Virtual Setups Using Intra Oral Scanners for Same Day Consultation

IOScan_exampleBy John White DDS, MSD, ABO

Having been in orthodontic practice for 35 years, I’ve seen a lot of changes in all aspects of orthodontic care.  Most changes have been totally under our control and are merely choices. Whether you choose to use self-ligating appliances or not impacts your mechanics but not really your ability to produce an excellent result. Most cases do not require a CBCT to adequately diagnosis or treatment plan to achieve that same excellent result. Robotic orthodontics, also known as pre-bent appliances, have benefits and drawbacks, but once again are unnecessary for creating that “perfect smile”. Most of us have never done more than dabble in lingual appliances; without any loss to our practice. And while clear aligner therapy has probably the greatest (potential) impact on the traditional delivery of orthodontic care, there are plenty of very successful orthodontic practices that presently don’t use it at all or only on a limited basis.

That being said, competition in the market place has changed significantly, from the outside. We can’t rely on the “gold plated” referrals from our GP colleagues like we once did. Second opinions are becoming the norm. We have one chance to develop a relationship while we present our treatment “design”.  We deal less with patients and more often with consumers.  Where we used to do exam / records / consultation on separate visits, the sequence has evolved for many of us into a single visit. We used to show our beautifully finished cases with plaster models and photos, or cut and pasted smiles from the AAO smile library and so forth. Today’s consumers want more.

The advent of CAD/CAM treatment planning and design software is changing all that.  We now have the ability (and even possibly the responsibility) to do virtual treatment planning, trying out options and alternatives with accuracy and predictability. The ability to customize everything about treatment from the beginning goes beyond the capability to modify and adapt the otherwise generic prescriptions and archforms of the past to match the particular patient’s needs.

Tens of thousands of patients have seen their clear aligner predictions or pre-bent setups. This is changing the exam and consultation process. Patients are becoming aware that we can show them what their teeth will look like post treatment. An interactive approach to smile design and occlusion function is not only possible but a significant advance in marketing and patient appreciation of what goes into their treatment plan beyond just straight teeth.

For purists, one of the leaders in CBCT scanners is currently beta testing 3D integration of IO scans with CBCT imaging and computerized jaw tracking.

There are stand-alone software that permits visualization and treatment planning of IO scanned data, and some IO scanners come bundled with similar software.  Some scanners are not only able to directly scan to aligner companies, but also come bundled with “Treatment Simulator” software.

While I am invested primarily in a single technology, I routinely use several of these and am doing trial runs of others. The learning curve is not terribly steep for any of these. And they all work.

The logistics of same day exams with IO scan and treatment simulation becomes the biggest hurdle.  We do an office tour ending with a CBCT (with face scan) and photos, if the IO scanner is available and the patient has time, we do an IO scan. This combination takes 30-40 minutes (as opposed to 20-25 without IO scan). While we review CC and get acquainted, everything is loaded.  The treatment simulation is run in the background (the 3 treatment algorithm choices are preselected).

After we have reviewed my diagnosis we look at the treatment simulation and start moving teeth to reflect my recommendations and patient wishes.  This not only increases patient engagement but shows that I am intimately involved in the treatment design, not just letting the computer treatment plan for me. It helps explain tooth size discrepancies and why IPR may be necessary (even on extraction cases). We can measure expansion and torque requirements and cuspid inclination. And it is especially useful for pre-restorative setups; visualizing spacing and vertical setup, bonding undersize laterals, etc.. Multiple treatment scenarios can be done to help illustrate trade-offs in compromise cases.

Not only is there improved communication with and education of the patient/parent, but a unique understanding of the case above and beyond the “Old Days” where I fondled a set of soaped and polished study models or CR mounted models.

Finally, we can re-establish our reputation with consumers as the experts in orthodontics by using and properly explaining to them the benefits of this technology.

What is “Big Data” and How Is It Related to the Practice of Orthodontics?

