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Chartless—An office that uses electronic patient charts.
DICOM—Digital Imaging and Communications in Medicine. The use of a format (such as a jpeg, pdf, etc.) to store images (eg, digital x-rays) and communications, to provide standardization for distribution and viewing of images and communications.
EDR—Electronic Dental Record. Dental records stored digitally.
EHR—Electronic Health Record. Health records stored digitally; used interchangeably with EMR.
EMR—Electronic Medical Record. Health records stored digitally; used interchangeably with EHR.
HIPAA—Health Insurance Portability and Accountability Act. Legislation that requires the establishment of national standards for electronic healthcare transactions and national identifiers for providers, health insurance plans, and employers.
Paperless—An office committed to using the minimal amount of paper necessary.
THE DENTAL TEAM’S ROLE
In many parts of the country, a majority of dental offices still have not adopted Electronic Dental Records (EDR). Whatever the reasons that have kept an office from converting, the fact remains that at some point all dental offices will need to convert to EDRs. By taking initial steps now, the transition and implementation can be completed within a more relaxed time frame. A healthy pace can be established by the dental team before legislation forces the issue.
Knowledgeable dental team members are in a good position to bring the subject to the table and get the process started. Once the process is underway, a designated team member must continue to monitor the entire team to see if additional training is necessary, and ensure that established protocols are working. To do so, that team member must understand the flow of the office and be knowledgeable regarding the various electronic options and digital products available.
MOVE AHEAD WITH THE STEPS
Step 1: Getting the Team on Board
When presenting the idea of implementing EDRs, it is important that key members of the dental practice team are on board. Take the time needed to review the benefits and get the dentist(s) and leadership on board. Share the following benefits with those who will make the decision to move ahead with the process. As with all new concepts, benefits may need to be presented in small increments and multiple times before achieving success.
Step 2: Assess Software and Hardware Needs
The practice may already have a practice management software program that everyone feels comfortable with and meets current expectations. Keep in mind, however, the practice’s needs will be changing as it expands its patient base. Practice management software is the foundation upon which the entire EDR will be built. Small inadequacies can become big problems once the practice depends upon software for patient charts.
Benefits of Electronic Dental Records
• No need to gather all components of a paper chart.
• No need to pull and re-file charts.
• Easier and faster writing of chart notes—no need to continually write the same chart note over and over again. Templates can be constructed for frequently used notes.
• Patient information is easily available for all staff members, at the same time if necessary.
• No need to create paper charts, forms, or labels.
• No need for developer and fixer.
• No foil waste from radiographs.
• Appropriate firewalls and passwords protect patient, practice, and personnel data.
• Backup of the database stored off-site protects all information in the event of theft or damage from a fire, flood, or earthquake.
Increased Office Space
• Extra space becomes available that is currently used to store active patient charts.
• No need for a separate dark room for processing radiographs.
Improved Infection Control
• No cross-contamination from paper charts.
Effective Practice Evaluation
• More comprehensive reporting.
• Several types of reports can be generated to confirm the financial health of the practice.
• Production reports can be helpful during employee reviews.
Internal and External Office Communications
• Radiographs are accessed and transferred easily and quickly to referring offices or insurance companies.
• Images are shared easily with other providers for consultations and referrals.
• Marketing newsletters and information can be available to patients.
• Office policies and memos can be sent to the dental team as needed.
Improved Patient Care
• No chance for charts to be misfiled.
• Easier and faster to filter and sort information.
• Pop-up alerts ensure important patient information will not be missed.
• Efficient delivery of patient education by video.
• Patients can view radiographs and photos to better understand their dental conditions.
• Provides access from remote locations. (Example: If there is a snowstorm or someone is sick, patient data can be accessed from home, including necessary information to reschedule patients or offer emergency treatment recommendations to patients in need.)
• More effective to show a patient changes in their dental health history when using charts and graphs that are a part of most dental software programs.
Points to Consider During the Evaluation of the Current Software
Room for growth as the practice grows and expands.
Meets all needs of the practice, now and in the future, including:
• Electronic Insurance Claims
• Flexibility in Scheduling
• Clinical Components
• Financial Management Reports
Available updates as technology evolves.
Ease of access and response time for support calls.
Integration for digital products.
Ease of component expansion, such as adding digital radiography products, intraoral camera, back-up devices or signature pad to accommodate a digital chart.
If the current software program falls short of the desired expectations, it is time to change software programs. Research other available software programs and contact other dental offices that have already implemented EDRs to discuss their chosen software program’s advantages and disadvantages. Attend seminars and read everything available on different software programs. An additional resource will be various dental supply representatives that have literature available. There is a great deal to consider, and choosing a new software is one of the most important decisions in the process.
