implementation of an electronic dental record, dentrix, at

Evolution or Revolution?EDRs as a Vital Component of

CHC Dental Practice Expansion

Clifford Hames, DDSDental Director/CDO/CICO

Hudson River HealthCare, Inc.

National Primary Oral Health ConferenceSan Diego, California

December 12, 2007

EVOLUTION?

or REVOLUTION?

‘Evolution’ or ‘Revolution’, which wordbest fits the development of today’sEDRs?

1984: The dawn of the Personal Computer (GUI)

2007: Dentrix (G2)

WHO SAID?….

“I only hope that we never lose sight of one thing–that it was all started by a mouse.” Walt Disney!

What’s next after the…..

iPhone????

“I DK MY BFF, DAVID!”

iTooth with Bluetooth! iPhone

Background…..

2000: U.S. Surgeon General, Dr. David Satcher, issues report card on the state of oral health in the U.S.

2002: President Bush’s creates health center expansion initiative which mandates that oral health be included as an integral component of the process.

Oral health is recognized as an important part of the new site/expansion formula!

2002-2008: Expansion networking multiple dental sites with an EDR share patient data with an EMR to create an EHR.

SULLIVAN

Pine Plains

Amenia

POUGHKEEPSIE (2)Dover Plains

BEACON

PEEKSKILLCHC+School-based

Greenport

Monticello

New Paltz

WALDEN

GOSHEN

Health Center

Migrant Health

Migrant Voucher program

Public Housing

(Dental in BOLD CAPS)

Haverstraw

DENTAL VAN

+

How did we CONNECT all of our HRHCare sites?

So how did HRHC Dental go digital?PHASE I: Digital Radiography/Ø EDR

2000 2 Dental sites, Peekskill and Goshen, in our 3 site network. Both using x-ray film and paper charts.

2001 Beacon Dental space started with only 500 sq. feet No room for a traditional darkroom. DenOptix was the only digital PP system for both BWs/PAs and

Pans. Image server located onsite. Paper charts.

2004 Peekskill Dental adopts digital radiography. Image server onsite. Peekskill still using paper charts. Goshen using film and paper charts.

2005 Walden Dental opens with digital radiography and paper charts. Image server onsite.

Our Peekskill dental practice in 2000:-Organized but in needof a “makeover”

HRHC’s Dental Sites/Programs in 2007:

Peekskill CHC (since 1975):

HRHC’s Dental Sites and Programs in 2007:

Peekskill’s School-Based Sealant & Fluoride Rinse Program (since 1985)

Communication with Patient Communication with Staff

Commitment to the Community

HRHC’s Dental Sites and Programs in 2007:

Peekskill’s School-Based Sealant & Fluoride Rinse Program:

Collaboration with School Nurse Caries Control Education

Cooperation with Teachers

Working in small spaces….Nurses’ Offices and Little Mouths

Confined spaces with no room for computers

And yet IMPRESSIVE results…..With GREAT retention…..

Sealant Retention rates after 1 year of placement

96.698.4

100.098.7

91.1

99.2

92.1

97.9

98.4

91.6 91.9

93.7

98.8

86.6

93.2

75

80

85

90

95

100

1996 1997 1998 1999 2000

Cohort

Percent

Mandibular Occlusal Maxillary Mesial Maxillary Disto-lingual

With 50% reduction in caries!HRCH School-Based Sealant Program 1996-2001

Sample Size N = 140 ChildrenThese children remained in the program for ALL 6 years

0

0.5

1

1.5

2

2.5

3

3.5

1996 1997 1998 1999 2000 2001

Years

Total # Variables

TDMFS

TCAR

TFILL

HRHC’s Dental Sites and Programs in 2007:

Goshen [Migrant CHC]:(since 1990)

HRHC’s Dental Sites and Programs in 2007:Beacon CHC(11/01,7/06):

HRHC’s Dental Sites and Programs in 2007:

Walden (8/05):

HRHC’s Dental Sites and Programs in 2007:

Poughkeepsie Family Partnership (1/07):

2006: Setting the stage for going digital with an EDR….

Basic concepts, vision, and mission remain the same for patient care.

Whatever worked on paper should have a digital counterpart AND take less time!

Be aware of work flow changes to maximize digital technology. Less paper, more scanning!

Modify job descriptions with new changes. A “chartless” office is NOT “paperless!”

WHO here is using a comprehensive medical-dental paper chart?

WHAT happens to your paper dental chart when Medical goes with an electronic record?

WHEN will Medical shift to an EHR? WHERE will your paper dental chart be

stored AFTER Medical shifts to an EHR? WHO will bring your paper dental chart to you?