Dr.-Puntillo-PictureBy Anthony M. Puntillo DDS, MSD

Have you heard of the term “Big Data”?  My guess is that for many orthodontists the term is likely a bit like the term “The Cloud.”  They may have a general idea of the concept, but are not entirely sure how it is or will be important to them.  In fact, there is a strong relationship between the two terms that I will discuss later in this article.  First, however let’s look at “Big Data” by itself.  According to Wikipedia “Big data is a blanket term for any collection of data sets so large and complex that it becomes difficult to process using on-hand data management tools or traditional data processing applications.”

In 2009 the United States Congress passed the American Recovery and Reinvestment  Act (ARRA) which included the Health Information and Technology for Economic and Clinical Health Act (HITECH).  [For a detailed summary of this legislation please see Kirt Simmons blog posting from July 9, 2012 “The Electronic Patient Record: How it Affects the Private Practitioner”]. One of the requirements of HITECH is that full implementation of electronic health records (EHRs) for all patients is required by 2016.  The requirements of this act specifically pertain to healthcare providers who participate in the Medicare and Medicaid programs.  That means that currently few dentists are covered by this mandate.  However, this does not mean that we are not being affected.  Since 2009 doctors and hospitals across the country have spent billions of dollars, with the help of government subsidies, converting paper based systems to electronic digitally based health records.  These new digital systems are now collecting vast amounts of valuable data related to patient care.  Much of this information was collected before the legislation, but in a paper non-standardized format that was not easily aggregated and retrievable for meaningful analysis.  The value of all of this collected digital data is only beginning to be fully understood.  Big Data from all healthcare providers is being aggregated and programs to analyze the data are being used to improve the quality, safety, and efficiency patient care.  Hospitals are examining treatment protocols and doctors are making better informed treatment decisions based on the previous care of thousands of similar patients.

As I stated earlier, the EHR requirement of HITECH does not specifically pertain to most orthodontists so why is this important to us?  Many orthodontists have or are now also in the process of converting their practices to paperless systems (without the assistance of the government money).  Several of the orthodontic specific software vendors offer cloud based systems and here is where “Big Data” and “The Cloud” come together.  The aggregation of data from hundreds or thousands of individual private orthodontic practices into cloud servers is beginning to open the door for data analysis (mining).  Just think about how valuable that information can be to our patients and practices.  Most of the research studies published in our journals today involve treatment samples of less than one hundred.  The biannual Journal of Clinical Orthodontics Practice Study generally relies on the input for a few hundred survey responders (out of a possible pool of more than 8,000). Wouldn’t it be helpful for us to know the most efficient type of Class II corrector based on the actual metrics collected from the previous care of thousands of patients treated in practices all across the country or the globe?  Wouldn’t the knowledge that your treatment times/appointments vary significantly from the national or regional averages be useful? There is little question that access to “Big Data” analytics will offer our profession the opportunity to improve treatment quality, safety and efficiency for our patients just as it is beginning to do for the other fields of healthcare.

What to Consider Before Buying an Intraoral Scanner

By Anthony M. Puntillo DDS, MSD


It is a New Year and I would guess that some of you may be considering new technology to add to your practice in 2014.  If you have read my previous posts, you know that an impressionless orthodontic practice is finally a reality.  The two pieces of equipment that are essential to achieve an impressionless practice are an intraoral scanner and a 3D printer.  I have been asked to discuss intraoral scanners at the upcoming AAO annual session in New Orleans.  As a prelude to that presentation, I thought I would highlight a few things to consider when deciding which scanning machine to purchase.  (To be clear I have no skin in this game.  I am not affiliated with or employed by any manufacture or supplier of these machines.  My practice began using a scanner more than 6 years ago.  We have used a few different models since that time and currently have three machines in use.)

The first major consideration before purchasing any machine is ACCURACY.  Before you buy any intraoral scanner you want to make sure that it will accurately capture the data you are looking to collect.  Some machines capture data by collecting still pictures and then use computer software to stitch the individual images together.  Other machines eliminate the computer ”guess work” involved with stitching and use real time streaming video feed technology to capture images.   Furthermore, some machines enable the user to select a high or low-resolution scan.  You should know that the method of data capture and scan resolution can have a direct affect on image accuracy as well the image capture time.

