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Health Information Technology

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What should be considered before adoption of a health IT system for oral health?

  • What health IT functionalities do dentists need?

Before selecting and implementing any health IT system for oral health, some key items need to be considered including: privacy and security, the cost of the system (both upfront when implementing the system and recurring costs associated with upkeep), what functionalities are necessary, and workflow capacity.

Privacy and Security
As more health information becomes available electronically, such as through electronic health records, the issue of privacy and security must be considered. Oral health providers are subject to the privacy and security regulations as detailed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Specifically, two HIPAA regulations – the Privacy Rule and the Security Rule – are applicable when it comes to how oral health providers handle health records. As detailed by the American Dental Association in a 2010 Report on Dental Records, an oral health provider who uses electronic transactions of any type are considered a “covered entity” and must therefore comply by both the Privacy Rule and Security Rule. The Security Rule relates specifically to electronic personal health information (ePHI), and requires any dentist using an electronic health record or who stores health information electronically maintain its “confidentiality, integrity, and accessibility.”

A 2003 article from the Journal of the American Dental Association Exit Disclaimer provides an excellent resource on what specific security measures need to be addressed as oral health providers manage electronic health information. Additionally, for those oral health providers who are considered a “covered entity” under HIPAA, extensive information on Privacy and Security considerations when implementing electronic health records is available in the Privacy and Security section of HRSA’s Health IT Implementation Toolbox.

Cost
As discussed in the Pediatric Oral Health and Health IT module, the evaluation of expected costs is crucial in determining whether or not providers can adopt health IT into their clinics and offices, and is often one of the strongest and most common barriers. A 2010 report from the California HealthCare Foundation Exit Disclaimer explored the literature for barriers to EHR adoption.  Barriers reported include cost, burden of added work, and reimbursement difficulties, among others. Other potential upfront costs include hardware and software, staff training, initial productivity loss as users adapt to a new system, labor hours to transfer paper records into the system, and outside consulting services. Common recurring costs stem from upgrades to hardware and software, maintenance, and licensing fees.  Return on Investment (ROI) is another concern for providers, and can vary across different types of dental practices and be particularly difficult to measure.  A 2008 study in the Journal of Dental Education Exit Disclaimer determined that for the electronic patient record used by the dental care site studied, “The payback of the initial investment was a mere 2.5 years.”  These challenges may be more profound for dentists practicing in safety net clinics.  A 2008 report from Murchinson and colleagues Exit Disclaimer notes that purchasing and implementation expenses were the biggest barriers to EHR adoption among safety net providers.

A 2008 report from the Congressional Budget Office also discusses the expected benefits and costs associated with the adoption of health IT. Cost savings, for example those related to reduction in cost of care or due to avoiding repeating tests unnecessarily, are often highlighted as one of the expected benefits of health IT adoption. Others include increased efficiency with respect to delivery of care, facilitating health information exchange between dentists and other providers, and improvement in the overall quality of care, among many others. As previously discussed, health IT systems may improve care coordination for referrals within dentistry and between medical and dental care. Health IT also offers an avenue for dentists to reach out to medical care providers to provide patients with a more comprehensive approach to care. There is general consensus that there are common risk factors for many dental and medical problems, suggesting that a more holistic approach to care might be more effective.

Functionality
In many ways, the field of dentistry was in the forefront of the movement towards technology in health and the computerization of health records. As early as the late-1960s and through the 1970s, computers made their way into the dentist’s office. Many early systems were simply the result of oral health providers developing ways to better run their offices with systems developed on their personal computers, according to a 2005 article by Hamilton from the Journal of the American Dental Association (JADA). Exit Disclaimer Another article Exit Disclaimer from 2000 by Delrose and Steinberg notes that by the 1980s, computers were mainly tools for practice management systems. Electronic practice management systems are used by providers to assist in tasks such as patient registration, accounting, or billing.

A 2003 article by Schleyer and colleagues in the Journal of the American Dental Association (JADA) Exit Disclaimer identified important functionalities of a dental computer-based patient record include access to images, electronic creation of charts, medical alerts and histories, ADA codes for billing, patient lookup and identification capabilities, and treatment planning tools. This article examined clinical and administrative functions of EHRs, classifying functions as “must-have”, “nice-to-have”, or “optional” for dentists. Those functions identified as “must-have” include:

  • Collection of medical and dental health status for each patient;
  • Medical alerts; and
  • Recording planned and completed procedures.

Those functions identified as “nice to have” include:

  • The ability to track patient care and progress through a variety of indicators such as medical/dental history, signs and symptoms, diagnoses and outcomes;
  • Graphical documentation of missing teeth, fillings, and other indications or oral health status; and
  • The capability to capture, store, display and analyze digital images from a variety of sources.

Although not specifically identified in the article, it is also important to consider interoperability when oral health providers are selecting an electronic health record system. A product that is not certified for Meaningful Use may not be able to exchange health information with all electronic health records.

Workflow
Usability of health IT is often cited as a concern for dentists including difficulties with implementing health IT and the loss of time and productivity. The potential for such consequences often dissuades dentists because they rely on maintaining a volume of patients to ensure financial sustainability. According to a 2006 article Exit Disclaimer from Schleyer and colleagues, clinical computing has been adopted in dental offices to improve workflow and increase efficiencies in operations. However, the article recognized the need to conduct future research regarding the role of workflow support in successfully adopting health IT in dental offices.

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