Electronic medical record and its implications for orthodontists

The year is 2014. Your receptionist, Mary, greets a potential transfer patient, Terry Smith, in your front office. Mary scans Mrs Smith’s driver’s license and then hands her a tablet computer so that she can sign in. Mary asks Mrs Smith whether her archived electronic health record (EHR) is up to date. Mrs Smith is not sure, because she just left the general dentist’s office down the street, but she does have the electronic dental record (EDR) data in her cell phone—it was uploaded for her before she left that office. Mrs Smith logs into a special secure office wireless connection so that she can transfer this new information. In the meantime, Mary downloads Mrs Smith’s archived EHR to the office’s cloud-based software; the EHR is kept on file on secure government servers, and Mary can access it only after Mrs Smith has entered her password.

Mrs Smith is then asked about financial arrangements, and she provides her insurance card; Mary scans it, while Mrs. Smith again uses the tablet computer to enter her password for her insurance.

Mrs Smith is then escorted into the clinic by an orthodontic assistant, who signs into the chair-side computer and pulls up Mrs Smith’s EHR and EDR, splitting the computer screen so that both can be viewed as desired. She asks Mrs Smith whether she is having any problems with her appliances at this time and what her current concerns are; the responses are entered into the computer via voice-recognition software.

You select chair 5 on your secure tablet computer and pull up the EHR and the EDR. You note that the patient just came from Dr Kelly’s office down the street, where they performed an examination and prophylaxis, and took bitewing radiographs, which you review. Per Dr Kelly’s notes, the patient has some pocketing around her mandibular molars, and he is concerned enough that he has scheduled her back for scaling and root planing, and has suggested removing the orthodontic bands until the periodontal condition resolves. You also note that he prescribed chlorhexidine and tetracycline.

Next, you pull up the radiographs taken by Mrs Smith’s previous general dentist and orthodontist. After examining them, you agree with Dr Kelly’s assessment and further note that Mrs Smith has not had an examination or cleaning in the previous 2 years and has not seen her previous orthodontist in the last 5 months. You further note that the appliances are Roth prescription, 0.022-in slot, from Tolstoy Orthodontics, the current archwires are 0.018-in nickel-titanium from US General Wire Company, and she has 2 temporary anchorage devices (serial numbers, TO-00012345 and TO-00012346) that were placed 9 months ago.

Now, with all this information at your fingertips, you arrive at the chair and introduce yourself to Mrs Smith. You pull up the bitewings on the tablet computer Mrs Smith is holding and review Dr Kelly’s notes and suggestions. Displaying the original orthodontist’s treatment plan on the tablet computer, you review approximately where her previous orthodontist thought she was in her treatment when last seen 5 months ago. You proceed with your own clinical examination and order a new cone-beam computed tomograph (CBCT), localized to the mandibular molar area, to better assess the treatment progress to date and evaluate any bone loss in this area.

Before you leave Mrs Smith, she asks how much she will have to pay for the new records. You pass this query electronically to Mary, who accesses Mrs Smith’s insurance file and relays the appropriate insurance section and coverages back to the tablet computer Mrs Smith is holding, showing that her insurance authorizes coverage of the procedure at 80% up to a maximum of $100, leaving Mrs Smith with a charge of $20 today. After the CBCT is obtained, the assistant notes that you requested her to please compare the new CBCT with her original one. The assistant pulls up the original image, which is compatible with digital imaging and communications in medicine (DICOM), into your image analysis software, which recognizes the date, type of machine, parameters, and so on from this pretreatment scan and then loads it and displays your doctor-specified volumetric analysis.