8 Important Questions to consider:

8 Important Questions to consider:

WHY NOW? HOW will you be able to see your patient’s medical

notes, Rx histories, etc. after Medical shifts to an EHR?

HOW do you plan to seek FUNDING to expand your dental practice and implement an EDR?

HOW will YOUR role change as Dental Director AFTER the expansion of your dental practice and implementation of an EDR?

Establish your budget:

Include: Capital Improvements (Architect, Plumbing,

Electric, Carpentry, HVAC) Office furniture for staff and patients Large Equipment Needs (Dental & IT) Small Equipment Needs (Dental & IT) Dental Supplies Extra Personnel

When adding more locations....

Evaluate access to: The building The dental department The treatment room The dental chair

Translate preliminary layouts of space into bubble diagrams separating: Reception/Waiting Space Business Area Clinical Area

B

WC

PHASE II: Planning for a “chartless” office

Review your daily operations step-by-step from the moment staff walk in the door in the morning to when staff leave at night.

Evaluate the computer competency of ALL staff.

Realize the paradigm shift in going digital and chartless will affect other areas of your CHC: Medical Records staff and how they will pull charts How demographics will be transferred from centralized

practice management software to EDR (HL-7) Other clinical services and how you share information with

them as well as how they share information w/you

Utilize the Information Highway Infrastructure from digital radiography when preparing for an EDR….

As sites were being upgraded or constructed, new cabinetry would reflect the inclusion of computers, flat screens, keyboards, mice.

EDRs function better with flat screens which take up less space than CRTs.

EDR servers were centralized in Beacon from inception in 2006 to: Facilitate access to patient information Simplify internal backup of data. Improve management of information

by department leadership.

Planning for a “chartless” office

Questions to consider for YOUR office space: How many computer stations will you need in

total? Business Area? Reception Area? Clinical Areas?

Dental Treatment Room Dental Sterilization/Lab Room Dental Radiograph Processing Room Doctors’ Offices Director’s & Office Manager’s Offices

Planning for a “chartless” office

Questions to consider for the treatment room: Where will I place my computers in the dental operatories?

Behind? Front? Side? Of patient? Do I need new cabinets or do I have space for a computer

cart? Where should I place the keyboard, mouse, and monitor for

best viewing by staff and patient? Are wireless peripherals better than cables? How can I protect my computer

from water spray?

Planning for a “chartless” office

Digital Radiography Evaluate the advantages and disadvantages of

having digital radiograph processing of x-rays in place BEFORE becoming “chartless”. ADVANTAGES:

No more chemicals, waste disposal, film storage/processing “darkroom”, equipment maintenance.

Opportunity to lay down the hardware infrastructure in preparation for adding the EDR in the future

Less expensive up front than starting out with an EDR Great way to EDUCATE your patient with large x-ray

images Easier way for dentists to consult from remote locations.

Planning for a “chartless” office

Digital Radiography DISADVANTAGES:

Difficult to “retrofit” (transfer) previous digital images into integrated EDR image software even though DICOM compliant; thus, need to maintain former database of images.

Image Quality (Image 4.5 software processing) Images vanishing into cyberspace (ScanX) Doing Digital Radiography first requires:

an additional local server at each site to store/retrieve digital radiographs within a database, and/or

a central server to store all patients from all sites.

YOU choose which digital system best suits the needs of your office….Sensors vs. Plates

Planning for a “chartless” office

Work closely with the Information Technology (I.T.) group in your organization and realistically plan your expansion budget. Consider your needs and # of connections for:

Telephone Communication Computer Networking within your location as well as

outside your location Computer Servers for your electronic dental record as

well as image management

Plan for IT staff to meet with the electrician.

Our I.T. Department and Server ‘Hub’ at our Beacon site.

You’re only as strong as your weakest link!

Key Points to Remember:

Count the maximum number of all computers operating at the same time, including EHR (medical) computers and practice management (billing) computers, plus phones to determine the proper configuration and minimum requirements to give you maximum speed.

Connecting multiple sites will require a minimum of T1 line speed of 1.544 Mbps.

It’s ALL about BANDWIDTH!

T1 versus Cable versus Dial-up

T1 = 1.544 Mbps (Megabits/sec) Fractional T1 = cheaper than a full T1 line with

growth options of 56 Kbps or 64 Kbps increments as required.

Compare to Cable: 512 Kbps to 20 Mbps Compare to Dial-Up: 2400 bps to 56 KbpsMbps is a measure of bandwidth (the total information

flow over a given time) on a telecommunications medium, standing for 'millions of bits per second'

Kbps stands for ‘thousands [kilo] of bits per second’

T3 = 44.736 Mbps. Optical fiber. Faster but expensive.

