Project on Clinical Data Integration

Articulating dental
and medical care and data for patients to support
optimal chronic care, prenatal care, pediatric care
and other categories of care

Health Care Reform Community Discussion

Medical/Dental Integration Site Entry Point: http://www.infroref.org/MedDentDataArtic.htm

Page 18

A Healthcare-Focused Community Discussion for
the Obama-Biden Transition Team on
Integration of Medical and Dental Care and Data,
Wednesday, December 17th, 2008, 12:00 noon EST
(to accommodate time zone variance
Webex or conference call participants = 9:00 am PST,
10:00 am MST, 11:00 am CST.)

Robert Morris University, Moon Township, PA,
Benjamin Rush Center, which houses the RMU
Doctor of Nursing Practice (DNP) and
Nuclear Medicine Technology (NMT) programs.

This discussion is dedicated to the memory of Diamonte Driver, a 12-year-old boy with no access to dental care who died from complications of an abscessed tooth.

 

Text Box: The Washington Post reported today (February 2007) that a twelve year old Prince George's County, Maryland boy died Sunday after the infection from an abscessed tooth spread to his brain. The boy had not been receiving routine dental care.  According to the report, twelve year old Diamonte Driver first complained of a headache six weeks ago. He was treated at a hospital for a tooth abscess, sinusitis and the headache. Shortly after beginning treatment, he was hospitalized at Children's Hospital in the District of Columbia and underwent two brain surgeries, the Post said.  Diamonte's mother did not have dental insurance or Medicaid coverage; a timely $80 tooth extraction could have saved his life, according to the Washington, Post.The Post reported that when Diamonte first began experiencing a toothache, his mother was having trouble finding a dental provider who would accept Medicaid to extract six abscessed teeth from Diamonte's younger brother DeShawn.. After finally finding an oral surgeon who would accept Medicaid and making an appointment for DeShawn, she learned that her Medicaid coverage had lapsed and canceled the appointment. The coverage lapse apparently occurred when her family had moved from the homeless shelter address listed on the Medicaid application.  Source: http://www.associatedcontent.com/article/163856/child_dies_for_lack_of_dental_care.html President-elect Obama has made it clear that health care reform is one of his top priorities. That's why the Obama-Biden Transition Team is asking people to give their own thoughts and ideas for how to fix the system at Health Care Community Discussions all across the country.

Health Care Community Discussion on Integration of Medical and Dental Care and Data: Date and time: Wednesday, December 17th 2008, beginning at 12:00 noon Location: Robert Morris University, 6001 University Boulevard, Moon Township, PA 15108-1189, Benjamin Rush Center; Conference call and Webex information TBD (for remote participation information email or call co-hosts):

·         Valerie J. H. Powell, RT(R), PhD, RMU Computer & Information Systems, at 412-397-3467 (departmental office at 412-397-3430; fax: 412-397-2481) or Powell@rmu.edu (focus: medical informatics) or

·         Franklin M. Din, DMD, MA, Senior Informatics Consultant, Apelon, Inc., Ridgefield, CT, at 609-751-1055 or fdin@apelon.com (focus: dental informatics) or

Co-Sponsors:

Robert Morris University (School of Communications and Information Systems
and
School of Nursing and Health Science), Moon Township, PA

Apelon, Inc., Ridgefield, CT (Corporate Member of HIMSS)

RMU Moon Campus (location of Benjamin Rush Center) is about 15 min. from Pittsburgh International Airport.

