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September 12, 2008

By Carol Tekavec, CDA, RDH

There are certain aspects of record keeping that are basic to the endeavor, whether a dentist is using paper or computerized charts. According to a mandate presented in 2004 by President Bush, health-care providers are expected to be using digitized records by 2014. That is only six years away!

Digitized records are already being used in many offices for a portion of necessary record keeping. Often, this includes financial records and reports, accounts payable and receivable, insurance claims and follow-up, statements, and others. A few dental offices — some sources say only 1.8% — are using digitized records for all aspects of patient care. In general, issues surrounding software, security, and expense are slowing progress toward total electronic records for patients.

On the medical side, many hospitals and physicians have already encountered problems with computerization. On the dental side, some of the issues are similar. The rest of the world is computerized. Health care eventually will be as well. Here are a few of the hurdles currently facing digitized records:

• Universal standards — The ADA is working to develop standards for what constitutes an electronic health record. The ADA Standards Committee on Dental Informatics is comprised of 60 voting members from 60 organizations. That is a large number of individuals to get "on the same page" concerning any type of concrete format. The members work on subcommittees devoted to several general subjects. These include Devices, Electronic Dental Records, and Electronic Dissemination of Dental Information. Their purpose? To develop voluntary consensus standards. (Source — ADA.org. ADA Standards Committee on Dental Informatics ADA SCDI) Standardization is essential for a useful "universal" style health record. Reports are being generated, but the task is daunting.

• Assorted barriers — According to the HIPAAdvisory online Web site, an electronic health record may be thought of as a depository of information which includes "all clinical and administrative information about a patient's care throughout his or her lifetime. The documentation of any practitioner ever involved in a person's health care would be included in the record, from prenatal to postmortem information." According to the HIPAA site, barriers to this type of electronic health record include:

a. Lack of clinician acceptance

b. Concerns about inability to align workflow with a standardized electronic health record (EHR)

c. Concerns that automation of clinical charting requires more time than paper charting

d. Lack of uniform standards for documentation of clinical services

e. Lack of standardized technical platforms to support EHR (If an office adopts a certain system, will it be compatible with any other system or payer program?)

f. Lack of support for startup expenses (A paper chart can cost as little as $1.00 per chart, while computerization expenses can run into thousands of dollars.)

• Anecdotal reports — Reviews by individual clinical operators are often less than glowing. For example, in Healthcare Informatics magazine, April 2008, an article titled "Trouble at the Bedside" chronicled the issues nurses are having with wireless methods of accessing patient information on laptops rather than using a paper chart. The nurses found that they "had to strain their eyes in order to read the information on the compact screens. Some even had to get bifocals." To remedy this problem, "the staff brought in bigger models that were easier to read, but difficult to maneuver. The devices (larger computers) sustained a great deal of damage from being picked up improperly and dropped." In addition, nurses also reported being unhappy concerning the amount of technology for record keeping that was being required. According to Marion Ball, professor at the Johns Hopkins School of Nursing, "Their job is not to be technologists. They're there, believe it or not, to take care of the patient." Many in dentistry feel the same way.

• Format/field limitations — Finally, a 2007 analysis in the Journal of the American Medical Information Association made this conclusion: Current computerized dental record models do not cover all of the information (due to limited fields) that may be included in a paper record. In other words, for the time being, a paper record may be more complete.

With all of these issues, are there any advantages? Proponents of computerized records list the following as advantages to an electronic health record (taken from the HIPAAdivsory Web site):

1. Immediate and universal access to patient records

2. Quicker navigation through patient records

3. No lost charts

4. Standardization of care among providers in an organization

5. Clinical data formatted to be easy to read and analyze

6. Reduction of paperwork, documentation error, and filing activities

7. Coding efficiency

8. Alerts for medication errors, drug interactions, and patient allergies

9. Ability to electronically transmit information to other providers

10. Availability of clinical data for use in quality, risk, and utilization review.

Finally, dentists, physicians, nurses, and hospitals would likely support computerized records more wholeheartedly if there were comprehensive, logical, easy-to-use models available. In addition, issues concerning security continue to plague computerized systems and worry health-care practitioners. Cost is also a huge problem. It is difficult to persuade practitioners to invest in computerization when they are already facing so many other economic obstacles.

Eventually, electronic record keeping will be embraced — or forced upon — the health professions. How these records will "look" remains to be seen. Proponents of digitized records say computerization will eliminate a host of difficulties, including lost information and lost charts. However, many others in the health professions say, "What happens when the computer goes down?"

Carol Tekavec, CDA, RDH, is the president of Stepping Stones to Success and a practicing dental hygienist. She is the author of six patient education brochures, a series of informed consent forms, and the Dental Insurance Coding Handbook. She is also the designer of a patient chart, The First Encounter™, which has been endorsed by the Colorado Dental Association and others. Contact her at (800) 548-2164, or visit www.steppingstonestosuccess.com.

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