Throw away the buggy whip. Three simple steps propel you to the multiple uses of electronic health records, regardless of whether you're a 'native' or an 'immigrant'
BY Patti DiGangi, RDH, BS
The horse and carriage are obsolete as modes of transportation, so we no longer need buggy whips. The cellular phone has made the traditional central phone in the hall near the bedrooms obsolete. The continuation of technology is creating the same obsolescence for paper charts. Interoperable electronic health records (EHR) will be the most dramatic change in your dental practice during the next five years. Many dental practices are moving toward paperless documentation, which is not the same. EHR is much more about connections. Smart practitioners, no matter their setting, are beginning to position themselves toward this inevitable future.
The Great Divide
The terms "digital native" and "digital immigrant" were coined by Marc Prensky in 2001 and popularized by many others. The interpretation of these terms varies. The digital natives/digital immigrants idea is basically an easy way to identify the attitudes formed by those who grew up in the old, predigital culture, particularly when attitudes clash with those of the natives, whose attitudes were formed in the new, digital culture.
Although often perceived by digital immigrants as having a lack of connections, digital natives connect in a wide multiplicity of ways. The connection is most often through pocket cellular devices. The Pew Research Center surveyed a broad spectrum across all age groups, asking the question: Do you sleep with your cell phone? Fifty-seven percent of all respondents answered yes; among digital natives (millennials), the percentages shot up to 83%. This can be seen as an overattachment, or it can be seen as a craving to connect.
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PBS created a three-part series that explores improving our social relationships, learning to cope with depression and anxiety, and becoming more positive, resilient individuals (pbs.org/thisemotionallife/topic/connecting). Research on happiness discussed in this series reveals we are social creatures. Connecting with others may be the best thing we can do for our happiness. The desire of digital natives to connect by staring endlessly at their cell phones is not what it might appear to be to digital immigrants. It is this innate need to connect.
Connecting through records
The purpose of all record keeping - no matter how it is done - is to:
• Tell about the past
• Assist in the present
• Identify the future opportunities
Connecting is very important. Yet, documentation is often an afterthought or so rote that record after record read the same. The future of health care is all about connecting dental to medical to hospitals to pharmacies to chiropractors to nutritionists, and so on. The list of those who interact about the health and well-being of an individual can be nearly endless.
Documentation is part of the process of dental hygiene care. In 2008, the American Dental Hygienists' Association created the "Standards for Clinical Dental Hygiene Practice" (adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf). The standards updated the expectations of dental hygienists for the 21st century. At the time, during our clinical education, many of us learned the five components to the dental hygiene process of care:
• Dental hygiene diagnosis
This process is abbreviated as ADPIE. A key component in the ADHA updated document is the addition of a sixth component: documentation, creating ADPIED. Figure 1 shows ADHA's definition of documentation.
While presenting seminars around the country, this author asks if a hygienist can diagnose. Most often, the response is that an RDH cannot. Why? Did they hear it in their dental hygiene education? Someone in a powerful position said it from the podium? Or because other resources have parroted the sentiment over and over? Repetition does not equate to accuracy.
The Commission on Dental Accreditation (CODA), a committee appointed by the American Dental Association, sets educational standards. One of those standards includes teaching the dental hygiene process of care. The first D in ADPIED stands for dental hygiene diagnosis. The other D is to document all aspects of the process of care. This means we are required to document the dental hygiene diagnosis.
Figure 1: Excerpt from the Clinical Standards of Dental Hygiene Practice, ADHA, 2008
Standard 6: Documentation
Documentation is the complete and accurate recording of all collected data, treatment planned and provided, recommendations, and other information relevant to patient care and treatment.
1. Documents all components of the dental hygiene process of care (assessment, dental hygiene diagnosis, planning, implementation, and evaluation).
2. Objectively records all information and interactions between the patient and the practice (i.e. telephone calls, emergencies, prescriptions).
3. Records legible, concise, and accurate information (i.e. dates and signatures, clinical information that subsequent providers can understand, ensure all components of the patient record are accurately labeled).
4. Recognizes ethical and legal responsibilities of record keeping, including guidelines outlined in state regulations and statutes.
5. Ensures compliance with the federal Health Information Portability and Accountability Act (HIPAA).
6. Respects and protects the confidentiality of patient information.
ADHA updated a position paper in 2010 on the dental hygiene diagnosis saying, "The dental hygiene diagnosis is a necessary and intrinsic part of dental hygiene education and practice. The dental hygienist employs critical decision-making skills to reach conclusions about the patient's needs related to oral health and disease that fall within the dental hygiene scope of practice." ADHA 2014 President Kelli Swanson Jaecks is right on the target in speaking of the dental hygiene diagnosis.