For directions, RMU web site: www.rmu.edu link to visitors

Persons who schedule participation and notify us, sending phone number, email address and a 1-paragraph bio for the discussion report, will be listed here. R.S.V.P.: Please indicate (1) remote participation so we will send Webex and conference call information or (2) participation in person, as we want to have lunch and documents ready for you if you will be present in person. Participant Bios on page 18a: MedDentDataArtic18a.htm

Participant Statements on page 18b: MedDentDataArtic18b.htm

Coverage of Teleconference in Pittsburgh Tribune-Review: http://www.pittsburghlive.com/x/pittsburghtrib/s_603452.html

North Carolina: About NCHICA: The North Carolina Healthcare Information and Communications Alliance, Inc. (NCHICA) is a nonprofit consortium of 230 organization dedicated to improving healthcare in North Carolina by accelerating the adoption of information technology. NCHICA members include: hospitals and clinics; medical and dental practices; professional societies and nonprofit associations; national, state and local health agencies; health plans; law firms; healthcare and IT consulting firms/vendors; health education and training providers; and research organizations. For more information, visit www.nchica.org.

HIMSS Davies Public Health Awards 2008 – CHO category including dental; see http://www.himss.org/ASP/ContentRedirector.asp?ContentID=68465&type=HIMSSNewsItem

·        Columbia Basin Health Association (Washington)

·        White River Rural Health Center (Arkansas)

·        Community Health Access Network and Member CHCs (New Hampshire)

Our panel of participants/contributors [time zone in brackets]
(
( = Participated in teleconference Dec. 17th):

·         Ms. Joanna C. Baker, ( MSPH, MT(ASCP)cm SC C QPOCTE, Laboratory Information Officer, Department of Pathology, Moncrief Army Community Hospital, Fort Jackson, SC 29207 [EST]

·         Dr. Frederick Eichmiller, ( VP & Science Officer, Delta Dental of Wisconsin, 2801 Hoover Road P.O. Box 828, Stevens Point, WI 54481 [CST]

·         Dr. Len Finnochio, Senior Program Officer, California Healthcare Foundation, Oakland, CA [PST]

·         Dr. Matt Holder, Louisville, KY; practice focus: interdisciplinary medical, dental and behavioral clinic to serve people with ND/ID. [EST]

·         Dr. Ron Inge, ( Institute for Oral Health, Seattle, WA [PST]

·         Ms. Susan Johnson, ( Director, King County Health Action Plan, Public Health - Seattle & King County, Seattle, WA 98104 [PST]

·         Mr. Kenneth F. Chenosky, ( Oral Health Program Administrator, Division of Health Risk Reduction, Pennsylvania Department of Health, Harrisburg, PA 17120 [EST]

·         Dr. Michael Josef Kowolik, BDS, PhD, ( Associate Dean for Graduate Education, Indiana University School of Dentistry, Indianapolis, IN; research focus: connecting periodontal disease and type 2 diabetes. [EST]

·         Ms. Darlene O’Neill, ( Business Manager, Institute for Oral Health, Seattle, WA [PST]

·         Mr. Herbert Ong, ( President, Dental Medical Analytics Corporation, Seattle, WA [PST]

·         Ms. Lisa Podell, ( Manager, Kids Get Care Program, Seattle, WA [PST]

·         Mr. Shaun C. Shakib, MPH, Medical Informaticist, 3M Health Information Systems, Inc. [CST]

·         Dr. Justin B. Starren, ( MD, PhD, Assistant Director for University of Wisconsin Institute for Clinical and Translational Research (UW-ICTR), Director Biomedical Informatics Research Center at Marshfield Clinic, WI [CST]

·         Dr. Miguel Humberto Torres-Urquidy, ( Center for Dental Informatics, School of Dental Medicine, University of Pittsburgh [EST]

·         [Possible] Dr. Ignacio Valdes, University of Texas Health Science Center at Houston, Houston, TX, and Editor, Linux Medical News. [CST]

·         Ms. Mary Young, ( RDH, MHA, Institute for Oral Health, Seattle, WA [PST]

·         [Possible] Dr. John L. Zimmerman, Assistant Dean for Information Resources at Columbia University’s School of Dental and Oral Surgery, ,Associate Director of the Columbia Center for New Media Teaching and Learning, and Assistant Professor in both the School of Dental and Oral Surgery and the College of Physicians and Surgeons in the Department of Biomedical Informatics [EST]

Contributors/Participants who have joined the panel since December 17th:

 

Statements by Participants or others: See page 18b: MedDentDataArtic18b.htm

·         Leslie A. Best, Chronic Disease Director, Pennsylvania Department of Health, Room 1000, Health and Welfare Building, Harrisburg, PA  17120

Relevant documents, statements, or links submitted:

·         A Participation Guide has been received from Secretary-Designate Tom Daschle and is being emailed to each participant. See Participant Guide reference list below with many online links.

