Plugging into EMR
Once dentists come on board with EMR, they generally are sold on its benefits
By Laura Thill
There’s no turning back. In the spring of 2010, the medical community is expected to learn about new requirements for being up and running on an electronic medical record (EMR), with the capacity to be part of a national electronic health record. The dental community likely is next in line, according to experts. But, would dentists want it any other way?
In time, dentists will have to become "mouth doctors" rather than teeth experts, says Mike Norton, director of sales, Burkhart Dental Supply (Tacoma, Wash.). The future is all about comprehensive oral healthcare, he points out. "There will be a tremendous need for dentists to communicate and network with outside sources and physicians. [To this effect], oral cancer will be one of the main drivers of EMR."
But, that’s only the beginning. "A big benefit to having EMR is being able to share information in real time," Norton continues. As such, he envisions a dental community with the capacity to share information with labs regarding restorative procedures, or orthodontists and periodontists regarding treatment plans. "Dentists with EMR [will be able to] refer a patient in the chair to a specialist with one click of the mouse," he adds.
For some dentists, EMR signifies a loss of the "daily personal touch" with patients, notes John Mancus, national technology manager, Benco Dental (Wilkes-Barre, Pa.). However, a comprehensive electronic medical record system puts dentists and their staff in much closer touch with their patient’s needs, he points out. "According to the American Dental Association, over 30 percent of performed procedures are missed at the time of [patient] checkout," he says. With EMR, much of the checkout procedure can be completed from the treatment rooms. "Charting and treatment planning while the patient is in the chair allows for co-diagnosis and greater case acceptance," he points out.
"I have never heard of a dentist who has made the transition to EMR wanting to go back," says Jana Berghoff, corporate technology marketing manager, Patterson Dental (St. Paul, Minn.). Sure, implementing an electronic medical record is an investment that requires time. But, there are ways to minimize this, and in the end, EMR saves time and facilitates better patient care, she notes. For
example, an electronic medical record system makes it much easier for staff to enter patient information and retrieve it. "If a patient calls with a question regarding treatment, with two clicks, the front desk [staff] can see what the dentist discussed with the patient at [his or her] last appointment and what type of follow-up is needed." And, more and more, patients are coming to expect this level of service, she adds. "They want to know their dental office is up to speed with the newest technology."
What’s to fear?
Few would argue that the cost of implementing a comprehensive computer system, along with the time involved in training the staff to use it, is a major deterrent to dental practices adopting EMR. In addition, there’s a general "fear of change" among dentists when it comes to implementing EMR, notes Dawn Christodoulou, president, PEB XLDent, a practice management software company based in Loretto, Minn. "[Particularly in the case of] older staff and dentists, [those] who are close to retiring may not want to pump more money into the practice," she points out. "We tell dentists who are close to retiring that they will have difficulty selling it without digital technology in place. New buyers want a practice with the electronic infrastructure and processes already in place."
Another concern about EMRs among dentists is that power outages will incapacitate their computers, making it impossible to treat patients. "In reality, there’s not much in the way of treatment that one can provide without power," says Nick Hein, DDS, a Missouri-based practitioner who believes this fear may be "exaggerated."
Berghoff agrees. "If a dental practice loses power, the X-ray system won’t work, the chairs won’t move up and down and the lights will shut down," she points out. "So, the loss of EMR will not further impact this situation." Some dentists are concerned about computer system failures, even when the electricity is running. "But, the reality is, technology has advanced and many of today’s systems have safety devices built into the hardware to back up and preserve all information," she says. ""Servers often store data on multiple hard drives within the server computer, enabling dentists to maintain access to patient information even if one hard drive fails. Often there are multiple sources of power for a computer. [And], dental practices can stock self-developing film packages as a backup should their computer system be temporarily unavailable."