A message on your tablet alerts you to return to chair 5 to view the image comparison. Upon displaying this image on Mrs Smith’s tablet, you explain how you believe the treatment has progressed to date. You also show her where some bone loss has occurred around her molars, which is Dr Kelly’s concern, and explain that, on checking Mrs Smith’s medical record, you noted that she was recently diagnosed with diabetes, which might have accentuated her periodontal problems before it was under control. Reviewing the laboratory results of her last visit to her internal medicine physician, you see that her diabetes is now well controlled, so that her periodontal condition should improve with proper oral care. You then lay out what you think Mrs Smith’s further orthodontic treatment will entail and tell her that, if she wants to be treated here, she can begin today, but regardless she should consider removing the mandibular orthodontic bands as recommended by Dr Kelly. The assistant is recording, with the voice-recognition software, everything you say into the clinical notes and also Mrs Smith’s questions and comments.

Mrs Smith indicates that she is interested in treatment but needs to know the costs. A quick note is sent to Mary with your treatment estimate; she accesses Mrs Smith’s insurance again and quickly sends back the patient’s financial responsibilities and the office’s payment options and plans to Mrs Smith’s tablet. Mrs Smith indicates that option 1 is acceptable, selects it on the tablet, and scans her credit card into the tablet scanner, whereupon the office’s policies and consent form are displayed. Mrs Smith reads these and digitally signs the forms.

Your assistant removes the mandibular bands and cement and follows your other directions, documenting these into the computer and her EDR via voice recognition as she works. Once finished, she reviews the clinical note, electronically signs it, and says “Goodbye!” to Mrs Smith. Mrs Smith checks out with Mary, who has already sent her an electronic confirmation and receipt for her credit card payment, as well as electronic copies of the office policies and consent that she signed. Mary then asks whether Mrs Smith would like a download of her updated EDR from the day’s visit herself and also whether she would like a copy sent to Dr Kelly. Mrs Smith electronically approves the transfer to Dr Kelly on the tablet, signs out of it, and returns it to Mary. Mary tells her that, if she would like to, Mrs. Smith can use her smart phone next time rather than an office tablet and gives her the web address to download the office’s smart phone app. All this occurs while Mary has been downloading Mrs Smith’s updated EDR into her smart phone. Mary then inquires about Mrs Smith’s return visit and states that the office also has an app that will automatically search Mrs Smith’s home and work calendars for potential open times and dates, cross-matched with Mrs Smith’s preferred days and times. Mrs. Smith opines that would be wonderful and downloads it on the spot, while still connected to the office’s secure Wi-Fi. At the end of the day, you review Mrs Smith’s notes and make any necessary corrections or additions; these are electronically added her to EDR, which is 1 part of her EHR, and the updated information is uploaded to the national database with all your other patients’ EDR updates for that day.

Reading through this scenario, some of you might find it fanciful; some perhaps believe it is just wishful thinking on my part (especially the part about the appointment app), but much of it has been mandated by the federal government to take effect by 2015. The American Dental Association, with input from our organization and others, is working hard to standardize all dental records so that they can be put into a standardized digital form that can be accessed by any certified EHR or EDR software program. This includes clinical notes, photographs, radiographs (of all kinds), laboratory prescriptions, pharmaceutical prescriptions, and so on as part of a universal electronic health record currently mandated to be on file for every American citizen by 2015. We shall see whether this aggressive timeline is kept and can be met, but it is surely coming.

Perhaps the scenario above will allow you to appreciate some of the benefits this technology can provide to us, as medical and dental providers, but also as patients ourselves. The ability of this technology to flag such things as potentially dangerous drug interactions, allergies, limiting medical conditions, and so on in nearly real time is the technological promised land. Of course, there will be many trials and tribulations in implementing this technology, and the federal government has recognized at least the potential costs of doing so by authorizing up to $40,000 per qualifying “professional” (including dental professionals) for implementation of the meaningful use of this new technology. The definition of meaningful use—ie, who the qualifying professionals will be and the exact means of dispensation of these funds—is still under review. Many changes are coming in this particular area of our practices, so please stay tuned for further articles and updates as they present themselves. As your American Dental Association Standards Committee on Dental Informatics and DICOM representative, I welcome your comments and suggestions.

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Apr 13, 2017 | Posted by in Orthodontics | Comments Off on Electronic medical record and its implications for orthodontists
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