Keywords
medical–dental - axiUm - electronic health record - electronic dental record
Background and Significance
Background and Significance
Oral health is an integral part of total health and wellness, and achieving optimal
oral health and wellness necessitates interprofessional collaboration and coordination
among the health care team.[1] A common electronic health record (EHR) enhances care coordination and facilitates
the exchange of clinical information among care providers.[2] Unfortunately, most medical and dental patient records exist in silos.[3] User-friendly access to dental information is critical to delivering a holistic
care approach.[4] Several large health care systems in the United States have pioneered the integration
of dentistry into their care delivery models.[5]
[6]
[7] To date, no studies or case reports on adapting an electronic dental record (EDR)
for primary medical care within U.S. academic dental centers were found in the extant
literature.
Objective
The primary objective of this case report is to describe the development and implementation
of customized primary care elements into axiUm, a popular dental practice management
software primarily used in dental schools, to facilitate medical–dental clinical integration.
Clinical integration refers to the coordination of person-centered, medical and dental
care at chairside. This work was undertaken to provide the infrastructure for nurse
practitioners (NPs) and dentists to deliver a holistic, person-centered approach to
care at chairside, and facilitate effective communication and care coordination.
Case Description
The Academic Dental Center (ADC) is a state-of-the-art dental care facility located
within the School of Dental Medicine and situated in the Longwood medical area of
Boston, MA. The ADC utilizes axiUm (Exan Group, Henry Schein, Melville, New York,
United States) EDR, a Health Insurance Portability and Accountability-compliant, certified
system that includes billing and practice management applications. The axiUm platform
was designed to address the needs of educational institutions and over 90% of North
American dental schools use axiUm.[8]
Methods
A multidisciplinary design team was guided by three underlying principles. (1) Medical
care components of the EHR are aligned with an evidence-based patient-centered framework
for health promotion and disease prevention. (2) Medical health information is centralized
for convenient, user-friendly access by all health care providers. (3) Data entry,
clinical decision support, and medical coding/billing are priority areas for medical–dental
clinical integration. The design team consulted with end-users to test the workflow
and design of the changes.
Development Process
The Centers for Disease Control and Prevention's Framework for Patient-centered Health Risk Assessments
[9] informed the development process. Medical components of the EHR were derived from
the Medicare Annual Wellness Visit (AWV).[10] Key components and elements of the AWV are listed in [Table 1]. Other important components were included such as patient referrals, appointments,
treatment planning, provider alerts, problems lists, educational resources, progress
notes, and medications.
Table 1
Components of the Annual Wellness Visit
|
Component
|
Specific elements
|
|
Health risk assessment
|
Collect the following information:
• Demographic data
• Self-assessment of health status
• Psychosocial risks
• Behavioral risks
• Activities of daily living (ADLs), including but not limited to: dressing, bathing,
and walking
• Instrumental ADLs, including but not limited to: shopping: housekeeping, managing
own medications, and handling finances
|
|
List of current providers and suppliers
|
Obtain a list of current providers and suppliers that regularly provide medical care
to the patient
|
|
Medical/family history
|
Collect information about:
• Past medical/surgical history
• Current medications and supplements
• Family history
• History of alcohol, tobacco, and illicit drug use
• Diet
• Physical activities
|
|
Review risk factors for depression and other mood disorders
|
Obtain current or past experiences with depression and use any appropriate screening
instrument for patients without a current diagnosis of depression
|
|
Review functional ability and level of safety
|
Use appropriate screening questions to address the following areas:
• ADLs
• Fall risk
• Hearing impairment
• Home safety
|
|
End-of-life planning
|
Provide verbal or written information about the patient's ability to prepare an advanced
directive
|
|
Exam
|
• Height
• Weight
• Body mass index (BMI)
• Blood pressure
• Visual acuity screening
• Any other relevant factors
|
|
Educate, counsel, and refer for other preventive services
|
Include a written plan, such as a checklist, for the patient
|
Source: Adapted from The ABCs of the Annual Wellness Visit, Medical Learning Network,
2014.
