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Managing a dental practice with conventional processes and approaches is no longer effective in the digital age. All areas of practice are affected by the shift to digital—patient care, education, and treatment planning; financial and patient records; and marketing.
To use these components effectively now and in the future, dentists need to understand how and why electronic health records (EHR) were developed, as well as the benefits and challenges; they need to use digital processes to improve workflow and otherwise operate a more efficient practice; and they must understand how to convert the power of the Internet into new patients—patients who understand and accept recommended treatment, and satisfied patients who make referrals.
Electronic Health Records
Many questions surround introducing EHR into dentistry. Mostly, dentists want to know the when, where, how, and why to make the introduction and conversion from traditional paper charts.
The use of EHR began with a 1965 initiative by the National Library of Medicine in an attempt to make biomedical information available to healthcare providers. The modern definition was established by the Institute of Medicine as the following: “health record information on an individual that conforms to nationally recognized interoperability standards and create, manage, and consult by authorized clinicians and staff across more than one healthcare organization.”1
Key to this was the concept of interoperability—established by International Association for Electronic and Electrical Engineers—and defined as: “the ability of two systems to exchange information, and to use the information that has been exchanged.”2 All providers would be able to share accurate information rather than having a patient complete a medical history at each provider’s office (Figure 1).
However, between the limitations of technology through the 1990s and the reluctance on the part of doctors and community-based resources to collaborate—ie, share biomedical information—those efforts have faltered despite obvious advantages, including:
Then, in November 2001, the National Committee on Vital and Health Statistics called for building the National Health Information Infrastructure (NHII), so that all providers could share patient data more efficiently using regional networks that interact and have secure gateways to allow an information exchange.3
This was followed in 2004 by a presidential executive order for all medical providers to have EHR in place by 2014.4 Although the initial focus was on medicine, in April 2005 the American Dental Association (ADA) recognized the need for dentistry to be involved. However, because dental needs were different—laboratory codes, for example—the ADA NHII Task Force was established—an interdisciplinary project not only for the ADA, but with medicine and other healthcare providers to recommend a strategic direction and help set ADA policy.
The ADA, under the ADA Electronic Health Record Workgroup, created six advisory groups to coordinate work with various ADA agencies dedicated to the areas of standards, vocabulary, member, advocacy, certification, and information exchange.
The ADA and dentistry has been working with specialty organizations on these standards, and an internationally recognized dental terminology, the Systematized Nomenclature of Dentistry (SNODENT®), has been developed for capturing detailed clinical data in a coded structure.5 Further, quality measures are being created in conjunction with the Centers for Medicare and Medicaid Services through the formation of the Dental Quality Alliance,6 and the ADA is also working proactively with the Office of the National Coordinator for Health Information Technology to ensure dentistry is represented.7 Because the ADA is also working with the certification commission that validates appliance systems, dentists who buy these systems can be assured that they will work with all the standards in place at that time.
Although this process is ongoing, the profession is now closer to the end than the beginning. With these efforts, dentists can hope to have a better understanding of what is involved in putting an EHR system into place in their offices.
Where the Electronic Health Record Comes In
As collaboration and coordination of care requires communication, an EHR must facilitate communication between all members of the treatment team. The use of written informed consent has become the standard of care in oral surgery; however, it is also the standard among all performed surgical procedures with associated risks.
Reasons to Convert
The Centers for Medicare & Medicaid Services (CMS) have given physicians, hospitals, and other healthcare providers clear financial incentives to converting to EHR through “meaningful use,” based on a specific set of objectives that these eligible professionals and hospitals must meet to qualify.8 CMS projects that by 2019, 80% of primary care physicians in large group practices could achieve meaningful use.9 In contrast, only about 14% solo dentists in the United States are using EHR, according to a study published in the January 2013 issue of the Journal of the American Dental Association.10 However, Medicare covers only a miniscule percentage of dental procedures, therefore the financial incentive provided by meaningful use does not exist for dental healthcare providers to the extent that it does for medical healthcare providers.