The second and seemingly most obvious consideration is PRICE.  I say seemingly obvious, because most of these machines have underlying costs associated with their purchase.  These “after sticker” expenses include support or warranty costs, supply costs (i.e. disposable wand tips), and costs to store your captured 3D models.  On the positive side, however, several of the companies also offer cost discounts or rebates on the use of associated products (i.e. clear aligners, orthodontic appliances, etc.).  Make sure to consider all of the costs, and discounts, before buying any machine.

The third and final thing to consider is EASE OF USE.  Ease of use actually is a broad term which includes several considerations such as: (1) Scan time- How long will it take for your assistants to capture an image? (2) File type- What type of file is created by the scan and is it a type that is accepted by the labs/companies you may want to send your scans to? (3) File storage and export – Are the scan files stored locally on your computers or in the cloud and how easy is it for your staff to transfer these files to a 3rd party for appliance fabrication? (4) Unit size and wand size- How portable is the unit? Can it be easily moved within an office or transported from office to office?  How heavy and or bulky is the scanning wand?  (5) Scanner software– Is the scanner software intuitive or will there be a significant learning curve for your staff? (6) Patient comfort- Does the machine require that the patients’ teeth be coated with a powder prior to scanning to improve accuracy?

In conclusion, the purchase of an intraoral scanner is a significant investment for most practices.  There are several things that should be considered when determining which machine is the right one for your practice.  I hope this quick review provides you with some insight that will be valuable in the consideration of your purchase.  If you would like to hear a more detailed discussion on this topic, I encourage you to attend my presentation in New Orleans and look forward to seeing you there.

The Basics – Improving Office Efficiency

By Anthony M. Puntillo DDS, MSD

Dr.-Puntillo-PictureIn my last few posts I have focused my discussion on intraoral scanners and 3D model printing. Currently, these technologies can allow a practice to eliminate impressions and truly represent the cutting edge when it comes to the clinical practice of orthodontics. However, I am constantly amazed by how many orthodontists are still not incorporating the most basic of technology into their practices. My partner and I recently acquired an orthodontic practice from an orthodontist approaching the end of his career. After spending the summer merging our systems, I thought I would take a step back and discuss a few of the systems every orthodontist should be using right now to improve the efficiency in their offices.

Computer scheduling with appointment templates
There is nothing more inefficient than a paper based scheduling system. Most orthodontic offices using paper based scheduling systems could comfortably eliminate at least one patient day per week and maintain the same level of productivity. Many orthodontists have purchased software management programs that already include scheduling modules. They simply have not taken the time to set them up and use them. If you do not feel comfortable setting up a computer based scheduling system yourself, hire a consultant. You will easily see a return on this investment in no time.

An automated scheduling confirmation system
This goes hand in hand with computer scheduling. The days of paying an employee to spend their day pulling charts and calling each of your patients to confirm their appointment for the following day should be over. If your schedule is computer-based you can easily incorporate programs that will not only electronically call, but also text and email appointment reminders to all of your patients. This will improve the efficiency and effectiveness of the process and your staff will be happy to give up this tedious task.

Digital radiography
I am going to stay out of the 2D/3D debate in this post. However, orthodontists still taking 2D radiographs should only be doing so digitally. The move to 3D machines has led to a secondary market for 2D digital machines at reasonable costs. You can easily pay for a 2D digital machine with the improved efficiencies that they provide i.e. no film or chemical costs, no staff time processing the radiographs, decreased need for retakes, overall improved image quality, and lower levels of radiation for your patients.

Digital charting
The amount of data generated for each patient we see is simply too great to efficiently manage using a paper based system. All hospitals and medical systems have been mandated to move to electronic health records and all orthodontists should do the same (see post by Dr. Kirt Simmons 3/2/2013). We have all received the call from a patient that has been out of treatment for a number of years that now is now experiencing some relapse. It is simply much easier to pull up the final records and treatment history that accurately documents the patient’s lack of cooperation from your electronic database, than it is to search your basement files or storage unit for the chart that has “disappeared.”