Additional questions to consider when changing software products:
How will the current data convert?
Not every software company offers conversions from a previous system. Ask for a trial conversion so you will know what data can be converted and, more importantly, find out what cannot be converted. Do not assume that all previous information will convert or that all software company conversions are equally successful.
Who will install the new software?
Verify if the software company provides technical support staff for installation and if they are located within the area for follow-up with any problems and to offer ongoing support.
How will the training be conducted on the new software?
It is important to know how the software company provides training. The dental team must know if the company will send a trainer or if a trainer is available locally for additional training going forward. As technology expands the dental team should be aware of any opportunities to receive advanced training with the software.
What are the support costs going forward?
It is necessary to ask how often updates are to be expected to be released and what the anticipated cost will be per update. It is necessary to know if there will be a separate support charge on digital radiograph products and peripheral devices.
If there is going to be a change in software providers and currently computers are not used clinically, consider obtaining the software and using it as the front desk software for a period of time prior to converting completely to EDRs. It may be advantageous to know the flow of the software at the front desk prior to introducing the clinical staff to the process.
After the software has been selected, the next step is choosing the hardware (computers). There are specific minimum hardware requirements that are necessary to run each software program. Be sure the hardware meets or exceeds these requirements. Any software provider will be able to provide a list of these specifications. Some providers may also sell their own hardware brand or can recommend hardware providers.
It is highly recommended to work with a hardware provider that understands the special needs of the dental practice when making this important purchase. Installing hardware in a dental office with digital radiology and limited space is very different than installing hardware in a general business office.
If existing hardware will be used, ask the following questions about that hardware:
• Is all of the necessary hardware in the office and the treatment rooms?
• Is the hardware less than 5 years old?
• Does the practice need/want access to the Internet?
• Is the existing system adequately protected from computer viruses?
• Is the printer adequate for reports, radiographs, and images?
• Is a dedicated server computer required?
• Is the warranty still in effect for repairs?
• What are the estimated costs for hardware expansion?
• How will data be backed up?
It is critical to invest in a reliable backup system. There are backup programs and devices, which can be used to run a scheduled backup of the database. The backup device should be removed from the office or sent electronically to an off-site security firm each night for additional protection, as it does little good to have a backup if it is destroyed in an office disaster. Backups that can be physically removed from the office each day are small external hard drives that can be easily transported out of the office. Purchase several external hard drives as rotation of the devices provides additional security in case one does not perform to expectations. Also, multiple copies from different days on the different hard drives adds additional protection.
Some offices prefer to use an online backup company, which will connect via the internet and backup the data on a routine basis. The cost of this type of service varies by provider.
Other offices prefer to use both a local, hard drive backup and employ an online backup service. Remember HIPAA regulations mandate that dental offices monitor, protect, and secure all patient data.
Step 3: Investigate Electronic Services to Implement
One of the many benefits of EDRs is that there are many electronic services available to help relieve some of the workload at the front desk. Pricing on these services vary based on provider and usage. Check with the software provider for availability and pricing on any of these services.
Step 4: Choose a Digital Radiology System
There are many digital radiology options in today’s market place but basically they fit into two categories: indirect and direct.
In indirect digital radiology a phosphor plate is used to acquire the radiograph. The plates are very similar to radiographic film as far as flexibility and size. These plates are priced higher than traditional films and are designed to be reused. Because the plate cannot be sterilized, it must be inserted into a bag and sealed before placing in the oral cavity. Once exposed, the plate is removed from the bag and put into a small box to protect the image from light. Once all the images are taken, the box is transported to a scanning device that will scan the image into the software and then expose the plate to light, thus erasing it for the next patient.
Direct imaging systems use a sensor. This device is sized about the same as traditional dental film, except it is thicker and rigid. The placement of sensors is a bit different than conventional film. Based on the manufacturer of the sensor, there may be one size of sensor or multiple sizes to choose from. Once the sensor is placed in the oral cavity and exposed, the image appears in the software within seconds (Figure 1).
• Insurance Claims—submit claims via the Internet.
• Verify insurance eligibility.
• Claim status—follow up on outstanding or delayed claims.
• Send attachments and additional information as requested.
Credit Card Processing—processing of patient payments.
Statements—send practice statements to a clearinghouse to print and mail.
Remittance Advices/Explanation of Benefits (EOB)—receive and store remittance advices over the Internet.
Appointment Reminders—send phone calls, text messages, and e-mails to patients automatically to remind them of upcoming appointments.