Even lacking the financial incentive to convert to an EHR system, dentists have much to gain in terms of providing better patient care, obtaining more efficient recordkeeping, and even reducing the risk for lawsuits by selecting and implementing an EHR system that uniquely meets their practice needs. The switch should come especially naturally to dentists in the Millennial generation, who are much more comfortable with technology than those in previous generations.
Among the reasons EHR are better than paper (Figure 4):
Standardization of procedures.
Improved risk management; better records provide enhanced quality of care and documentation, thus helping to provide a shield against frivolous lawsuits.
Choosing the Right System
In general, the selected EHR system selected should follow the office workflow, which makes it more intuitive for the staff, and use a standardized vocabulary—ie, SNODENT—and current dental terminology (CDT®) codes. Terminology should be synchronized between the billing system and dental practice’s clinical records (Figure 5 and Figure 6). The system should also contain information on the efficacy of certain procedures and how effective they are in treating particular dental conditions.
The staff should be involved in the choice of system and all aspects of conversion. This might start with a discussion of issues in the office, which will aid “buy in”—especially when staff members are aware of how the system can improve their own efficiency and chart management.
Several recommended companies should be contacted and asked for a web demonstration of their products, focusing on how their specific applications function to solve the problems previously identified by the dental team.
Questions to Ask How the Software is Offered
Is it by subscription? Is it by license? If so, what is it based on—number of doctors, staff members, computers? Is it in a cloud, or is it a network application?
Other Costs That May Be Involved
Is training an additional cost? Is there an annual subscription for updates; if so, what does that subscription cost?
Most practices still operate in an environment with a local server-based network with workstations at all dental chairs.
Determine how the training will be provided. The worst and most expensive way to receive training is to have a trainer travel cross-country for several days and lose a day from practice production. The training should be accessible 24/7, and the dentist and staff should be able to determine when it will occur. A typical scenario is for the software company to offer training videos about the functionality of each of their applications.
After System Selection
After questions have been answered and a system that is compatible with the company’s equipment has been selected, installation and training must be scheduled.
Guidelines for Training
The training period is similar to planning for a play. First the cast members receive the script—in this case, the staff receiving the training videos. Then comes the rehearsal, which culminates in the first live performance. Each person in the practice needs to view these videos but in a specific sequence to facilitate learning—first the dentist, then the practice manager, and then the staff members. A respected staff member—perhaps the practice manager or hygienist—should be identified as “the champion” of the project, to be the one to field the staff’s questions and to interact with the training support group from the software company. This person will generally manage the project and facilitate learning.
During the “rehearsal,” at the end of the training afternoon, the staff members attempt to enact what they have been learning—eg, entering the notes for a procedure on which they just assisted.
A practice needs approximately 1 month of this rehearsal. As for “going live,” that first performance should be scheduled for a relatively light day, with time to catch up at midmorning and midafternoon.
This process described may seem overwhelming, but practices that have used it have found it feasible and successful. It helps for staff to know they are using a process that is known to work. Best of all, it will improve their ability to perform their jobs and to provide better patient care.
Internet Media and the Dental Practice
Dentists who enter private practice need to recognize that the dental office is first and foremost a business that will fail if it is not operated properly—regardless of the clinician’s talent and ability for dentistry. In truth, many outstanding clinicians with inadequate business skills struggle, while those with lesser professional skills thrive because they have excellent business skills—eg, patient relations and marketing skills.
An important aspect of marketing a practice includes the use of Internet media and advertising. If implemented properly, Internet media can significantly help the practice. However, a haphazard approach can lead to lost time and money for a practice.
What Consultants Can and Cannot Do
Many dentists hire consultants to help them understand online marketing and create effective ways of using the Internet to build their practices. Consultants typically sell new clients on the idea of search engine optimization (SEO), a technique that generates organic search results, which are free, as opposed to pay-per-click (PPC) advertisements, which can cost anywhere from $10 to $20 per click.