In short, while the impression-less practice will soon be the norm, it is now time to be paper-less and film-less. If you are not, it is costing you money. Change is usually uncomfortable and rarely easy. I am certain, however, that if you commit to incorporating these four basic systems into your practice, they will improve the orthodontic experience for you, your staff, and your patients.

Send Big Files Using Email

by Juan Martin Palomo DDS, MSD

Have you ever sent an email with pictures or radiographs attached only to see it returned with a message notifying you that the file exceeded the size limit? This happens because most email services have an attachment limit, and lately it seems that most of them agree that 25MB is it.  With the use of high resolution images, videos, and CBCT files (DICOM), this limit can be passed very easily. Fortunately there are options.

One way to transmit big files over the Internet is to share the file on a virtual drive (cloud) and provide the recipient with access to it. Services like Dropbox and Google Drive provide for this. If this is only one time transaction however and you want to keep it as easy as possible, there are several websites you can use to send large files directly to your recipient’s mailbox.  The web is filled with such options, usually free up to a certain size, and with a charge for really large files or storage capabilities (a common sales model called “Freemium”).  Some of the most popular, with their current free size limit, are: mailbigfile (2GB), largefilesasap (2GB), dropsend (2G), transferbigfiles (100MB), and hightail (former yousendit, 50MB).  There are many others, and most of them would allow the transfer directly from the browser without the need to install any program.  But as anything that is free, make sure you read the privacy terms, and that you use an encrypted option if transferring patient information.
At the same time that you transmit your file to the third-party site, notify your recipient in a separate email that you sent them a file and which program you used.  Otherwise the recipient may not recognize the company from where it arrives and think it is spam.  The recipient will receive an email from the file service which contains a message from you and a link which will allow the download of your files directly to the recipient’s computer.  Usually the information stays available for 10 or 20 days depending on the company, for the free transfers.  After this period expires, the files cannot be downloaded anymore.
Some programs limit the number of files that you can send.  A way out of this limitation is to place all files inside a folder and then compress the folder.  This will not only reduce its size, but also will turn the folder into a file, which is easier to select and transfer, since it only needs to be done once. Transmitting patients’ information via the Internet is a hot topic right now and one which the AAO Committee on Technology is currently exploring. Stay tuned to this blog and the main AAO website for more information.

Digital Retainers- Part II / Impression-Less Orthodontics

By Anthony M. Puntillo D.D.S., M.S.D.My last article received so many comments that I felt it warranted an extension of the discussion.  In the last twenty years of practicing orthodontics, our profession has gone paper-less, film-less, brace-less, wire-less, and coming soon….IMPRESSION –LESS.  Several companies now produce intraoral scanners and by all accounts they are selling them like hot cakes.  I want to reiterate that I have no financial interest in the sale of any of these machines.  However, if you have not bought one yet, my guess is most of you within the next five years will.  We would all love to eliminate our post-lunch gaggers.  But there are more tangible reasons why this trend is gaining momentum.

First and foremost the majority of our patients simply dislike having impressions taken.  Second, intraoral scans produce more accurate models for the fabrication of better fitting appliances. Third, intraoral scans eliminate the expense and wasted time associated with impression retakes and inaccurate model pours.  Fourth, intraoral scans allow for the elimination of alginate, PVS, and plaster expenses.  Finally, the move to digital patient records has been driven largely by the improved efficiency in handling, manipulating and transferring files, photos, and radiographs.  The same benefits also can be said for models.

Digital models have been around for several years.  I believe the recent mainstreaming of intraoral scanners and 3D printers has now pushed us to a “tipping point.”  Most orthodontists today using intraoral scanning, still digitally transfer their .stl files to the lab of their choice for fabrication of models or an appliance.  But what if you could simply hit “print” and create a bubble free model in your own lab?  The model could then be used to create an in-house retainer or indirect setup just as you would with a plaster model.   In fact, this is now possible.  Some may say that the costs of 3D model printers are too expensive.  Depending upon the size of their practice, you may currently be correct.  I say currently because most of us can remember the costs of color printers when they were first released.  Now they are very affordable and ubiquitous.  Why?  Because corporations such as Hewlett Packard discovered that they could sell the machines at a loss and make their profit on the sale of ink.  I submit to you it will not be long before the same dynamic occurs with 3D model printing.  And when this happens, we will all have one in our office and alginate and plaster will go the way of film-based photography.

