Medical-Dental Systems Interoperability

The Next Critical Step To Improving Collaboration And Understanding

By Mark W. Jurkovich, DDS, MBA, MHI, MAGD

Today, the amount of data being produced in healthcare has exploded as compared to just a decade ago. IQVIA and other large data analytics firms estimate that hospitals alone are producing over 50 petabytes of data a year. For context, 1 PB is equal to 1,000 terabytes or 1 million gigabytes, and 50 PB is more than twice as much data as is housed in the entire Library of Congress. This amount is growing at a rate of 36% annually, with as much as 97% of this data currently being unused.(1) Adding hospital data to outpatient data, dental data and other sources expands the amount of health-related data dramatically.

Tools that help healthcare clinicians sort through information are valuable and perhaps essential from an efficiency standpoint. Currently, our physician colleagues have tools that use various types of artificial intelligence (AI) that assist electronic health record (EHR) systems in summarizing information, allowing physicians to have a more cohesive picture of the patient that may be based on the chief complaint or simply their medical history. Further, as the medical team adds more information on current findings and observations, lab results, etc., during the exam, the systems can actually provide decision-support assistance, such as determining whether more or other tests are warranted.

It is not uncommon for primary care physicians to be scheduled with three or even four patients per hour. Like most healthcare clinicians today, medical teams are pressed for time. To expect them to review written communications, change workflows or take other actions may be asking too much. Our historical methods of exchanging data simply are not working with our data explosion.

This is where information-exchange tools and interoperability make a difference. Without these tools, the opportunity to more clearly understand how medical and dental conditions impact each other and how care coordination might improve outcomes, lower costs and more may be out of reach.

What Is Interoperability?

Strictly speaking, true interoperability is a streamlined way of exchanging information. In this article, the concept of health information exchange represents the basic exchange of healthcare information, which can include medical and dental history and treatment and administrative data and charts unique to the patient, still well beyond phone calls, faxes, etc. Interoperability will be represented as the most advanced form of information exchange, because EHR systems can be used more effectively to identify patients, identify key information being exchanged, and, with greater frequency, “consume” or populate the EHR with information received from another system with little or no human interaction or input beyond a simple approval. This is not common in the dental field at this time, but it is rapidly growing in medicine.

The Oral-Systemic Health Connection

For well over a decade now, research has been identifying numerous correlations between good dental health and improved overall health. Studies involving periodontitis have shown linkages to more problems with diabetic control, heart disease, strokes, arthritis and several other chronic medical conditions. Anecdotally, it remains uncommon for our physician colleagues to refer patients with these conditions for a dental examination (and likely few referrals from dentists to physicians are made to explore how improving inflammatory chronic medical conditions can help dental care). Improving communication and cross referrals has significant potential to help patients through increased related data and better knowledge about related health conditions. Further, without additional “proof” that there is an oral-systemic health connection that can be leveraged to improve outcomes or lower costs, healthcare systems may look to other areas of care first, where the digital “language” of their care systems more easily integrates with information in EHRs. A good example of this might be pharmaceuticals. Pharmaceuticals is a cost center more than twice as large as the dental industry.(2,3) Its records and the language used already integrate with most (medical) EHRs, allowing for a much lower upfront cost for care systems using AI to identify correlations and relationships that could produce better results and savings.

Dental systems often struggle to communicate effectively with medical EHRs. We in dentistry tend to use a different set of terms and codes, as well as limited amounts of structured and standardized data. Instead, dentistry tends to rely on patient self-reporting of medical conditions rather than obtaining this information directly from patients’ medical records.

How Can We Work to Develop a Better Picture of the Oral-Systemic Connection?

Dentistry has led the charge of education to both the profession and the general public regarding the oral-systemic health connection. Further, dental benefit plans and Medicare periodically have expanded benefits for individuals with certain medical conditions, further enhancing public awareness and belief that there is a connection between oral and systemic health. Yet, a 2021 study of information exchange and dentistry looked at 97,460 dental visits and identified just 164 requests for medical information.(4)

Additionally, patients with certain problems may already be interacting with both a dentist and a physician to resolve their concern(s). The need for clear and timely communication to assist these patients in problem resolution may be critical.