However, to obtain those organic results, it is necessary to appear on the first page of search results. A reputable Internet media company will disclose that it often takes at least a year to achieve this. Consultants are also likely to suggest adding Facebook and Twitter campaigns, followed by a YouTube effort. They may offer to manage these programs for the practitioner for a small fee.
The fees and costs for running these campaigns can range from $6,000 to $10,000 per month. For those willing to wait a year for first-page search results, the outcomes are often palpable. The dental practice that started on page six of a search result prior to working with consultants is often on page one after the year of SEO work. In addition, the practice may now have thousands of Twitter followers and an active Facebook page. The consultants will note these gains and say that it is now time to renew the contract for another year. After being shown such progressive results, many dentists may be tempted to renew their contracts.
However, having such impressive results does not necessarily translate into more patients; this is simply a means of driving users to the practice’s website. The next challenge is converting these hits and site visits into scheduled appointments. Spending thousands in SEO and PPC advertising dollars to attract users to a practice’s website only to have them leave after 10 seconds is a loss of investment.
Unfortunately, this scenario happens all too frequently. Clinicians who hire consultants for Internet advertising should understand the limitations. Consultants, for example, cannot explain a procedure in the same manner as a clinician. All too often, consultants use a prewritten generic copy of a procedure, which, in some cases, may not match the clinician’s philosophy and treatment approach. This is often confusing to patients who may read the clinician’s website only to hear the same dentist contradict the website content. Therefore, clinicians must ensure the quality and accuracy of the content and monitor updates that are made.
Issues and Insights
A typical mistake many dentists make is to drive the user to the practice’s homepage, which may cause an unintentional effect. The home page is like a train station from which the user can visit many other places on the website. The problem is that the home page typically has very little detailed information and numerous links, which overwhelm the user experience. This often results in what is known as a “bounce”—the searcher who clicks on the home page quickly clicks away from the site. Some websites can have bounce rates as high as 95% if the design and content are not strategically thought out.
A more ideal approach is to link the online advertisement to a page that matches the prospective patient’s search with the practice’s service. For example, if the practice’s online advertisement focuses on dental implants, the page linked to this advertisement must focus solely on dental implants. Not only will this reduce bounce rates, it will also increase the advertisement’s effectiveness rating with search engines such as Google.
If the site is being professionally managed, the clinician can request analytics, which would provide information on the length of visits and which pages are viewed. With these data, the clinician can focus efforts on pages that resonate with patients while eliminating or improving pages that have low hits. Having too many links on a website may confuse and overwhelm patients and cause them to miss the important marketing messages.
After the landing page, the page patients view the most is the “About the Doctor” page, which should include a relatively recent picture and information about the clinician’s training, experience, and unique skills. The prospective patient cares about what the dentist can do for him or her, not the clinician’s hobbies and interests. Another important aspect to promote is how the clinician is different. Patients expect specialists to have board certifications. However, the clinician can stand apart from the competition with lists of published articles, lectures, and other activities that suggest expertise and leadership. Typically, the published author who lectures several times a year may get more attention from prospective patients.
The website should show before-and-after pictures of procedures with clear explanations, so patients can understand how a given treatment (eg, crown lengthening) can help them. Both the images and descriptions should be of the clinician’s actual cases. Some clinicians populate their websites with stock photographs and procedure descriptions provided by the website hosting company. This practice should be avoided because patients may perceive this as misleading and unethical.
Another way to set a practice apart is by having positive online reviews. Many practices ask their patients to post reviews on sites such as Yelp. However, some caveats should be kept in mind. While having many positive reviews on Yelp is a quick way to reach a large demographic, this tactic is not without its limitations. One problem is that many first-time users have their reviews flagged as “fraudulent” by the system’s automated software. This often frustrates users and ultimately may discourage them from writing reviews. Furthermore, because so many dentists on Yelp have 5-star reviews, the practitioner may find it is often easy to get lost in the crowd.
Embracing the digital world is vital for the dental practitioner who wants to build a strong, viable practice. By approaching this world with confidence, the clinician can charter a successful future. The ongoing shift to digital technology will continue to impact every aspect of the dental practice—from patient care and education; treatment planning; financial and patient records; and even practice management and marketing.