There are suggested advantages to either direct or indirect style imaging products. Indirect scanner-style devices allow many existing extraoral devices (panoramic and cephalometric machines) currently in an office to be outfitted with a large phosphor plate to allow for digital images at a much lower cost than a new digital extraoral machine. Phosphor plates may be faster for the operator to adapt to as they are similar in flexibility to regular dental film.
Direct sensor systems have the advantage of an immediate image. By seeing the image immediately, direct sensors allow the operator to see an image prior to moving the sensor or the tube head. The operator knows immediately if a retake is necessary, and by keeping the positioning static between takes, it becomes much easier to take a successful retake image. Removing the additional step of making the trip to a scanner to scan the images is an obvious time saver. Appropriate training is critical for success with both indirect and direct sensor imaging.
When choosing the direct sensor option, consider if the practice wants to maintain a processor to continue to develop regular extraoral films, convert any extraoral devices with digital kits, or replace the device completely with a digital product. The dental supplier used to purchase the radiology devices will be able to help guide in this discussion.
It is also critical when choosing digital radiology products to consider which manufacturer’s products work best with the practice management software. Not every software product works with every device. Some software products work better with some digital vendors and can offer a direct integration. Simply put, the software used to manage the practice will also be able to acquire and store the digital images. Other software/digital combinations are not as compatible and may even require one practice management software, one imaging software product and a third software piece (or bridge) to allow the two to talk to each other, allowing the management software to access the films for the patient as needed. There can be additional ongoing support costs associated with using systems that require two separate software products—one for practice management and another for image acquisition and storage.
Questions to consider before investing in a digital imaging product:
• Is it a direct or indirect system?
• Does the company support the system well?
• Can additional costs be expected?
• Does this company have a good reputation with the product?
• Does the company provide trainers for the dental team?
• What will the warranty cover and for how long?
Step 5: Develop a Patient Flow Protocol
It is critical that every dental team member in the office knows the plan for patient flow and how the collected data is entered into the system. Equally important is that every dental team member knows their role in the data collection.
For example, a decision needs to be made as to how patient demographic and medical history information will be obtained. Will the information be acquired:
• At a computer kiosk? This can be located in the reception area for patient access.
• In the consultation room? This may require the assistance of a dental team member or treatment coordinator.
• Chairside? This will require the placement of a computer monitor and data entry source with easy access to the patient.
These points concerning access will have to be decided for every facet of the patient’s electronic record. The entire dental team, or a designated group that has been chosen to establish patient protocol, should meet and plan the flow of the patient’s dental visit, from start to finish.
This process can be started by developing three different protocols: one for the new patient visit, one for a hygiene appointment, and one for a patient seeing the dentist. Specialty practices may have additional appointment categories to address. The appointed staff members should examine a selection of existing charts and begin to record the process. A sample spreadsheet is provided as a guide (Figure 2). By envisioning the patient visit, beginning with the initial phone call, to the patient walking through the door, and continuing until the patient exits the office, each step is recorded. Plan how the data collected at the appointment will be recorded, which team member(s) are responsible for recording it, and the need for any special digital device to record it. This process will take several meetings but will help the office in a smooth transition from the paper chart to the digital chart. Not only does this examination assist in preparing for a wonderful patient experience, but also helps the entire dental team clarify the responsibilities within the practice and aids in an efficient day once the system is in place.
This process is repeated for any other appointment types the practice uses (Figure 3 and Figure 4). It is very helpful to have a significant sample of paper patient charts available to cross-reference every piece of information in the chart. Every piece of information in the paper chart needs a comparable location in the digital chart.
The office may also want to design similar protocol for correspondence and miscellaneous paperwork that is generated at the front desk (Figure 5). This will include transfers of information to other dental or medical professionals. An efficient, established protocol will maintain ease of transfer and keep protected health information secure and private.
If the office has been using the practice management software they intend to ultimately use for their EDR, this process may go quickly. For an office that will be using new software for their EDR, the office may want to delay protocol meetings until they have received training on the new software. Once they have an understanding of the flow of the new software, the team can complete the protocol forms as a way to redefine and clarify what they have learned during the training. An office may even decide to invite the software trainer to assist in establishing the protocol forms.
Exception to the “Paperless” Rule
There may be times that an office decides a paper document must be kept for legal purposes, even after the document is scanned in the computer. In this case, a progress note or chart note that describes and summarizes the document is entered into the EDR. Information to include in the note is the date the document arrived in the office, notation that the document was scanned, and describes where the document is filed.
Step 6: Develop a Plan for Retiring Existing Paper Charts
It usually takes years to create all of the paper charts belonging to a dental practice. It is important to remember that the charts do not need to be retired immediately. One sure way to frustrate staff and patients is to file away charts prematurely, before transferring all required information needed to treat the patient with a full understanding of the patient’s prior dental history. To make sure all the pertinent information is transferred to the EDR, start by recording a list of all information stored in the paper chart in another spreadsheet (Figure 6).
