU@DentalSoftwareAdvisor.com.

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