·         American Academy of Pediatrics, AAP Highlights, October 11, 2008, “Oral Health Focus of PEDS 21,” and “A Message from the AAP President,” submitted by Dr. Wendy Mouradian, Associate Dean for Regional Affairs and Director, Regional Initiatives in Dental Education (RIDE), Professor of Pediatric Dentistry, Pediatrics, Dental Public Health, Sciences and Health Services (Public Health), University of Washington School of Dentistry, Seattle, WA; at http://s23.a2zinc.net/clients/aap/nce2008/CUSTOM/101108AAPHighlight.pdf . Dr. Mouradian pointed out that, “in her speech in October at the American Academy of Pediatrics, AAP President Renée Jenkins called for integration of dental and medical electronic records.”

·         Dr. Matt Holder, Louisville, KY, wrote that in building an interdisciplinary clinic, “Our very first question was ‘how can we integrate our medical and dental electronic records?’ The answer from the dental software people was essentially ‘you can't do it’.”

·         AHLTA Dental Has the Green Light, Sunday, March 16, 2008, Federal Telemedicine News, posted by Carolyn Bloch, “The next generation of AHLTA, the military’s EHR, will soon be able to integrate an electronic dental charting capability to assist military healthcare providers. For the first time in the Military Health System, dental providers will have electronic dental charting tools complimented by point-of-care access to complete medical records, test results, and images. Fielding the integrated medical and dental EHR represents a major milestone in healthcare information sharing. Use of the integrated record in dental care will support the early identification and documentation of oral symptoms which may indicate the presence of systemic health conditions. Through AHLTA, dental providers can document a patient’s screening results in the integrated record and make that information accessible to the patient’s primary care provider and even arrange a medical consultation when necessary,” link sent to us by Dr. Len Finnochio, Oakland, CA; at http://telemedicinenews.blogspot.com/2008/03/ahlta-dental-has-green-light.html

·         Various medical and dental providers have made clear their great concern with regard to the following points:

1.     Potential for medical ID theft (which can affect a person’s medical record, care, and insurability) and financial ID theft because of cybersecurity issues and thus prefer paper records to health information technology (HIT).

2.     Risks to liability due to cybersecurity and medical ID theft issues.

3.     Ricks to integrity of data, and this reliability, due to cybersecurity issues.

4.     Costs to individual and small practices of adopting HIT and impacts on the practices due to costs. This link was forwarded to us: Alex Nussbaum, Bloomberg.com, December 9, 2008, "Insurers, Costs Spurring Faster Rise in Online Medical Records,” at http://www.bloomberg.com/apps/news?pid=20601109&sid=aX4cYX.5J0pg&refer=home ; complaints about interests of “stakeholders” who stand to benefit from for-profit HIT adoption (as distinct from open source or not-for-profit organizations).

·         Dr. Robert Kolodner, ONC, pointed us to the current HHS effort with regard to cybersecurity: http://www.hhs.gov/healthit/privacy/identytheft.html

Participant Guide Reference List (Note online access for many references).

1Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits 2008” (Menlo Park, CA), Kaiser Family Foundation (2008), available at http://ehbs.kff.org/pdf/7790.pdf .

2 C.T. Robertson, R. Egelhof, and M. Hoke, “Get Sick, Get Out: The Medical Causes of Home Foreclosures,” Health Matrix, 18 (2008): 65-105, available at http://works.bepress.com/christopher_robertson/2 .

3 Len M. Nichols and Sarah Axeen, “Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms,” New American Foundation (May 2008).

