Electronic health records
At 10 p.m. on a Sunday evening I realized I needed my carpets cleaned for the holidays. Immediately I sat down at my computer and Googled "carpet cleaning."
Patients want the power of information at their fingertips
by Patti DiGangi, RDH, BS
At 10 p.m. on a Sunday evening I realized I needed my carpets cleaned for the holidays. Immediately I sat down at my computer and Googled "carpet cleaning." It was so easy to place my order for an appointment. The carpet cleaning experts received my order electronically; their team showed up on time, cleaned my carpets, and sold me a few add-ons. One of the workers swiped my credit card payment on his handheld device, gave me a receipt, and said, "Wow, just got another job." In the meantime, I scheduled a CE presentation engagement via my cell phone while doing research on evidence-based databases on my laptop.
Yet if I wanted a copy of my dental record, it would require a drive to the practice during office hours to sign a paper form. Eventually my radiographs of so-so quality might be sent to another provider – not given to me. If my dentist wants my medical records, I'd better get started immediately so I might have a few of them in a couple of weeks.
You have probably heard of the relationship between oral health and general health. So do you see anything wrong with this picture? Records must be readily available, not just to other providers but – more importantly – to individuals themselves. Whatever health decisions are made, ultimately each person – not the provider – lives with the consequences. These decisions must be based on the best and most complete information available. Duplication should be unnecessary. What people want is control of their health, including privacy.
Patients have redefined themselves as health-care consumers. Consider how often patients Google every diagnosis they get. The days of blindly "doing what the doctor says" are gone. Health consumerism means information power has shifted and that the record fundamentally belongs to the patient, because he or she is the record.
Some of you are reading this article in a digital format, likely from a mobile device like a cell phone or iPad. No matter what interests you, you likely have an Internet-enabled mobile device nearby so you can look up ... oh, just about anything. Cell phones have become ubiquitous in our society. OK, so what does that word mean? Ubiquitous means existing or being everywhere at the same time; constantly encountered. Now isn't that the truth?! By most estimates, as of December 2009, 91% of American consumers owned a cell phone. So is this article about health-care records available on cell phones? Not quite. Cell phones connect to one another and have fundamentally changed our way of life. Interoperable health-care records will do the same.
Have you ever thought about who created the idea of individual paper records? In 1883, the Mayo brothers, sons of a physician, invited other doctors to join them. Together they pioneered the idea of a multispecialty group practice: the famous Mayo Clinic. By 1901, Dr. Henry Plummer joined and designed the patient registration system and common medical record. Prior to that time, records were kept in a single dated log. Physicians would have to search through the logbook to find each individual patient's information. Dr. Plummer created the first individual charts, which contained all medical information pertaining to each patient. More than 100 years later, we are living with essentially the same system, even though health care itself has changed radically. Care is much more specialized, provided by multiple providers in scattered locations. People are living dramatically longer. Life expectancy in 1900 was 47 years old. As of 2007, according to the Centers for Disease Control and Prevention, average life expectancy was 77.9 years and it is continuing to rise.
We are in a new era of dentistry caring for baby boomers. Starting Jan. 1, 2011, 10,000 people will turn age 65. This will continue every single day for the next 20 years. That is an astounding number. It is no longer appropriate to equate geriatric dental care with denture care. In-office medical emergencies will increase as our population ages. Baby boomers (author included) and certainly those younger expect a different level of care. As professionals, we need complete health information available instantaneously. Electronic health records can deliver this. Similarly, our critical dental records can be at the fingertips of cardiologists, endocrinologists, and other specialists – all to the benefit of our patients.
An initiative to improve the availability of medical information goes back to 1965. This initiative was led by the National Library of Medicine, a part of the National Institutes of Health, U.S. Department of Health and Human Services (HHS). Though the federal government initiated the idea, electronic health records are not affiliated with any political party. In 2004, President Bush signed an executive order establishing a strategy for health information technology (HIT) implementation, which will require all health records to be electronic by 2014. The 2009 American Recovery and Reinvestment Act (ARRA) contains specific laws and incentives that apply to health information technology, specifically referred to as the Health Information Technology for Economic and Clinical Health Act (HITECH.) Have the acronyms confused you yet? See Table 1 for a list of acronyms.
Are you thinking, "No problem; we have computers in our office"? My first question to you then is: are you chartless? Some practices have moved from complete paper records to partial paper records. Some offices are already chartless. I worked in a practice that went chartless in 1991. There's good news and bad news here. Practices without charts are in better shape for the major changes coming. The key goal is interoperability. Even if your office is completely computerized, the background architecture to communicate with physicians, hospitals, labs, pharmacies, and various other health-care providers does not exist. Interoperability is what we have with our cell phones, but don't realize it. One person can have a BlackBerry on the Verizon system and talk to someone with an iPhone on AT&T as well as talk to someone on a landline phone. How does that work? As a clinical hygienist who is not an electronics wizard, it seems like magic. Interoperable means different systems and networks are able to exchange and use information. In September 2009, the American Dental Association signed an agreement with Health Level Seven International (HL7), a leading global authority on health-care information interoperability and standards, to develop consistent dental IT standards in order to enhance coordination between medical and dental offices.
Table 2 shows some of the hoped-for advantages of electronic health records. This potential seems apparent though it is yet to be realized. One of the advantages is to better inform and empower health-care consumers regarding their own personal health information. This is what patients want.