Although the enabling act of Medicare has strict limitations on covering dental conditions, when a medical treatment protocol includes the need for some type of dental care (often an exam, prophylactic treatment or periodontal maintenance of some sort), the potential need to provide necessary information relative to the patient’s medical condition that qualifies the dental procedures for coverage may not be cost-effective using current methods of exchange. However, it may very well be expected — i.e., doing preventive services for someone needing surgery and then having to provide significant amounts of information in a timely manner to the physician, as well as the insurance company handling Medicare coverage for the patient.

Additionally, the information necessary to properly coordinate the clinical care is often not easily exchanged. It may require phone conversations, faxed information, and possibly some basic information exchange through a state-operated health information exchange or other tools that many dental clinicians are unfamiliar with. These exchanges generally require manual input into the records systems of all parties. Further, unless the information is exchanged in a timely fashion, it may not be available to the other clinician, potentially resulting in repeated tests, imaging or rescheduled appointments, all of which are frustrating to patients. True interoperability or even basic health information exchange can reduce or eliminate these issues.

Dentistry is seeing some development of integrated EHR systems or the ability to improve exchange of information. A few healthcare systems, such as HealthPartners in Minnesota, some care systems in the Northwest, some university health centers, and a growing number of federally qualified health centers are beginning to or have been using “integrated” medical/ dental records for some time. One example is Epic, the largest provider of EHRs in the United States, which offers a dental component called Epic Wisdom. Epic Wisdom provides instant access to medical and dental information and the opportunity to better understand the correlations between systemic and dental health, as well as decision tools to more effectively coordinate care. With the vast majority of dental practices still independent of larger healthcare systems, linkages that involve a totally integrated EHR system may still be well into the future. Thus, there is a growing imperative to exchange data between dental and medical EHRs for the foreseeable future.

How Might Interoperability Impact Dentistry (and Your Practice)?

One large dental support organization, PDS Health (formerly Pacific Dental Services), has gone well beyond simple experimentation and is taking some key steps to enhance interoperability for its clinicians. PDS Health began transitioning to Epic Wisdom, which, in addition to being fully compatible with the Epic medical EHR system, is able to communicate through various well-established channels with most other EHR systems. This gives PDS Health dentists the capability of obtaining the most up-to-date medical information, laboratory results, medications, etc., in a growing number of instances as long as the patient consents to the release of this information. Potentially, this interoperability and exchange of information enables dentists to identify and further understand medical-dental relationships as well as provide information back to physicians and healthcare systems that may help improve patient outcomes and/or reduce costs. This may be of increasing importance in the marketplace if employers begin seeking more integrated care for their employees.

We are also in an era of changing patient expectations. Today, it is not uncommon for patients to use “patient portals” for all things related to their healthcare and health insurance. Again, dentistry tends to lag behind the medical industry with regard to implementation of these tools. Patient portals allow for scheduling, filling out necessary pre-visit forms, paying for services, and obtaining information about their previous visits as well as educational materials patients can use to potentially improve their health and treatment outcomes.

Increasingly, it may be assumed that patients have expectations that comparable capabilities are available regardless of what kind of healthcare professional they are visiting. Historically, patients have had to fill out similar health information for every clinician they visit. This is now much less frequent among medical clinicians and care systems, which may also be improving accuracy(5) and is better for patients, all due to interoperability. Again, dentistry is infrequently at this level, and patients can be frustrated by dental clinics’ inability to obtain information they may not fully understand but could be important to their dental care. A growing number of dental clinics are offering patients the ability to fill out certain paperwork in advance — which still means filling out similar information yet another time — and this paperwork may lack some key components, such as recent H1Ac results and current medication dosages. While the ability to complete paperwork in advance is a good step forward, it may not meet patient expectations in the not-too-distant future.

If a patient does understand the possible oral-systemic health connection and they have a dental problem that may impact their overall health, they may expect the dentist to explain it to the appropriate physician(s) and get any key information placed into their medical records — a reasonable expectation, given that this is already happening regularly among many medical providers. However, one of the simple problems dentistry continues to deal with is the lack of effective and timely exchange between general dentists and dental specialists. This can result in tests or radiographic imaging being repeated and billed a second time to the patient because dental benefit plans will often only cover one such procedure in a select time period. Better information and image exchange within dentistry has the potential to limit patient out-of-pocket costs as well as reduce radiation exposure; better interoperability among dental and medical systems can take this efficiency even further.

The State of Dentistry and Information Exchange Today

Some dental colleagues (oral surgeons, those dealing frequently with sleep disorders and/or temporomandibular conditions, etc.) already exchange data with medical clinicians with greater frequency than many other dentists. This provides a basis for developing a platform to exchange, identifying where improvement might be possible, and evaluating how this can be done most efficiently from a workflow standpoint. These colleagues would be a good source of information, should you be interested in learning more.

