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2015 EHR deadline 'just around the corner'

As the U.S. Government moves the National Health Information Infrastructure initiative forward, Association leaders continue their push to ensure that when the time comes, all the pieces to create a usable, electronic, clinical record for dentistry are in place. The project, the government says is to be finished within the next six years, requires ADA action on multiple levels.

The Board of Trustees in June 2007 appointed the Electronic Health Record Workgroup and the SNODENT (Systemized Nomenclature of Dentistry) Editorial Panel. These workgroups are enlisting ADA councils, committees, volunteers, staff and dental specialty groups to participate in developing the dental portion of the electronic health record. They work to ensure the unique character of dental practice will be understood in the dental components of the EHR and to maintain as much control for dentists, as government will allow.

This article is intended to serve ADA members as both a refresher and a reminder. "What Will NHII Mean For You?" was published in the Jan. 22, 2007 ADA News and articles about NHII progress, interviews with U.S. Department of Health and Human Services officials and ADA leaders followed. Look to ADA News for future installments of this ongoing, occasional series that will include practical details about how the electronic health record will affect dental practices and how the ADA will help. For more on the electronic health record from the Council on Dental Practice, links to articles and information, visit www.ada.org/goto/ehr.

By 2015—when the National Health Information Infrastructure will be operational—a patient's dental record will no longer travel alone.

Dental records will be included within electronic health records that also include patients' entire medical histories, pharmacy, vision, laboratory tests and all other clinical information. EHRs will travel from health care provider to health care provider on the NHII, a communications system often described as a network of information highways.

Although not widely discussed within the general membership to date, the development of the electronic health record will likely be the most challenging and ultimately defining initiative the ADA deals with in the next 5-10 years. Those working to ensure dentists are prepared say that with only six years left until this dramatic change, 2015 is just around the corner.

Although it was the Bush administration that in 2004 set the goal and timeline for electronic health records for Americans, a fully compatible national health information infrastructure is gathering bipartisan support.

"We can expect a national strategy for managing and communicating patient information as the electronic health record initiative moves forward," says ADA President Mark Feldman. Dr. Feldman also serves on the Electronic Health Record Workgroup. "The ADA will advocate to keep compliance scalable for a small business operation and keep our members informed of what they will need to do to comply."

The federal government's intent is to increase information technology to promote overall quality and cost reduction of the entire health care system. The HHS, under whose purview the NHII falls, defines it as "an initiative set forth to improve the effectiveness, efficiency and overall quality of health and health care in the U.S."

The ADA is currently monitoring and providing input on 11 bills in Congress related to the electronic health record. Most recently, ADA regulatory and legislative staff June 5 attended a stakeholders meeting with the Energy and Commerce Committee to assist in further development of a health information technology bill. That bill would provide a roadmap for how to best integrate the federal government's role in the promotion of HIT, set forth stronger privacy protections and make the Office of the National Coordinator of Health Information Technology within HHS permanent. (ONC was established by President George W. Bush's 2004 executive order promoting the development and implementation of a nationwide health information technology infrastructure.)

The NHII communication system hinges on a comprehensive, longitudinal electronic health record for all patients, of which the ADA has long taken the lead. (The 1996 House of Delegates adopted a resolution to promote free exchange of health information across professional borders.)

Electronic health records for patients have to be consistent, have to speak the same language to get the information across to different types of health care providers. Standards that can make patient information accessible to any health care provider and enable that information to cross practice management and software systems from different vendors are necessary to achieve interoperability.

A working group of the ADA Standards Committee on Dental Informatics developed the standard that creates the interoperability necessary for dentists to communicate information in electronic patient records to all health care providers—American National Standards Institute/ADA Specification No. 1000 Standard Clinical Data Architecture for the Structure and Content of an Electronic Health Record.

"The bottom line in achieving interoperability is that you have to be able to compare apples to apples," explains Dr. Robert Ahlstrom, a practicing dentist who serves on the ADA Standards Committee on Dental Informatics and the Council on Dental Practice, as well as both the EHR Workgroup and the SNODENT Editorial Panel.

