By Ann-Marie C. DePalma, RDH, MEd, FADIA, FAADH
The majority of today's patients are digitally connected in various areas of their lives. Over the past several years, dentistry has been moving at varying speeds into the digital arena. From digital radiography to chartless practices, the hygienist of today must be comfortable with using technology in its varying forms.
How did we get to this point? In 2010, the American Reinvestment and Recovery Act (the Stimulus Act or ARRA) was signed into law by President Barack Obama. In addition to financial incentives for construction projects, schools, and childcare, there was a portion of the law that dealt with computerization of health records: the Health Information Technology for Economic and Clinical Health (HITECH) Act. This investment was the foundation for the Patient Protection and Affordable Care Act (ACA).
In the ACA, medical practices were mandated to computerize all of their patient information and record keeping. However, most (but not all) dental practices are not subject to the regulations at present. Several states are also mandating aspects of electronic records into dentistry. In January 2015, Minnesota required general dentists, orthodontists, and oral surgeons to maintain an electronic dental record. The state of New York was set to begin requiring electronic transmission of prescriptions in March 2015; however, this has been postponed until 2016. In other states, insurance companies provide lower reimbursements if a paper claim is submitted rather than an electronic claim!
To assist patients in achieving their health goals and to improve efficiency, communication, and profitability, many dental teams have moved to the digital platform. Practice management software, digital radiography, and CAD/CAM dentistry have enhanced the patient experience. Patients have come to expect their dental practice to be current in the latest technologies. Practices and teams that are not technology-savvy are being left behind. Even so, the transition in moving from paper charts to chartless practice often can be difficult for teams. This article will review some steps that make that transition less stressful.
Dentistry may or may not be paperless-you still have papers when you visit your primary care provider-but we will become chartless. What are the differences between chartless and paperless? A paperless practice is one in which all operations are conducted electronically, while a practice that scans and shreds documents is considered a chartless practice. Charts are the records of the patients' information and can be digitized based on the practice's chosen management software. Each dental practice management software program is different, but in general there are steps to improve the overall integration of the program into the daily hygiene routine.
Establish a chartless practice
First, the entire team must understand the goals behind moving to a chartless practice. How does this move benefit your patients and the practice, both as a whole and individually as team members? During this discussion, any fears or objections must be voiced and discussed. If there is someone on the team who is apprehensive about the move, his or her concerns need to be addressed. This communication process provides the team with the understanding that the move to digital is not going to change how one practices dentistry or dental hygiene, but rather how data is entered and stored only. Being chartless means no more lost or misfiled charts and easy access to patient information at any time with the information recorded in clear and concise manner for all to understand. With this transition, however, security and HIPAA take on a much larger role.
There are numerous regulations surrounding patient data and the team needs to understand the implications of these regulations. There are various CE programs that provide this information for practices.
Many dental teams fail to properly prepare for the transition and often go about it haphazardly. This sets the team and practice up for failure, frustration, and anger. Asking these questions and creating a viable transition process plan diminish this. A good process plan will include:
• A review of current protocols/systems in the paper chart.
• Development of how these protocols and systems will appear in the digital record, including how the team will handle patient registrations/medical histories, HIPAA, insurance information, patient identification, account information, treatment plans/informed consent, clinical notes, radiographs, lab slips, prescriptions, referrals, and reports.
• Determining how paper charts will be handled, i.e., when they will be retired and where they will be stored in compliance with legal and state board requirements. How will the team know that a digital record has been created?
• Deciding on a D-Day (Digital Day) when no information will be entered into paper charts and sticking to it!
The practice can create spreadsheets to track information for: (1) both new and existing patient records including specific areas of the chart (e.g., medical history, patient registration, HIPAA forms), (2) where it exists in both paper and computer, (3) who is responsible for entering information both on paper and in computer (e.g., business team, assistants, hygienists, doctors), and (4) any pertinent notes. These spreadsheets can be used to ensure that each patient's information is converted from paper to computer and serve as documentation of the transfer process. When determining how to retire the paper chart itself, the practice should also create a system of what to do with the existing documentation. The practice needs to ask if the information is relevant to the patient. If it is relevant (e.g., radiographs), the information can be scanned into the system and then retired. If not relevant (e.g., lab slips for work that has been previously seated), then it can be retired and stored or shredded as appropriate. Each practice will need to determine which materials are relevant and which are not based on individual practice needs and state regulations; however, all of the paper information does not need to be included in the computer chart.
The importance of training
Since each practice will use different types of practice management software and digital radiography, it is difficult to provide specifics within the scope of this article. Thus, training is essential to any successful transition to a chartless practice. Depending on the software vendor, in-office, online, or phone training is available. In my experience, practices that fail to use the software vendor's training services often experience less successful transitions.
The team often ends up "surviving" in the software rather than using it to the fullest potential to benefit the practice and patients. Making the investment in time and money for appropriate training empowers the team with the skills and knowledge to grow and protect the practice through technology. With that stated, a few generalized guidelines can be utilized.