It is equally important to recognize that exchange is not new to the profession. Things like using clearinghouses for insurance claims, sending digital scans to a laboratory, the example earlier about online form completion, and a few other administrative types of tasks are already being used in dentistry, and some represent true interoperability as defined above. Where dentistry is behind medicine is in the capability for and actual exchange of clinical information. Many of the administrative forms of interoperability have measurable financial value (time savings) to the clinician. The costs of exchanging clinical information are frequently borne by the dental practice, both in upgrading technology and in the charges for exchanging the information. These costs may create a financial limitation, but they may also be of significant value, much like electronic claims submission can be.

Clinical information exchange is also significantly more complex. It was noted above that dental and medical EHRs do not easily “talk” to each other. One of the reasons is that dentistry records different information and even the same information in a different way. Where a physician might document a certain type of problem such as diabetes in a separate data field in their database, some and perhaps many dental EHRs do not. Even if they do, they might use a different term or metadata that requires further work before it can be transferred.

Another key aspect is making sure the correct patient is identified. This sounds like it should be straightforward, but it is and remains a very complex task. AHIMA, one of the larger training organizations for administrative and clinical staff, has been advocating for unique patient identifiers for healthcare, not unlike what the government currently does with Social Security. The primary reason for this advocacy is that a small percentage of patients are very difficult to properly identify due to similarity of names and ages, or frequent address changes, thus eliminating the capability of exchange and creating barriers to true data “consumption” into an EHR system. Another check is needed by clinical staff before the data can be integrated, which means more staff time spent.

How Can Dentistry Move Toward Improved Clinical Information Exchange?

Some of the basic elements involve standards, security tools, improved systems and affordable ways to participate in health information exchanges. About a decade ago, the American Dental Association (ADA) endorsed a firm that could provide secure email to allow for more rapid, HIPAA-compliant and legally acceptable ways to provide information to another clinician. Some dental specialists went further by providing a secure portal, allowing referring dentists to input information that became instantly available to the specialist. Today, one of the absolute costs of doing business for anyone with computerized records and a connection to the internet is having a computer operating system that is regularly updated to address any newly identified security vulnerabilities.

Standards are another area that is key to information exchange, and they are changing rapidly. Exchange formats used by our medical colleagues can include continuity of care documents (CCDs) and can consist of a download of medical information that could be very extensive, making them less useful because of the time it takes to review the information. Over the past few years, the United States and most of the world has been moving toward a standard that can streamline these documents to more specific needs and be transferable in real time. This standard is called HL7 FHIR, where HL7 stands for Health Level Seven International, the standards organization that develops exchange tools and protocols, and FHIR stands for Fast Healthcare Interoperability Resources. U.S. government agencies, such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, have been encouraging and working to make FHIR the primary exchange format. FHIR tools allow for much more focused, and thereby limited, information exchange. A specific American National Standards Institute (ANSI)– and ADA-approved dental standard, No. 1084, Core Reference Data Set, serves as the basis for development of some of the FHIR exchange sets used in dentistry. We are gradually seeing the adoption of FHIR capabilities by some dental EHR systems due to demand by users. The Veterans Health Administration and some federally qualified health centers have been some of the leaders in pushing the dental EHRs they use into having this capability. Yet, CCDs remain far and away the most common form of document exchanged.

Recently, the ADA Standards Committee on Dental Informatics completed a new ANSI-approved standard, the Oral Dataset Interoperability Standard (ODIN). ODIN provides for the permissioning, data bundling, authentication and necessity validation for structured electronic data elements to support key information exchange among and between dental and other healthcare settings. This includes the bidirectional electronic sharing of essential patient demographic, dental and medical encounter data, as well as patient clinical data in a structured, computable format between dental or other healthcare venues.