4 Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine, To Err is Human, Washington, DC: National Academy Press (2000).

5 Elizabeth A. McGlynn et al. “The Quality of Health Care Delivered to Adults in the United States,” NEJM 348 (26): 2635-2645 (June 26, 2003).

6 McKinsey & Company, “Accounting for the Cost of Health Care in the United States” (January 2007).

7 Stan Dorn et al., “Medicaid, SCHIP, and Economic Downturn: Policy Challenges and Policy Responses,” Kaiser Commission on Medicaid and the Uninsured (April 2008), http://www.kff.org/medicaid/upload/7770.pdf .

8 Institute of Medicine, “Care Without Coverage: Too Little, Too Late - Report Brief,” Washington, DC: National Academy Press (2002), available at http://books.nap.edu/books/0309083435/html/73.html#pagetop .

9 P.J. Cunningham, L.E. Felland, “Falling Behind: Americans’ Access to Medical Care Deteriorates, 2003-07,” Center for Studying Health System Change, Tracking Report No. 19 (June 2008).

10 Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson, “Chronic Conditions: Making the Case for Ongoing Care,” Partnership for Solutions, Johns Hopkins and Robert Wood Johnson Foundation (2004).

11 Center for Disease Control and Prevention, “Chronic Disease Overview,” http://www.cdc.gov/nccdphp/overview.htm .

12 Center for Disease Control and Prevention, “Preventing Chronic Diseases: Investing Wisely in Health,” http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/diabetes.pdf .

13 Jeanne M. Lambrew, “A Wellness Trust to Prioritize Disease Prevention,” The Hamilton Project, Brookings Institution (2007), available at http://www3.brookings.edu/views/papers/200704lambrew.pdf .

14 Agency for Health Care Research and Quality, “Screening for Breast Cancer: US Preventive Services Task Force” (February 2002), available at http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm; American Academy of Family Physicians, “Periodic Health Examinations: Summary of AAFP Policy Recommendations & Age Charts,” available at www.aafp.org/exam.xml ; Feig, SA, D'Orsi, CJ, Hendrick, RE, et al., “American College of Radiology Guidelines for Breast Cancer Screening,” American Journal Roentgenology, 171:29, 1998; Amir Qaseem et al, “Screening Mammography for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians,” Annals of Internal Medicine (April 2007) Volume 146, Issue 7, Pages 511-515, available at http://www.annals.org/cgi/content/full/146/7/511 .

15 National Center for Health Statistics, “National Health Interview Survey in Health, United States, 2007 with Chartbook on Trends in the Health of Americans,” Table 87, available at http://www.cdc.gov/nchs/data/hus/hus07.pdf.

16 Centers for Disease Control and Prevention, “2008-09 Influenza Prevention and Control Recommendations,” available at http://www.cdc.gov/flu/professionals/acip/flu_vax_adults0809.htm#box2 .

17 National Center for Health Statistics, “National Health Interview Survey in Health, United States, 2007 with Chartbook on Trends in the Health of Americans,” Table 85, available at http://www.cdc.gov/nchs/data/hus/hus07.pdf .

18 Agency for Health Care Research and Quality, U.S. Preventive Services Task Force, “Guide to Clinical Preventive Services,” (2008), available at www.ahrq.gov/clinic/prevnew.htm .

19 National Center for Chronic Disease Prevention & Health Promotion, “Behavioral Risk Factor Surveillance System: Cholesterol Awareness 2007,” (2007), available at http://apps.nccd.cdc.gov/brfss/list.asp?cat=CA&yr=2007&qkey=1487&state=All .

Our submission to the Transition Team to establish the discussion:

    1. Date and time of event:

                                                              i.      Wednesday, December 17th 2008, beginning at 12:00 am noon EST (to accommodate participants from West Coast).