Digital Retainers? Now at a Lab Near You

By Anthony M. Puntillo D.D.S., M.S.D.

It’s the middle of September and a patient you just debanded last month is enjoying her first year of college… and her new smile. After 24 months in orthodontic appliances, however, you are now both relying on her retainers to make sure her smile remains perfect. Unfortunately, her roommate has just accidentally stepped on that very same retainer and with campus 6 hours away from home she has no way of returning until Thanksgiving. Her parents assume that the impressions you took last month can be used to make a new retainer. Not wanting their orthodontic investment to be for naught, mom is calling your office requesting a new retainer with plans to ship it to her daughter. You are now in the unenviable position of delivering the bad news: the original model was damaged during the fabrication of the retainer and her daughter will need to return home for a new impression or attempt to schedule an appointment with an unfamiliar orthodontist closer to campus.

If you have been practicing orthodontics for any length of time, I have no doubt that the circumstances of this story sound familiar. The good news is that technology can now offer both you and your patients a better option. The increased movement toward digital models and intraoral scanners has not only improved our ability to store and manage our patients’ records, but it has also led several well-known commercial laboratories to add capabilities for processing these 3D digital files (STL- stereolithographic). Labs that have made the investment in the technology and equipment can now accept files over the internet and then use the digital data to create any number of well-fitting orthodontic appliances. Using STL files in this manner will save you the material, staff costs, and schedule constraints associated with taking a replacement impression. Furthermore, it saves the patient and parent the inconvenience of an additional trip to the office. So the next time a frantic parent calls requesting a replacement retainer ASAP, if you’re using digital models you can let them know you’ve got it handled. Simply forward the final records STL file to your favorite commercial lab and the replacement appliance will be on its way!

The Rise of Digital Orthodontics

By Anthony M. Puntillo D.D.S., M.S.D.


The Industrial Revolution of the mid seventeen hundreds to the mid eighteen hundreds ushered in numerous social, economic, and cultural improvements to the everyday lives of people of the day. Along with these improvements also came disruptive forces. Businesses had to adapt to the new way of doing things to stay competitive. The modern Technology Revolution is having similar beneficial and unsettling influences on our lives. Technology is being employed to improve the efficiency and effectiveness of virtually every aspect of our society. In the field of healthcare, we have seen the mapping of the human genome, improved medical imaging techniques, and robotic surgeries. Modern orthodontics has also incorporated digital technology to improve the accuracy of orthodontic diagnosis and treatment planning. As the quality of and methods for obtaining digital data have improved, so has the orthodontic specialist’s ability to use this data to improve the level of care he can provide his patients.
Two examples of recent technology that have changed the way orthodontists provide care are intraoral scanning devices and three-dimensional Cone Beam Computed Tomography or CBCT. There are several intraoral scanners currently available. These machines typically use visible light and an intraoral “wanding” procedure to create very accurate three-dimensional digital dental models. It is possible to use these 3D models not only to diagnose, but also to fabricate active clear plastic aligners and other treatment appliances. Invisalign, Insignia Clearguide, and ClearCorrect are examples of aligners systems created using digital models. SimpliClear is a digitally designed clear biomer wire fabricated with adjustments bends already in place. Insignia uses digital data obtained from an intraoral scan to create patient specific brackets and custom bracket placement jigs.

Patients can benefit from intraoral scanner technology by avoiding the impression procedure and by the improved accuracy of the appliances provided by their doctor. Orthodontists benefit by the elimination of costly impression materials and the improved efficiency of digital models. One shortcoming of intraoral scanners however is that the models they create are limited to supragingival tooth structures only.