A couple of other concerns dentists express about EMR are infection control and tailoring a system to fit their personal style. "[Whereas] in most medical settings, the person doing data entry is not handling bodily fluids, in dentistry the dental assistant or hygienist is often trying to do data entry at the same time as working on the patient," says Hein. And, he or she is wearing gloves, he adds. "This causes a major infection control problem," he says. "There is no good way to disinfect a keyboard. I foresee a huge increase in the use of touch screen technology, and EMR companies that make a graphical user interface that can easily be adapted to touch screen usage will likely have a leg up in the future. Touch screens can be used with an easily cleanable stylus, or barriers can be placed [and] easily changed [after being touched by contaminated gloves]."
As far as dentists trying to tailor an EMR to their personal style of record keeping, they really should change their approach, according to Hein. Some dentists will modify paper charts to fit their office flow and practice style, he explains. "With EMR, these decisions are made at the software development level and are generally unalterable," he says. "Many ask, ‘How do I make the software put a data field here?’ A more appropriate question is, ‘Where do I write [this] down?’ It’s a paradigm that requires the operator to learn to use the software [rather than] tailoring it to [his or her practice]."
What are the benefits?
Generally, dentists who make the leap to EMR find the benefits well worth the effort, say experts. In a nutshell, electronic medical records offer "accuracy of data, speed, improved processes and workflow, improved patient acceptance, and they keep all staff members on the same page with regard to each patient," says Christodoulou. Particularly when a practice works around one concentric patient record (with billing and patient recordkeeping in place), the operator can attach images and access demographic data, charting, billing and more, she points out.
Third party reimbursement has become substantially easier with EMR, according to Hein. "The days of filling out a claim form, sending a duplicate radiograph and waiting for extended periods of time for reimbursement are quickly coming to an end," he says. "Today, the claim is generated by the same system that is used to check out the patient. A digital radiograph from that same software is pulled, and the entire submission is done electronically. This can dramatically reduce payment turnaround times."
What do they need?
If a dental practice is going to invest in EMR, it should go the distance in order to get the most value and efficiency, according to experts. In other words, a piecemeal electronic medical record system probably won’t yield the same level of efficiency as a concentric system. "Dental practices need both the practice management and clinical functions," says Christodoulou. "Image management, charting (both restorative and periodontal) and clinical progress notes all tie into billing." What dentists want to avoid is ending up with two systems – one electronic and one on paper, she adds.
Practically speaking, it can be difficult for a dental practice to work with multiple software vendors, notes Berghoff. "Yes, two software programs can often be bridged together," she says. "But, if something goes wrong, which vendor will take responsibility? The practice management software company? The dental imaging software company?" Not only is it often confusing to work with more than one vendor, the dentist must pay multiple support fees as well, she adds.
Indeed, in the past dentists often have acquired devices and software piecemeal, says Hein. "They would buy this intraoral camera [followed by] a piece of software and then a digital radiography system that required a separate bridge to connect to the previously purchased software." But, updating the software inevitably "would break the interface from one device to another," he explains. "It was a frustrating proposition for all involved. In a for-profit dental office, often using a professional information technology (IT) integrator (a consultant or company who not only sells computers and/or software, but installs the program, manages it and trains the staff to use it) is the most efficient route. This is especially true when the dentist either has limited time or knowledge of implementation and operation of computers, networking and technology in general."
After years of working to perfect EMRs, "the emphasis today has shifted to a seamless integration of billing, radiography, clinical record keeping and, now, digital photography, digital impressions and patient education," says Hein. And, as the government continues to promote a national electronic health recordkeeping system, this trend inevitably will grow, he adds.
What can they expect?
The average cost of implementing an electronic medical record for a midrange practice can be as much as $20,000, according to Christodoulou. This includes clinical software, patient education, charting, a communications system and practice management. In addition, there is the expense of hardware and support services. Dentists should allow three to five days, depending on whether the practice already has a portion of a system running, or whether it is starting from scratch. "Or, it could take between six and 18 months for a completely paper-dependent practice to transition all systems to a digital record, including charting and imaging," she says.