Configuring a centralized location for medical information so that patient health
information could be accessed quickly by all providers was a priority. An ideal location
for the addition of medical information was identified within the forms tab of the EHR ([Fig. 1]). New medical templates were created and embedded within this central location,
including health risk assessment ([Fig. 2]), depression screening, and fall risk assessment. A group of end-users tested the
workflow of the new templates and recommended changes.
Fig. 1 The existing forms tab was identified as the location for the addition of medical information.
A new security level was created in axiUm for the NP. Security levels are also configured
so that users have access to only the information they need to perform the duties
of their job. Data fields were programmed to generate alerts for providers, and data
entry was configured into individual fields to facilitate data mining and reporting.
For example, alerts were created to notify dental providers that their patient was
past due for a primary care visit, and NP providers about due dates for dental cleaning
and/or periodic oral examination. A free-text form was created for the documentation
of progress notes. Specific clinical data fields (e.g., blood pressure, pulse, height,
and weight) were duplicated in the nursing and dental history and assessment forms
to ensure that dental student providers were developing competency in obtaining vital
signs and pertinent health information.
A medication inventory list was created so that all providers could access patient's
current medication list and view changes. The ADC uses DrFirst (https://www.drfirst.com), an e-prescribing solution that gives providers access to all medications that the
patient has been prescribed in the United States, and a common method of connecting
and communicating via a fast, secure, and reliable network. DrFirst automates new prescriptions and refill requests/responses and improves the overall
efficiency of the prescription process. UpToDate, an evidence-based, electronic clinical
decision support resource, was made available to the NP. Patient education materials
and resources on common health topics, such as asthma, blood pressure, and smoking
cessation, were added to the EHR.
Current Procedural Terminology (CPT) and International Statistical Classification
of Diseases (ICD-10) diagnostic codes were configured into axiUm. The CPT codes activated
for services rendered by the NP could be linked to ICD-10 codes for medical billing.
A super bill or charge slip/ticket template ([Fig. 3]) was created to capture the medical services offered and served as a prompt for
NP providers to document billable services. Codes were derived from the American Medical
Association's evaluation and management guidelines[11] and ICD-10CM diagnostic and procedures codes.[12] Bundled codes were created based on the components of the AWV.
Fig. 2 Health risk assessment template.
Fig. 3 Sample superbill.
Implementation Process
Prior to implementation, usability and error testing were conducted to evaluate users'
ease of documentation, form behavior, data mining, and reporting. After the system
was designed and implemented in the axiUm test system, the new forms were presented
to the design team. The design team tested workflows for errors and suggested enhancements
to improve usability. The clinical applications director worked with axiUm developers
to migrate all final documentation pathways and forms into the production system.
Providers received training through didactic sessions with hands-on demonstration.
During the implementation period, we incorporated user feedback to fine-tune the system.
Modifications were tested for improvement using plan-do-study-act (PDSA) cycles and
reviewing customized data reports. To ensure ongoing quality improvement, custom reports
were developed to query data on clinical outcomes. Results were analyzed monthly,
shared with providers, and reported quarterly to the ADC Quality Committee.
Discussion
Customized primary care EHR templates were successfully implemented to facilitate
medical–dental clinical integration. To date, medical information on more than 260
dental patients over 600 clinic visits has been documented in the EHR. The outcome
was a replicable electronic infrastructure to support the clinical integration of
primary care medical services in an academic dental center. We recognize that the
outcome is not an integrated EHR, and agree that to fully support person-centered
care, we need robust, integrated and interoperable EHRs to move into the dental care
arena.[13]
To the best of our knowledge, this is the first dental education program to configure
the axiUm platform for medical–dental clinical integration. The integration of oral
health and medical/wellness services within U.S. academic dental clinics is gaining
momentum,[14]
[15]
[16]
[17] particularly in the context of advancing interprofessional education, person-centered
care, and collaborative practice competencies.[18] Since axiUm is widely used in most dental schools, this report contributes to advancing
these efforts in U.S. dental education by providing academic dental schools with a
feasible and affordable solution.