An office may choose to continue to pull existing paper charts for several appointments until all the relevant information is entered into the EDR or replaced by more current information. When the information on a form has been transferred to its digital counterpart, a note will be placed on that form stating that the information has already been transferred. These notes prevent duplicating efforts. When it is determined that the EDR is complete and that the paper chart has no content remaining to be transferred, the paper chart should be clearly marked and maintained according to the state’s guidelines regarding document storage.
A major dilemma in converting paper charts to EDR’s is what to do with years of old progress/treatment notes. It is important to maintain compliance with state guidelines. Start by reviewing all notes and, if state laws permit, enter a summary note at the beginning of the patient’s electronic record that reports any information that would be pertinent to continuing the patient’s treatment. Remember, it is not necessary to retire the paper chart while treatment is still active. After the summary continuation note is entered, the office can choose to store the complete paper record in a safe location (to be accessed if necessary) or an office may choose to scan all the previous notes into the patient’s EDR. It is very important to check with state regulations on this topic.
The office will also need to decide how to handle previous periodontal readings. The best course of action is to scan and store all previous readings into the EDR. Previous watch areas could be noted in an electronic periodontal progress note if a reading or scoring does not exist. Once relevant data is recorded electronically, the paper documents can be stored with the retired paper chart.
Step 7: Set a Goal Date
The office should set a target date by which all paper records must be transferred to an EDR. The chosen date should be far enough into the future to allow all the steps to be completed properly, but not so far off that there is no sense of urgency. Remember, the date can always be revised.
Financial ramifications also need to be considered. The practice’s financial advisor or accountant may be able to provide research concerning any government programs or tax incentives that offer an advantage to help in the transition. Consult with the practice financial advisor(s) as goal dates are planned.
Step 8: Acquire any Additionally Required Digital Devices
There are a variety of additional digital devices that may be needed or useful to the practice and should be considered during a conversion.
• Used to acquire the patient’s electronic signature.
• Maintains HIPAA guidelines and record privacy.
• Intra- and extraoral imagery for records and treatment plans.
• For storage and electronic transmission.
• Record and store electronically all new and existing information necessary for complete treatment.
• Needed for word processing, presentations, and spreadsheets.
Step 9: Implement the Plan
It is important to remember that every level of the plan does not need to be implemented at the same time. A place to start with is training on any new practice management software, followed by a few months of practice to gain familiarity and confidence. After confidence is gained, additional training on the clinical modules of the software can be completed. Implementation can begin soon after, with a date set for completion.
If there is not a change in practice management software, the plan may be fully implemented at one time, or start by entering periodontal charts in the record, followed by tooth charts, then finally the clinical notes. The implementation of the plan is as varied as the office itself. Implementation should be determined by the ability of the office to accept change, the level of the staff’s computer literacy, and the overall experience of the staff.
It is important to established deadlines for steps in the implementation along the way and attempt to maintain these dates. Dental professionals should not be afraid to contact software support with questions and make use of any webinars, seminars, or trainers that the software company may have available.
During the implementation, those leading the change should confer frequently with all staff to ensure that every dental team member is clear on the information flow and their responsibilities. Regularly ensure that protocols are working and stop improper techniques immediately. Protocols can be adjusted as time goes on to best suit the flow of the office.
Lastly, it is equally important to touch base with patients throughout the change to EDRs. Ask patients how the process went for them. What worked well and what caused concern? If they were unaware, patients should be informed about the new technology the practice is implementing and be assured that their record is secure and private.
Converting paper patient records charts into their electronic counterparts (EDRs) not only has many advantages, but also could become a legal requirement in the future. Several steps key to a successful transition includes assessing the needs of the dental team and what they require as a part of the implementation. Existing software and hardware must be evaluated for continued use and expansion. Proper protocols for information transfer must be established to ensure complete records while maintaining HIPAA regulations regarding patient privacy. Reduce anxiety by setting realistic deadlines and using trusted back-up methods.
ABOUT THE AUTHOR
Jana Berghoff, RDH, spent the first 23 years of her professional career working both in the clinical dental setting and in practice management. For the past 10 years she has worked in various capacities with Patterson Dental to bring technology into the dental office. She has specialized in Eaglesoft software, Schick Digital products, Patterson hardware offerings, CAESY Patient Education Systems and various other digital imaging products. Jana has conducted in-office trainings nationwide, as well as presented seminars and published articles to help dental professionals take the initial steps toward operating a computerized office. Jana presently serves as the Technology Marketing Manager of Patterson Dental.
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