The ADA in 2005 established the NHII Task Force to establish the role of the ADA in developing access, content, standards and code vocabularies for dentistry in the electronic health record and said in its report to the 2006 House of Delegates, "in order to make the NHII successful within dentistry, SNODENT must be reviewed, refined and tested." SNODENT—Systemetized Nomenclature of Dentistry—is the vocabulary designed for electronic health and dental records. The NHII Task Force evolved into the EHR Workgroup.

The ADA SNODENT Editorial Panel is charged with updating clinical terminology to make SNODENT interoperable with the rest of the electronic health record. All information captured in the EHR must be codified to ensure interoperability between computer systems. As part of its duties, the EHR Workgroup is monitoring and supervising the activities of the SNODENT Editorial Panel.

There are at least nine different code sets that have been identified that need to be part of an electronic dental record. This will involve the work of most ADA councils, as well as the ADA legal, standards and information technology areas, dental specialty groups and others. As well, the ADA will continue to negotiate for the Association's ability to produce and protect the clinical code sets as its own intellectual property.

"It's a vast and complex project," says ADA 3rd District Trustee William Glecos, chair of the EHR workgroup. "Many groups have important parts to play in the development of the dental portion of the electronic health record and it will take a significant commitment from all those working on the project to get this done."

The ADA Board of Trustees June 9 approved a resolution to go to the 2008 House of Delegates calling for the ADA to sponsor a meeting on EHR development and include the nine nationally recognized specialty organizations, the Academy of General Dentistry and other dental or medical organizations that are stakeholders in the dental portions of the health record.

ADA leaders say dentists will be the ones to establish the importance of oral health as part of overall systemic health and so dentists will define the standards and taxonomies needed to provide the content for dentistry as part of the NHII network.

"Ultimately, and beyond the development of interoperability standards, dentists will be encouraged to acquire the technology necessary to utilize the EHR to share patient information in a secure manner," observes Dr. Robert Faiella, ADA 1st District trustee and a member of the EHR workgroup. "This will allow us to have accurate past medical and dental histories, drug profiles and interaction, laboratory results and improve patient safety." Adds Dr. Faiella, "It will govern not only our access to vital information, but also change how we are reimbursed by third party carriers, and eventually, may impact the resale value of our practices upon retirement based on technological capability."

As the evidence of crossover between medical and dental conditions continues to emerge, ADA advocates for members see the electronic health record as essential in determining treatment and evaluating outcomes. As dentistry moves to a system of medically managing oral disease, dentists may find that electronic health records provide valuable data on their patients' medical conditions, current prescription medicines and potential drug interactions.

For an example, saliva testing is already being used in many states as part of key diagnostics for patient pharmaceutical compliance, substance abuse and disease monitoring. Some electronic patient records include saliva testing and monitoring and plotting of these under the laboratory section of the chart to correlate the results to drug dosages or treatments.

"The initiative demands our attention to the importance of technology in the practice of dentistry within the scope of overall health care," observes Dr. Faiella. "We will likely have an expanded code taxonomy—procedural, diagnostic and administrative—as part of our routine practice in an electronic format."

Those advocating for ADA members are aware that the idea of applying standardized code sets—which include diagnostic coding necessary in order to establish interoperability with existing medical code models—turns many dentists off. But they say the advantages outweigh any disadvantages, particularly because diagnostic coding will be developed by the ADA.

"If there exists a mandate for the development of a diagnostic code set, it is the duty of the ADA to develop that code set, to do whatever it can to ensure that the process and the ultimate code set is as fair-minded, patient protection oriented and as user-friendly as is humanly possible, and employs reasonable safeguards against confusion, misinterpretation and abuse," says Dr. Joseph Hagenbruch. Dr. Hagenbruch serves on the EHR workgroup and the SNODENT Editorial Panel, as well as the Council on Dental Benefit Programs.

To read the full report or the synopsis of The ONC-Coordinated Federal Health IT Strategic Plan: 2008-2012, released June 3, go to the Health Information Technology Section of the HHS Web site at www.hhs.gov/healthit/resources/reports.html.