Another major effort by the federal government is creating “exchanges” where patient information can be readily identified and moved to another entity with patient permission. Referred to as QHINs (qualified health information networks), they must pass rigorous criteria and use common methods to exchange information. This may be the path parts of dentistry will need to use, simply to contain costs. The most likely path will be for the dental EHR vendors to develop a pathway with a QHIN. If a dentist is then seeking information on a specific patient, that information request would be “packaged” by the dental EHR, then the information packet would be forwarded to the QHIN (hopefully with directional information on where to find the patient information). The original QHIN then works with all other QHINs in the exchange, and each QHIN or QHINs that contain information for the patient accesses it from an EHR system and forwards it back to the original/requestor QHIN and subsequently to the dental EHR or another tool that allows viewing of the information requested (if available). All of this takes place in real time, measured in seconds (minutes at most). Depending on the capabilities of the dental EHR, the information could immediately populate a patient’s record (likely after a single approval click from a staff member), update information when it is “new,” reduce patient time and make the information much easier for the clinician to locate. This is an example of true interoperability, and improved patient satisfaction, patient care and patient safety would be the result.

Many states have developed health information exchanges (HIEs) during the last decade or so. Some of these may require all healthcare professionals, including dentists, to participate. The healthcare professionals contract with a firm (much like the QHIN described above) to provide exchange services. A “roster” of all patients that the healthcare professional has records on is uploaded (and regularly updated) to this firm so that information requests can locate where the patient may have records and provide for rapid information exchange.

A Possible Path

Today, there are numerous resources available; however, many require a level of baseline knowledge to be useful to the average person. Depending on whether you are a solo practitioner, a small group or part of a larger group such as a DSO, the path forward could be very different.

If exchanging information beyond phone calls, texts and emails is new to you, you may want to use a basic approach to familiarize yourself with the processes. It may also result in better security and meeting state or federal privacy and security requirements.

A great source for learning more about information exchange in general is healthit.gov/topic/health-it-and-health-information-exchange-basics/ health-it-and-health-information-exchange.

Some Initial Steps

1. Make sure your operating system is up to date and you either regularly check for updates or have automatic updates turned on. Many dentists already use a technology company to take care of their computer systems; if so, the technology company should be doing this regularly.

2. Talk with colleagues who refer to you or whom you refer to. Find out if they are using portals, what information you should exchange with them, etc.

3. Explore with your patients what medical care systems they are members of, and find out if they use their medical care system’s patient portal. Often, they will also know the name of the EHR system their medical care system uses (patients frequently refer to “MyChart” or similar, and those names are usually proprietary to the EHR vendor).

4. Find out from your patients if they would use online forms, online scheduling, online payments, etc. While there are costs involved in these services, they do have the potential to save time and improve patient satisfaction.

5. Consider signing up for secure messaging capability as a possible starting point. There remain several vendors in the field. Secure messaging allows for information exchange securely with both other clinicians and your patients. You can find additional information from one of the largest exchange platforms here: directtrust.org/what-we-do/direct-secure-messaging.

6. Monitor frequency of use, how you might alter workflows or how this might allow you to improve workflows. An example might be that you have obtained the necessary information that allows you to properly counsel the patient on their medications before an extraction so you don’t “waste” an appointment because they need to take or stop taking some medication prior to treatment.

7. As you get more comfortable with exchange, research options such as state HIEs and who the vendors are. Discuss with your dental EHR vendor their capabilities to participate in an exchange, and encourage them to add or adapt their data structures to meet your needs for information available for the patient.

8. Consider participation with the ADA Dental Experience and Research Exchange (DERE) registry project. As it expands and grows, you will have greater capability to compare your practice to other similarly sized practices as well as improve the information available to help the profession better understand the oral-systemic health connection.

Mark W. Jurkovich, DDS, MBA, MHI, MAGD, is director of data infrastructure at Health Care Systems Research Network. He currently serves on the Minnesota Health Information Exchange Advisory Council, is a member of the ADA Standards Oversight Committee and is chair of the SNOMED International Dentistry Clinical Reference Group. He practiced general dentistry for almost 40 years. To comment on this article, email impact@agd.org.

References

1. Greene, Linnie. “How Healthcare Data Technology Is Leveraged by Leaders.” Arcadia, 6 Sept. 2023, arcadia.io/resources/healthcare-data-technology.

2. “Trends in Prescription Drug Spending 2016-2021.” Office of Science and Data Policy, U.S. Department of Health and Human Services.

3. “National Dental Expenditures 2022.” Health Policy Institute, American Dental Association.

4. Taylor, Heather L., et al. “Health Information Exchange Use During Dental Visits.” AMIA Annual Symposium Proceedings Archive, 2020, pp. 1210-1219.

5. Patel, Jay, et al. “Assessing Information Congruence of Documented Cardiovascular Disease Between Electronic Dental and Medical Records.” AMIA Annual Symposium Proceedings Archive, 2018, pp. 1442-1450.