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There is chatter among physicians, dentists and others in the health care community that the federal government will require health records to be electronic by 2014. The ADA is working hard to keep members updated on developments and to streamline the process. As chair of the Board of Trustees' Electronic Health Record Workgroup, Dr. Robert Faiella, ADA 1st District trustee, has been monitoring the issue and working to keep members informed. Below is a Q&A with Dr. Faiella about the EHR.

Q. How did the national movement toward adoption of an electronic health record begin?

A. The initiative to improve the availability of biomedical information began in 1965 by the National Library of Medicine, mainly to provide a resource for the medical community. However, in 2001, the National Committee for Health and Vital Statistics published "A Strategy for Building the National Health Information Infrastructure," which urged collaboration to improve the quality of care, increase access, improve patient safety and lower costs, while increasing efficiency in health care systems. This is a major shift from collection of information to providing coordinated information services to improve the delivery of health care.

In 2004, as a result of an executive order by the Bush administration, a strategy for health IT implementation was established, Secretary of Health and Human Services Tommy Thompson created the Office of the National Coordinator for Health Information Technology to coordinate federal IT expenditures and encourage adoption of electronic health records. These EHRs are defined as health-related information for an individual that conforms to nationally recognized interoperability standards and can be created, managed and consulted by authorized providers across more than one health care organization.

Q. What is the ADA doing to develop an EHR system?

A. Initially, the role of the ADA began shortly after HHS issued four requests for proposals in 2005 to pave the way for the development and implementation of a strategic plan to guide the nationwide implementation of health IT. The proposals were evaluated to determine how the ADA could position itself as the resource and advocate for dentistry's portion of the National Health Information Infrastructure.

A recommendation was approved by the ADA Board of Trustees at its April 2005 meeting to establish the ADA NHII Task Force to recommend strategic direction and policy regarding ADA positioning in the NHII. As the strategic direction moved toward how the ADA would become involved in the dental component of the EHR, the task force was dissolved in 2007, and the ADA Electronic Health Record Workgroup was established. The charge to the workgroup was to begin development and subsequent implementation of the dental components of the electronic health record, as well as coordinate EHR activities across ADA agencies.

Strategy: This chart illustrates which advisory groups will report to the Electronic Health Record workgroup. The advisory groups were formed within each area of need assigned under the ADA council with appropriate bylaws authority.

As chair, I realize that much of what is to be accomplished can occur through the expansion of the EHR workgroup by establishing advisory groups within each area of need, assigned under the ADA council with appropriate bylaws authority. As such, the workgroup will provide strategic oversight for the overall initiative, and coordinate the actions of the advisory groups working within the council structure (see chart). The advisory groups will oversee the work product involving development of standards for the EHR, vocabularies needed to document what we do, provide education to the membership, advocate for dentistry regarding HIT on the federal and state level, provide liaison activities with other standards development organizations globally, and participate in the certification of compliant systems for dentistry.

Q. Who would be eligible to implement an EHR?

A. Clearly, all dentists will be eligible to implement an interoperable EHR, when available. At this time, however, vendors are providing a standalone electronic dental record system, which may be used within a single practice or organization. What is lacking is the true interoperability intended among multiple systems.

It is important to understand that the American Recovery and Reinvestment Act contains specific laws and incentives that apply to health information technology, specifically referred to as the Health Information Technology for Economic and Clinical Health Act. Under these provisions, approximately $20 billion has been allocated toward adoption of HIT and Medicaid/Medicare incentives. Under the HITECH Act, CMS administers the EHR incentive programs under Medicare and Medicaid. In addition to providers, federally qualified health centers, children’s hospitals and rural clinics may be funded through the Medicaid program, coordinated through the states. It should be noted that the HITECH Act does not currently provide any incentives for dental school clinics, and the ADA has been working with the American Dental Education Association to provide comment to CMS regarding this potential barrier.

It has been estimated that dentists may qualify for up to $63,750 for implementation of an interoperable EHR under the existing HITECH incentives.

However, in order to qualify, there are two criteria that an eligible provider must meet: use of a certified EHR to achieve "meaningful use" within the context of the regulatory definition and a patient population of at least 30 percent Medicaid beneficiaries.