Dr. Rhodes owns and operates a company that develops clinical records for dentistry, including that described in his presentation. Drs. Faiella and Holtzclaw have no financial relationships to disclosure relative to this presentation or the resulting article in this supplement.
About the Authors
Robert A. Faiella, DMD, MMSc
Dan Holtzclaw, DDS, MS
Paul Rhodes, DDS, MSD
Developer and Consultant
San Francisco, California
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4. Promoting Innovation and Competitiveness: President Bush’s Technology Agenda [White House press release]. Washington, DC. April 26, 2004. http://georgewbush-whitehouse.archives.gov/infocus/technology/.
- Having patient data available at the point of care.
- Having all data in a single location, affording improved provider efficiency.
- Eliminating legibility issues with paper charts.
- Providing an improved quality of care due to better understanding about the patient’s needs and diagnosis.
- Increasing patient engagement due to the ability to transfer that information and giving the clinician the ability to explain what their needs are and have increased involvement in the provision of care to the patient.
- Improved workflow in the office.
- Privacy and security risks, primarily through unauthorized access to personal identify and health information.
- Data breach violations under HIPAA.
- The need to secure the data to prevent identity theft from both personal and financial perspectives.
- Possible compliance audits in the event of a breach requiring offices to follow certain reporting guidelines and meeting security requirements for maintaining or transmitting personal health information.
- EHR are legible; fewer errors occur with electronic notes than with handwritten information.
- EHR are portable.
- EHR are accessible; the clinician can back up patient data and access them electronically from a remote location if necessary.
- Backups can be performed routinely for disaster recovery, EHR are more secure.
- Multiple users can work within an EHR simultaneously.
- Fewer prescription errors occur due to e-prescribing; information about prescriptions fulfilled at US pharmacies is easier to access through EHR.
- Fewer errors occur due to drug-to-drug interaction information that is especially valuable when rendering care to patients taking multiple medications.
- More efficient sharing of clinical information; records using a standardized glossary or terminology, ie, SNODENT, facilitate clear communication with all staff members as well as collaborating specialists and laboratories.
- Better organization and more detailed chart notes make it easy to create and track a highly detailed treatment plan organized by phases, appointments, and procedures, as well as “graying out” the completed steps, so that the clinician can assess its progress at a glance.
- Improved patient confidence and acceptance of recommended treatment due to improved ability to present information clearly.
- Accessed October 27, 2015.
5. American Dental Association, Standards Committee on Dental Informatics. http://www.ada.org/en/member-center/member-benefits/practice-resources/dental-informatics/snodent. Accessed October 27, 2015.
6. Dental Quality Alliance. Joint Effort of the American Dental Association and the Centers for Medicare and Medicaid Services, US Department of Health and Human Services. http://www.ada.org/en/science-research/dental-quality-alliance/about-dqa#orgs. Achttp://www.ada.org/en/science-research/dental-quality-alliance/about-dqa#orgscessed October 27, 2015.
7. US Department of Health & Human Services. Office of the National Coordinator for Health Information Technology (ONC) Federal Health IT Strategic Plan: 2008-2012. Washington, DC; June 2008. http://patientprivacyrights.org/wp-content/uploads/2013/08/HITStrategicPlan08.pdf. Accessed October 27, 2015.
8. Centers for Medicare & Medicaid Services. EHR Incentives & Certification: Meaningful Use Definition & Objectives. https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives. Accessed October 27, 2015.
9. Blavin FE, Buntin MB. Forecasting the use of electronic health records: An expert opinion approach. Medicare & Medicaid Research Review. 2013;3(2):E1-E16. https://www.cms.gov/mmrr/Downloads/MMRR2013_003_02_a02.pdf. Accessed October 27, 2015.
10. Schleyer T, Song M, Gilbert GH, et al. Electronic dental record use and clinical information management patterns among practitioner-investigators in The Dental Practice-Based Research Network. J Am Dent Assoc. 2013;144(1):49-58.