A survey conducted in August 2010 by Zogby International, a watchdog organization for patient privacy rights, showed an overwhelming 97% of the respondents want to control their own private health information. Certainly we will have mountains of electronic information but with vast amounts of personal electronic data come many opportunities for new kinds of variously motivated theft and security breaches. These even have the potential to be orchestrated from continents far away. Uneasiness over the privacy and security of electronic health information falls into two general categories:
- Concerns about inappropriate releases of information from individual organizations.
- Concerns about the systemic flows of information throughout the health-care and related industries. These concerns are real and appropriate.
HIPAA privacy rules provide federal protections for personal health information and give patients an array of rights with respect to that information. The HITECH Act significantly expands the reach of the HIPAA and gives it more bite. As of September 2009, a new rule went into effect. It requires prompt notification of patients when personal health data has been compromised, and it limits the commercial use of such information. The HITECH Act increases civil monetary penalties for HIPAA noncompliance to as much as $50,000 per violation. HITECH authorizes state attorneys general to enforce HIPAA privacy and security requirements.
Where will all the information live? There is no one central collection system or endpoint for the information flow. One of many challenges is that the system is not ruled or developed by one body; it's one with many stakeholders who have different ideas and roles in the process. This could help reassure those worried about privacy.
In her excellent book, "Mouth Matters: Healthy Mouth Healthy Body" (www.mouthmattersbook.com), Carol Vander Stoep, RDH, BSDH, talks about some of the new bywords in dentistry, such as evidence-based decision making (EBDM). The imperatives of EBDM require us to take a fresh look at ideas and practices as science brings new realities. As she so eloquently states, "Unfortunately it does not guarantee change."
Each day, our body of knowledge on the oral-systemic links increases. What are you doing differently based on this new knowledge? Do you even have access to it chairside where it is needed?
Everything seems to be new in dentistry for 20 to 30 years. The old model is based on the long-standing cottage industry model under which most practices still work. EHR will profoundly and permanently change that model. Interoperable electronic health records are the future. This transition is inevitable and on track for 2014.
This quote is from an October 2010 article in the Journal of the American Health Information Management Association (AHIMA) of which I am a member:
"A fully integrated patient record and care model for both systemic health (medical) and oral health (dental) is needed for health information technology (HIT) standards, implementation, and interoperability to avoid discrepancies between records and to support quality of care, safety, and cost-reduction initiatives."
Why would a hygienist want to be a member of this association? To have a seat at the table to discuss a subject that will profoundly affect our future careers. Hygienists have long been seen as auxiliaries, more as tradespeople than as professionals. This, too, is changing. We can sit by and continue to allow others to chart the course of our future, or we can get involved. Your involvement might not come in the same form as mine. Perhaps your involvement is bringing this news to your practice. Perhaps your role will be as the privacy officer (needed per HIPAA) for your practice. Maybe your role is not to fight the future but, rather, to embrace and mold it to help patients get what they want and need.
Table 1 Acronym key
HSS Department of Health and Human Services
ARRA American Recovery and Reinvestment Act
HITECH Health Information Technology for Economic and Clinical Health Act
EHR Electronic Health Record
ADA American Dental Association
HL7 Health Level Seven International
IT Information Technology
HIPAA Health Insurance Portability and Accountability Act
HIT Health Information Technology
AHIMA American Health Information Management Association
EBDM Evidence Based Decision Making
Table 2 Hoped-for advantages of electronic health records
• To improve patient safety (alert for medication errors, drug allergies, etc.)
• To improve health-care quality (includes having the availability of complete medical records, test results, and X-rays at the point of care, integrating health information from multiple sources and providers, incorporating the use of decision support tools with guidelines and research results, etc.)
• For bioterrorism detection (will enable real-time aggregation of health data to detect patterns)
• To better understand health-care costs
• To better inform and empower health-care consumers regarding their own personal health information
Patti DiGangi, RDH, BS, is a vision-driven person finding strength and direction from her inner convictions. Like most true visionaries, she views obstacles as learning experiences that can be used for self-development. As a lifelong learner, her energetic, thought-provoking, and successful program development and mind-bending view of what can be shine a bright light for others to preview the future and find their place in it. She can be contacted through her Web site at www.pdigangi.com.
• Soderlund K. ADA continues work on EHR development. Aug. 10, 2010. Available at: http://www.ada.org/news/4603.aspx.
• Electronic health record: Will federal government require it by 2014? ADA responds. June 21, 2010. Available at: http://www.ada.org/news/4306.aspx.
• Health Level Seven and the American Dental Association Sign Agreement to Develop Joint Healthcare IT Standard Initiatives. Sept. 2, 2009. Available at: http://www.hl7.org/documentcenter/public/pressreleases/HL7_PRESS_20090902.pdf.
• Pully B. Patients Want Control of e-Records. Nov. 22, 1010. Available at: http://healthitupdate.nextgov.com/2010/11/patients_should_own_their_medical_records_survey.php?oref=latest_posts.
• Rudman W, Hart-Hester S, Jones W, Caputo N, Madison M. Integrating Medical and Dental Records: A New Frontier in Health Information Management. AHIMA October 2010. Available at: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048094.hcsp?dDocName=bok1_048094.
• Din FM, Powell V. Call for an Integrated (Medical/Dental) Health Care Model That Optimally Supports Chronic Care, Pediatric Care, and Prenatal Care as a Basis for 21st Century EHR Standards and Products. Pittsburgh, Pa.: Robert Morris University 2009.
• Vander Stoep C. Mouth Matters: Healthy Mouth Healthy Body. IANUA Publishing, Austin, TX, 2010.
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