ALL SERVERS HOUSED IN BEACON OFFICE.

Hardware and software recommendations for Dentrix Enterprise connecting with Citrix

Each server (DXOne and DXi) with: Two Processors: 3.4GHz or higher 550 GB of hard drive capacity

(the more the better)

3 GB of Memory Modules (more RAM is better)

Windows 2003 server for the OS MS SQL Server 2000 Standard Edition Antivirus Software

External Backup Tape Drive for both servers

Planning for a “chartless” office

More questions to think about: What type of computers do I need to function?

Thin clients (virtual desktops) versus “fat” clients (actual desktops)

How will our offices be networked? Internally and externally (outsourced)?

Where will the servers be housed? Back up plan? How will you handle no electric, phone/cable/fiber? At your

site or at server site? How will the distance between your sites affect the flow

and speed of digital information?

Servers for Citrix

Each server with: Two Processors: 3.4GHz or higher 140 GB of hard drive capacity

(for now!) 2 GB of Memory Modules

(the more RAM the better) Windows 2003 server for the OS Antivirus Software

Citrix presentation interconnectivity software (Citrix MetaFrame within Windows 2003)

Citrix and Terminal licenses (user count plus 20) Stay with same name brand for servers

(IBM/Dell/HP). Think of future expansions! Think of EHR!

Meet with the EDR software trainer to go over: Who will be your “Champions” or “Super users”. Ground rules, rights, and privileges.

Schedule dates and times to train staff from offices By office or by job function

Stagger “launch dates” for offices to go “live” Appointment lock out Have trainer and “super users” onsite

HRHC Poughkeepsie Beacon Walden Goshen Peekskill

PHASE III: Training Dental Staff on using an EDR….

Opening Day!

Let patients know about the transition and thank them for being patient during the learning curve.

Meet regularly with staff and review progress. Devise schedules for scanning documents,

appointment/insurance confirmation, etc. Provide encouragement! Ask for HELP!

Initial problems we experienced….

Connectivity HL-7 Interface Demographic Data Dump from

Practice Management Software to Dentrix did not map fields correctly and was slower than anticipated.

More distant sites had system traffic issues slowing clinical data insertion at exams, making exam visits and progress notes very frustrating.

Initial system specs recommended were not enough to provide us with the speed needed.

Ongoing problems we face….

Slow transfer of radiographic images over to Dentrix once processed by DenOptix.

Radiograph diagnostic image quality. Computers freezing and locking patient

records when logging into system from another room.

HL-7 demographic transfer timing glitches. No common EHR medication database for

viewing by both EDR and EHR users.

Ongoing EDR Expenses….

Annual tech support contracts Upgrading hardware to accommodate ever

increasing data collection (notes and images) Upgrading computer hardware to keep up

with Operating System changes and new versions associated applications.

Replacing worn, scratched phosphor plates. Costs associated with new EHR HL-7

integration.

Suggestions before you start….

Take some time to get in touch with YOUR VISION.

Visit friends and colleagues for IDEAS. We ALL are graduates of the school of hard

knocks and learn from our mistakes. There are many excellent resources available. YOU ALL ARE THE DENTAL EXPERTS in the

world of community health care services!

More ways to learn….

CHC Online Dental Tools: Safety Net Dental Clinic Manual

http://www.dentalclinicmanual.com/ Mobile-Portable Dental Clinic Manual

http://www.mobile-portabledentalmanual.com/ National Network for Oral Health Access

http://www.nnoha.org/ Dental Management Coalition

http://www.dentalmanagementcoalition.org NEW WEB ADDRESS: www.dmcnet.org

Some excellent resources….

Dr. Harry Demaree; THE Design http://www.thedesign.com/about/harry.php

Dr. Michael Unthank; Dentist & Architect http://www.unthank.com/main.html

Dr. Larry Emmott; http://www.drlarryemmott.com/ “Emmott on Technology,” Dental Products Report

Dr. Barry Freydberg; http://www.hitech2thdoc.com/

Dr. Dale Miles; http://www.learndigital.net/

Dentistry has ALWAYS been about a “DIGITAL” Evolution

Without our fingers, our “digits”, we cannot practice….

As we progress from Dental Student to Dental Graduate, from Dental Resident to Experienced Dentist, our skills with our “digits” have continued to evolve.

The human “touch” with our hands, what we create in terms of relationships, and how we restore oral health is what really matters!

Computers are just new tools to help us.

HP N6010Double-sidedScanner

Thank You!

chames@hrhcare.org