Several key factors contributed to a successful implementation. We found that a multidisciplinary
team approach was a primary success characteristic. A high-performing multidisciplinary
team is characterized by collaboration, recognition of individual roles, and contributions
to a shared purpose.[19] It was important to have professional, managerial, administrative, and front-line
support staff on the team. Our initial step was to establish consensus and ensure
commitment[20] around our strategic goal—to improve oral-systemic health for older adults living
with chronic health conditions. The team agreed on the need for incorporating primary
medical information into the EDR to support our integrated, person-centered care model.
We reviewed existing workflow processes and mapped new process flowcharts to support
the innovative care delivery model. High-level leadership and organizational support
was critical.[20] Our team reported to a strategic advisory group comprised of nursing and dental
school deans and directors. The leadership remained steadfast in supporting our purpose,
providing resources to achieve our goals, and empowering team autonomy with accountability.[19] The impact of executive leadership support was immeasurable in terms of professional
stakeholder buy-in, particularly with community primary care providers. Engaging primary
care providers and specialists in the community was important to facilitate referrals
and coordinate comprehensive care. An important phase of the project was usability
testing. We first conducted a usability heuristic evaluation with a small group of
evaluators. Heuristic evaluation is a systematic examination to identify usability
problems in the user interface design so that they can be addressed in an iterative
design process.[21] Next, we conducted end-user testing with NPs and dental providers in the dental
center which led to further system refinements. This step provided valuable information
about the use of and problems with the templates. Training and end-user support were
vital for effective implementation. Initial training was tailored for the individual
roles of NPs and dentist providers.[20] Interprofessional training was conducted in the dental center work environment and
included hands-on practice. We recognized the need for continuous training as new
students enter their respective programs yearly. It was essential to continuously
monitor and evaluate EHR refinements and changes in workflow processes. Our priority
was to acquire user feedback and respond to problems timely.[20] We followed a model for improvement for testing ideas using PDSA cycles to rapidly
reach our goals.[19]
Notable implementation challenges included axiUm's lack of interoperability and medical
decision support functionalities. The existing axiUm system at ADC does not have the
interoperability to exchange patients' health care information with outside medical
providers and specialists. Therefore, the NP requested copies of patients' medical
records and exchanges pertinent health information directly over the phone or using
facsimile transmission. In addition, the existing axiUm system was not programmed
with medical decision support functionality. To address this challenge, access to
UpToDate, an evidence-based, electronic clinical decision support resource, was made
available to the NP.
A major lesson learned was the need to budget sufficient time to plan with end-users
and collaborate with axiUm developers. We learned that axiUm developers or an experienced
Crystal Reports writer was needed to develop custom forms. We recommend that dental
schools start working with axiUm developers on the first day of planning so that the
design team has the opportunity to understand the limitations and customizability
options of the software.
The customization capability of axiUm facilitated efficient and effective development
and implementation processes. This capability allowed the school's axiUm administrator
to modify the software application without permission from the developer. Our decision
to design individual data fields allowed us to source data, generate reports, and
analyze information to improve clinical care and operations. Interprofessional communication
was facilitated by the existing internal messaging feature, axiUm messenger, which
enabled NPs and dental providers to communicate and exchange patient information timely,
accurately, and effectively. The medical–dental EHR is available to all health care
providers in the ADC. Our next step is to test the medical coding/billing infrastructure
for medical claims submission and payer reimbursement.
Clinical Relevance Statement
Clinical Relevance Statement
The successful adaptation of axiUm to include primary care templates presents an opportunity
for other academic dental centers to replicate and customize the dental EHR to facilitate
similar medical–dental clinical integration. Dental patients will benefit from clinical
integration through improved care coordination and communication between medical and
dental providers. Dental students and other health care professional students will
be prepared with competencies for clinical integration, including interprofessional
collaboration, communication, care coordination, and clinical informatics skills.