Sometimes, practices must close down for a few days for implementation and training. "Having staff trained over the weekend is one way to help ensure a smooth implementation process," says Berghoff. "Dentists may also bring in two trainers – one for the clinical staff and one for the front desk – to expedite training." Regardless, it’s very important to "give the staff the tools they need to do their job as efficiently and productively as possible. Ultimately, the practice comes out ahead if the office invests time in adequate training so that the staff fully understands the technology, the patient flow within the software, and feels comfortable using the software to perform their daily tasks."
"The most efficient implementation I have seen used a professional IT integrator," says Hein. "Generally, these are small, local outfits that are looking to partner with a distributor. They are IT professionals who spend an extensive amount of time learning industry-specific requirements (e.g., infection control standards). They can be the quarterback of the IT system for the dental office. And, because they are local and readily available for onsite consultation, they can dramatically reduce implementation and training times."
What’s the rep’s role?
Many dentists today are overwhelmed by new technology, as well as the cost involved. "Many practitioners grew up in a system in which they paid a high price for a piece of equipment, which they could count on for 10 or 15 years or longer," says Hein. But, that mindset doesn’t apply to computers and digital devices today, he points out. "Many dentists complain when they spend $50,000 or more on computer hardware, only to find that five or six years later, a new piece of software or a peripheral requires a costly upgrade to operate."
And while distributor reps are not necessarily computer experts, they should be able to point their dental customers in the right direction, according to experts. For starters, reps should learn what, if any, software system a dental practice is currently using and how their products interact with it, says Berghoff. "If the practice has no EMR, then reps should recommend that dentists invest in products and technology that integrate seamlessly and have the capability to grow with the practice in the future." Reps who are knowledgeable about dental practice management software options are in a better position to explain how their products work with each system.
Indeed, reps should "determine what the dental office wants to accomplish," says Mancus. "While some offices plan to incorporate imaging, others may just want an electronic claims or scheduling [function]. Finding each office’s need is key." Similarly, reps should know when it’s in the best interest of a dental practice to maintain its status quo, he adds. "The single most disruptive thing that can happen in an office is to switch practice management software. If an office is happy with its software and it performs all of the necessary functions, it is wise to reconsider switching."
Christodoulou agrees. "It may not be a good time [for some dentists] to change systems," she says. "Reps should assess what a dentist has in the way of EMR and diagnostic equipment, and determine whether their current system will be able to support a lot of technology in the future. Dentists need a system they can grow with." Distributor reps can help their customers by directing them to a number of educational resources, she adds. "Web sites allow dentists to research practice management products that are available. They can attend local dental conventions, where they can see demos and evaluate products. And, [distributor reps and dentists] can call in manufacturer reps who can provide personalized demos for different systems."
More and more, dentists will value sales reps who are "a point person when someone has a problem with [his or her] EMR," says Hein. Reps who are familiar with EMR issues and have the ability to help solve them at the dentist’s office "will have a major leg up" in providing the value-added service their customers have come to expect, he points out.
Is EMR necessary?
Patients today expect their dentist to have the newest diagnostic and record keeping technology, notes Berghoff. "And some hygienists and dental assistants will only consider [working in] offices that have already implemented EMR," she says. As such, distributor reps should work closely with their dental customers to put together an organized plan for adopting an innovative EMR from a trusted supplier who can offer a comprehensive integrated package and a strong support infrastructure.
"Today, more patients are looking to be part of their treatment plan, [as well as] pay their bills online," says Christodoulou. Dentists increasingly will need the tools to facilitate this, she adds.
Patients notice when a dental practice offers such services as digital radiography and e-mailed appointment reminders, says Hein. So, dentists will increasingly depend on EMR to remain competitive and attract new patients.
"For the practice that [can’t] do it all, [reps should suggest they] start by purchasing the front desk (practice management) software and train for a couple of days on this," says Berghoff. "Later, the practice can bring in a trainer to incorporate the clinical aspect. [In the end], reps should understand what EMR is, what their customers’ needs are and how to get there."
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