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Evolution or Revolution EDRs as a Vital Component of CHC Dental Practice Expansion

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2002-2008: Expansion networking multiple dental sites with an EDR share patient ... WHO here is using a comprehensive medical-dental paper chart? ... – PowerPoint PPT presentation

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Title: Evolution or Revolution EDRs as a Vital Component of CHC Dental Practice Expansion


1
Evolution or Revolution? EDRs as a Vital
Component of CHC Dental Practice Expansion
  • Clifford Hames, DDS
  • Dental Director/CDO/CICO
  • Hudson River HealthCare, Inc.
  • National Primary Oral Health Conference
  • San Diego, California
  • December 12, 2007

2
EVOLUTION?
3
or REVOLUTION?
  • Evolution or Revolution, which word
  • best fits the development of todays
  • EDRs?

1984 The dawn of the Personal Computer (GUI)
2007 Dentrix (G2)
4
WHO SAID?….
  • I only hope that we never lose sight of one
    thingthat it was all started by a mouse. Walt
    Disney!

5
Whats next after the…..
iPhone????
iTooth with Bluetooth!
iPhone
I DK MY BFF, DAVID!
6
Background…..
  • 2000 U.S. Surgeon General, Dr. David Satcher,
    issues report card on the state of oral health in
    the U.S.
  • 2002 President Bushs 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.

7
How did we CONNECT all of our HRHCare sites?
(Dental in BOLD CAPS)

DENTAL VAN
Pine Plains
New Paltz
Amenia
WALDEN
SULLIVAN
POUGHKEEPSIE (2)
Dover Plains
Monticello
BEACON
GOSHEN
PEEKSKILL CHCSchool-based
Haverstraw
Health Center
Migrant Health
Migrant Voucher program
Greenport
Public Housing
8
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.

9
  • Our Peekskill dental practice in 2000
  • Organized but in need
  • of a makeover

10
HRHCs Dental Sites/Programs in 2007
  • Peekskill CHC (since 1975)

11
HRHCs Dental Sites and Programs in 2007
  • Peekskills School-Based Sealant Fluoride Rinse
    Program (since 1985)

Communication with Patient
Communication with Staff
Commitment to the Community
12
HRHCs Dental Sites and Programs in 2007
  • Peekskills School-Based Sealant Fluoride Rinse
    Program

Collaboration with School Nurse
Caries Control Education
Cooperation with Teachers
13
Working in small spaces…. Nurses Offices and
Little Mouths
Confined spaces with no room for computers
14
And yet IMPRESSIVE results….. With GREAT
retention…..
15
With 50 reduction in caries!
16
HRHCs Dental Sites and Programs in 2007
Goshen Migrant CHC (since 1990)
17
HRHCs Dental Sites and Programs in 2007
  • Beacon CHC(11/01,7/06)

18
HRHCs Dental Sites and Programs in 2007
Walden (8/05)
19
HRHCs Dental Sites and Programs in 2007
Poughkeepsie Family Partnership (1/07)
20
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!

21
8 Important Questions to consider
  • 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?

22
8 Important Questions to consider
  • WHY NOW?
  • HOW will you be able to see your patients
    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?

23
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

24
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

W
C
B
25
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

26
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.

27
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
  • Directors Office Managers Offices

28
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?

29
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.

30
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

31
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.

32
Our I.T. Department and Server Hub at our
Beacon site.
33
Youre only as strong as your weakest link!
34
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.

35
Its ALL about BANDWIDTH!
36
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 Kbps
  • Mbps 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.
37
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

ALL SERVERS HOUSED IN BEACON OFFICE.
38
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?

39
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!

40
PHASE III Training Dental Staff on using an EDR….
  • 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

41
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!

42
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.

43
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.

44
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.

45
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!

46
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

47
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/

48
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.

49
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50
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