    1. Please describe your event:

                                                              i.      A full and frank discussion about the importance of including dental records as part of a comprehensive effort to enable a fully semantically interoperable health record.  The move toward this integration can be tracked through the past 18 years, but there has been little concrete progress. This current discussion is the direct result of the interest and encouragement shown by Dr. Robert Kolodner, ONC to issues regarding the integration of medical and dental.

    1. What are the major areas you want to discuss?

                                                              i.      Benefits in patient safety and quality of care from ability of medical and dental providers to have shared access to records of patients cared for by clinicians from both disciplines.  This avoids having two streams of care, medical and dental, both with medication and surgery events, affecting the same patients.

                                                             ii.      e-prescribing of pharmaceuticals is a common function that applies to both medical and dental records.  Similar benefits should accrue from the implementation of e-prescribing.  How can dentistry adopt e-prescribing?

                                                           iii.      A quick review of where the dental profession is on interoperability.

                                                          iv.      Address the challenges of integration of medical and dental care and data:

1.      EHR/EDR products with no provision for sharing data.

2.      The model being used to develop NHIN continues to support medical and dental care silos and thus should be reviewed with a goal of integration.

3.      Competing models from various RHIO, HIE, etc. have the potential to balkanize the effort to integrate medical, and dental records.  Where possible, standards should be established to prevent this.

4.      Dr. Kolodner, ONC, has recommended revising use cases to assure explicit inclusion of dental care and to explicitly state that both dental and medical clinicians/providers are covered by use case documents that support NHIN standards harmonization, by utilizing inclusive terminology.

5.      Lack of a generally agreed upon model for efficient interdisciplinary communication.  We need to mobilize an effort to achieve consensus on such a model

6.      Attention to cybersecurity, integrity of EHR/EDR from medical/dental ID theft impacts, and cost concerns of individual providers.

7.      Alignment with AAMC/ADA recommendations on medical and dental interoperability.

                                                            v.      Prioritize an action plan that address each of the agenda discussion points.

    1. Why should the health policy team send Scty.-Designate Daschle to your event?

                                                              i.      This is a topic that is not received any national-level focus. Scty.-Designate Daschle’s participation will be a real boost to the efforts of those of us engaged in the effort and will assure that integration of medical and dental care and data receives adequate attention and priority in the national health care agenda.

                                                             ii.      The meeting is virtual so Scty.-Designate Daschle does not actually have to travel to be fully engaged.

                                                           iii.      It is vital to be sure that the new HHS leadership will be informed regarding the significance of this effort in optimizing U.S. healthcare so that HHS can provide informed leadership.

 

Agenda format comments: We will need to manage the proposed agenda. We can spend a lot of time on any specific issue and I think the 1-1.5 hr. limit should apply to this meeting. Thus we will need to condense the arguments, discussions, etc. into some consensus prior to the meeting. We suggest that we use the time prior to the meeting to exchange documents to try to achieve as much harmony as possible. In theory, the meeting will be to allow unresolved dissent a public hearing, which hopefully will speed the proceedings. There is no need for complete agreement at this time. For any official determination of the group, the Supreme Court model seems to work well. A consensus statement (in the form of the action plan) with a short, well-reasoned dissent attached to each point. A one-paragraph bio will be requested from every participant.

We all need to bear in mind that we should focus on these issues at the policy level. We should not get bogged down in details, which can all be worked out later.

Principal supporting document: Valerie J. H. Powell and Franklin M. Din, “Call for an Integrated (Medical/Dental) Health Care Model that Optimally Supports Chronic Care, Pediatric Care, and Prenatal Care as a Basis for 21st Century EHR Standards and Products: EHR Position Paper,” Based on a paper distributed at the Conference on the Electronic Health Record: Best Practices and New Horizons, Wake Forest University Translational Science Institute, Winston-Salem, NC, USA, October 1-3, 2008; and presented for the Institute for Medical Biometry and Medical Informatics (IMBI), Albert-Ludwigs-Universität, Freiburg im Breisgau, Germany, October 13, 2008

 

Updated March 10, 2009