Currently, there is no final definition of "meaningful use" for dentistry (as well as certain specialty areas of medicine), and we have been working closely with the ONC to define that framework, and the ADA has provided comments to the CMS proposed rule defining meaningful use. The initial definition was not applicable across all provider types. The ONC has been primarily focused on quality measures for each area, and the ADA has taken a leadership role in the Dental Quality Alliance as approved by the House of Delegates in identifying those outcome measures and indicators for the profession. Until this has been defined, dentists may not be eligible to qualify for the incentives.

In addition, the current estimate of the number of eligible practices with a threshold of 30 percent Medicaid participation is approximately 12,000.

Of course, there is a larger business case for general adoption of EHR by dentists beyond those defined under ARRA. The ability to track outcomes, provide risk assessment for your patient populations, prescribe electronically, and obtain valid medical and laboratory histories may enhance delivery of care and improve patient safety.

A detailed description of health care provisions of interest to dentists under ARRA can be obtained from the ADA Division of Government and Public Affairs or by visiting the website www.ada.org/sections/advocacy/pdfs/hitech_in_arra_for_dentistsfin.pdf.

Q. What would it cost a dental practice to implement EHR?

A. Costs for implementation will vary based upon the level of electronic adoption already in place, as many practitioners are using electronic and digital data within their practice systems. In addition, the size of the practice and training of staff members will also affect the total cost. Estimates range from $20,000 up to $100,000, depending upon the size and demands of the practice.

Q. What are the benefits of EHR?

A. The benefits of an interoperable record were outlined in the initial NHII initiative. Informing clinical practice is believed to be fundamental to improving care and making health care delivery more efficient and safer. Bringing the appropriate portions of electronic health records directly into the clinical practice is expected to reduce medical errors, avoid redundant tests and treatment, and provide the opportunity for clinicians to focus their efforts on improved patient care.

The interoperability will allow the appropriate information to be portable and to move with patients who consume health care from one point of care to another. In this way, patient-centric information can be used to manage wellness and assist with personal health care decisions.

Q. What are the concerns?

A. First and foremost, the privacy and security of health information is essential for any interoperable system. In September 2009, the Health IT Standards Committee endorsed a set of security and privacy standards for electronic health record systems. The standards clarified requirements that electronic health record systems must meet so both vendors and health care providers could use a number of access controls in their electronic health record systems and practices.

The HITECH provisions of the economic stimulus legislation toughened HIPAA's security and privacy rules, and these standards are designed to enhance those rules.

Q. How will the ADA educate tripartite members and constituent states about EHR?

A. The provision of appropriate information to the membership is the charge to the Members Advisory Group, under the bylaws authority of the Council on Dental Practice. The scope of their charge is to provide and promote educational and implementation material about the electronic health record for the Association, the profession and public. This will include specific information to the tripartite to foster an understanding on the constituent level, in order to help state societies to engage in the development of state health information exchanges.

Q. What is the timeline for developing an EHR?

A. Since the Bush administration announced the goal of an interoperable electronic health record for all Americans by 2014, the recent push by the Obama administration for adoption of health IT as a significant means to achieve health care reform is likely to promote adherence to that time frame. We are working through the Office of the National Coordinator to position dentistry for implementation, which includes certification of compliant systems that meet the standards set for the dental component of the record.

In April 2009, President Obama announced the creation of a Joint Virtual Lifetime Electronic Record through the Department of Defense and the Department of Veterans Affairs as a system to seamlessly share medical information from the time a person enters the military, throughout their service, and after they leave active service. The announcement set the stage for the DoD and VA system to take the next step in the EHR implementation and interoperability on the federal level.

Q. What laws or regulations will dentists have to comply with?

A. The laws and regulations governing the sharing of electronic health information are evolving. The intention to provide for the appropriate dissemination of health information will be tempered by statutory and regulatory restraint and accountability. The Advocacy Advisory Group, under the oversight of the Council on Government Affairs, will monitor the legal requirements and regulatory activity for the appropriate implementation of the EHR in dentistry, and keep the membership informed as regulations are released.