Hygienists need to have a basic understanding of the individual software program and their expectations within the practice. Some practices allow hygienists to schedule appointments from the hygiene operatory, and others do not. It is generally recommended that the patient's next recare appointment be scheduled at the time of the present appointment; therefore the hygienist needs to be familiar with the scheduling process. Additionally, the practice must determine if the hygienist will be posting treatment to the account and/or making future restorative appointments. Each practice must decide these questions individually and from there make the appropriate recommendations and provide training.
Computerized clinical chart notes are legal documentation similar to what is written in the paper chart. Software programs have the ability to filter any deleted or edited notes. This information can be documented and tracked, depending on when the note is finalized. Similar to error correction in the written format, each program will do these deletions and edits differently; who can edit and delete these notes is a security issue.
Any information that is nonclinical in nature (e.g., patient interests, recent trips, family information) should not be included in the clinical note area. This information is important and helps build the patient relationship, but is not pertinent to the clinical information and should be noted elsewhere in the digital chart.
For example, Eaglesoft has a memo field for such information that can be edited or deleted with no tracking. As dentistry moves toward coding systems, it will become more important to document fully in the patient's clinical chart notes since the digital chart will be an essential component. If the practice will be using a visual, virtual clinical or periodontal chart, the software needs to be configured to the appropriate settings. Depending on the software, these settings may be global (established on one computer for all networked computers) or workstation specific (established on one computer but not affecting other computers).
How's the infrastructure?
Does the practice have the infrastructure in place to accomplish tasks needed for digital dentistry? In order for a smooth transition from paper charts, the following are some of the questions that need to be addressed:
• Does the practice have computers in all operatories, business areas, and doctors' offices? Is there a plan to purchase needed technology and equipment? Will this be done in phases or all at once? Is there reliable Internet within the practice?
• Will digital radiography be used? If so, what type? Are radiology units equipped to handle digital imaging? Will intraoral cameras be used on every patient, every time?
• Will clinical treatment notes be kept in the computer? How will insurance claims be processed?
• Does the office have a scanner?
• Will the office be using Smart Doc/Document Center for all documents?
• Will digital signatures be required from patients? Does the office have signature pads or tablets?
• Is there a solid backup protocol that is validated regularly?
• Does the team have the motivation to be chartless?
• Is there a plan for where, how, and by whom information will be recorded and who will be responsible and accountable?
• Is there a transition process plan in place?
Other areas of the software that are important for the hygienist include imaging, patient education, and recare scheduling. Will digital imaging be used in the practice, and if so, how does it integrate with the clinical chart? How are images taken, enhanced, and stored? If intraoral cameras are used, how will images be integrated into the chart? Are patient education materials available within the software? In handling recare scheduling, does the software search for a variety of patient criteria such as patients with appointments, patients without appointments, patients not seen within a stated time frame?
Can the recare notice be sent to the patient in a variety of formats (e.g., postcard, email, text)? Most dental practice management software will have the ability to email; however, the email may not be encrypted. HIPAA regulations govern emails containing protected health information and the practice should investigate current regulations and how the software performs this function.
With the digital chartless practice, numerous avenues are available to engage patients and have them become more involved in their own health. Patient education multimedia presentations such as CAESY can be utilized throughout the practice, whether chairside, during consultations, or in the reception area. Providing confirmation messages via phone, text, or email affords the practice better team member efficiency while meeting the patients' communication needs. Services such as RevenueWell or Patient Activator offer the ability to engage patients with marketing materials, birthday and holiday greetings, digital postop instructions, appointment scheduling and confirmations, patient education videos via email, and online patient portal that includes bill paying. These may be integrated into the patient's digital record depending on the software.
The chartless practice will also have the ability to track information more effectively and efficiently. Depending on the software, it can be simple to obtain practice and provider metrics with a digital record. Dentistry today is not only about treating patients but also about being a business, and these metrics provide critical information for the team. Additionally, as the mobile world is expanding, the ability to retrieve patient information while away from the practice is also an important consideration of the chartless practice.
Moving from a paper chart to a digital chart can present the practice and team with daunting challenges. But having a plan in place to address these challenges so that the team can embrace digital technology, improve workflow processes, and enhance the diagnostic, restorative, or surgical procedures will improve the overall patient experience and provide the team and practice with satisfaction and growth opportunities. RDH
Author disclosure: Ann-Marie C. DePalma is a technology advisor for Patterson Dental. She did not receive any compensation from Patterson for this article.
ANN-MARIE C. DEPALMA, RDH, MEd, FADIA, FAADH, is a Fellow of the American Academy of Dental Hygiene and the Association of Dental Implant Auxiliaries, as well as a continuous member of ADHA. She presents continuing education programs for dental team members on a variety of topics. Ann-Marie is collaborating with several authors on various books for dental hygiene and can be reached at [email protected].