"Treating without a diagnosis is like driving a car without GPS. Treating without a diagnosis is malpractice," Swanson Jaecks said while describing the ADHA 2010 position paper.
The traditional model has been the dentist completes an evaluation after the dental hygienist has completed care. As such, the dental hygienist has made a dental hygiene diagnosis already. Yet this is not recognized and most often is not documented. All care, including preventive prophylaxis, requires a written diagnosis.
CDT and SNODENT structured data
The discussion of documentation requirements becomes more important as dental hygiene practice evolves and with the looming advent of EHR. An interoperable EHR will require the use of uniform health information standards, including a common language. Data must be collected and maintained in a standardized format, using uniform definitions, in order to share health information among systems. Clinical terminologies and classifications represent a common language, allowing clinical data to be effectively utilized and shared among EHR systems.
The current standard language for dentistry is Current Dental Terminology (CDT). This system is generally thought of as being only for efficient processing of dental claims. Dental hygienists often take a "hands-off" attitude in this regard. Though CDT is for dental claims processing, it is not the only purpose. Another purpose for CDT is as a standard language to populate EHR.
Another standard language, also brought to us through the American Dental Association, is the Systematized Nomenclature of Dentistry (SNODENT). It is a vocabulary designed for electronic health and dental records. The intended purpose, per ADA, is to:
• Provide standardized terms for describing dental disease
• Capture clinical detail and patient characteristics
• Permit analysis of patient care services and outcomes
• To be interoperable with electronic health records (EHR) and electronic dental records (EDR)
SNODENT is a diagnostic coding system and another form of structured data.
Affordable Care Act Strategic Goal 1: Strengthen Health Care
Objective A: Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured
Objective B: Improve health care quality and patient safety
Objective C: Emphasize primary and preventive care, linked with community prevention services
Objective D: Reduce the growth of health care costs while promoting high-value, effective care
Objective E: Ensure access to quality, culturally competent care, including long-term services and supports, for vulnerable populations
Objective F: Improve health care and population health through meaningful use of health information technology
Why structured data?
Most data currently in health records is collected in the notes section. A rich store of information is in those notes. Unfortunately, it isn't readily accessible; nor is it measurable. Most everyone agrees that health care in the United States costs too much. Although how to resolve this is not universally agreed upon, EHR can potentially assist in bringing down costs by reducing duplication of services and through measurability.
The sidebar ("Affordable Care Act Strategic Goal 1: Strengthen Health Care") shows the first strategic goal of the Affordable Care Act to strengthen health care. Homing in on Objective F - "Improve health care and population health through meaningful use of health information technology" is the key to understanding the message of this article. "Meaningful use" is a term heard a lot on the medical side of health care. If you have been to a hospital or physician's office in the recent past, you have been asked about your smoking status, your blood pressure was taken, and much more. Meaningful use sets specific objectives for health-care records. There are funds, as much as $63,750 over six years, set aside by the government to facilitate EHR upgrades even in dental practices. The incentives have a time limit, with 2016 as the last year an eligible professional may begin the program.
Three simple ways to start
Getting ready for EHR will take many phases. "Meaningful use" has not been defined for dentistry. We can take a lesson from medical meaningful use standards that apply to dentistry and start with a few simple steps. The idea of structured data can start by setting up a system for documentation. Find and/or create a place for routine documentation of:
1. Smoking status
2. Blood pressure readings
3. Dental hygiene diagnosis
If you are not sure how and where this can be uniformly recorded in your software, find a digital native to help. Then calibrate with the rest of the practitioners in your office.
This is by no means an exhaustive list. These small, uniform, structured data steps can be the first steps in the journey toward interoperable EHR. It is not a journey to buy a buggy whip. The biggest steps are in your thoughts, attitudes, and habits. EHR is not about technology only and will be the most dramatic change in your dental practice in the next five years. You have the choice to fight it and lose; wait for someone else to set the rules for you; or to guide the winds of change and position yourself toward this inevitable future. RDH
PATTI DIGANGI, RDH, BS, holds a publishing license with the American Dental Association for Current Dental Terminology, and is an American Dental Association Evidence-Based Champion. DiGangi's book, "DentalCodeology: Jump Start Diagnostic Coding," is available at DentalCodeology.com.