Orthodontists are interested not only in the alignment of the crowns of the teeth, but also how the entire dentition (including the roots) are positioned relative to the supporting bone and facial structures. Using cone beam (CBCT) technology, orthodontists now have the tool they need to evaluate the alignment of the teeth in three dimensions. There are several CBCT machines and software programs currently available that enable orthodontists to view the teeth and supporting structures in all planes of space. This alone can improve orthodontists’ ability to diagnose and treatment plan to the benefit of their patients. There is now one system available (SureSmile) that incorporates the bone data from a CBCT scan into its digital 3D models. This allows orthodontists to make better treatment planning decisions regarding the roots of the teeth by revealing the limits of the supporting structures. The software can then follow the orthodontist’s “prescription” to robotically generate custom archwires containing every necessary tip, torque, and angulation needed to finish the treatment.
The rise of digital orthodontics has also spawned a resurgence in lingual orthodontics. The ability to digitally create custom brackets and wires (i.e. Harmony, Incognito, Suresmile QT, etc.) has made it easier for orthodontists to manage the intricacies of lingual treatment. Consequently, an increasing number of orthodontists are now offering lingual treatment options to their patients.
Technology has drastically increased the pace of change in our society. As orthodontists adapt and incorporate technology into their practices, their ability to provide better treatment for patients will also increase at an exponential rate. It is our challenge and obligation as orthodontic specialists to identify and evaluate new technologies, and when appropriate incorporate them into our patient care in a cost-effective manner.

Who moved my DICOM?

by Juan Martin Palomo DDS, MSD

Most orthodontists associate the term “DICOM” with Cone Beam Computed Tomography (CBCT).  DICOM however represents much more than that.  DICOM, which stands for “Digital Imaging and Communications in Medicine,” is the international standard for all medical images and related information.  Any radiograph, 2D or 3D, as well as photographs and even text documents can be stored as DICOM files.  DICOM represents is a non-proprietary file format that can be accessed by any software regardless of the hardware and software used in the capture stage.  Think of it as the equivalent to a .jpg, .tif, or .pdf, with many extras. Most importantly, it replaces company-specific file formats making data accessible by anyone in the healthcare field.

Many of us have had to at some point in time change management software systems, or send information to referring or transfer offices.  This would be very simple if everybody involved used the same software or if all software read the same formats. When this is not the case complications may occur.  Software programs use their own proprietary file formats because 1) they have invested a lot of time and resources to make the files efficient, and 2) they want to protect their intellectual property.  This can be a shortcoming to the user if there is no option for exporting the data in a format that can be opened with other programs.  It is important for anybody buying clinical software (regardless if it comes with x-ray equipment or not) to make sure that not only can it read DICOM files, but that it is able to export data into that format too.

A DICOM file has multiple layers of information embedded within it.  A DICOM file contains the patient’s name, demographics, information about the capture system, the date, etc. So a DICOM file located on a computer hard drive is much better than an unlabeled radiograph or picture laying on the desk. It has all the identifying information embedded within it.  This is obvious when a DICOM file is opened and the patient’s personal information is quickly displayed.  Additionally, most DICOM viewers also use the data embedded within the file to assign the patient’s identity, helping avoid the mismanagement of images (i.e. placing the wrong image into a patient’s file).  If your current software does not read DICOM files, don’t worry.  There are plenty of DICOM readers free of charge that can be easily downloaded that will perform most necessary tasks.

Lastly, when archiving images, make sure to do so in the DICOM format because there is no guarantee that your specific software will be available forever.  I would further recommend that you go back to your previously archived files and see if they are in the DICOM format. Don’t be surprised if they are not!  Luckily most, if not all, dental and medical capture devices now provide a “save as DICOM” option. Just be aware that DICOM is not usually the default.

The Electronic Patient Record: How it Affects the Private Practitioner

By Kirt E. Simmons D.D.S., Ph.D.
Prior to engaging in a discussion of this topic it is imperative to provide some definitions, as there are some common discrepancies in the terms associated with the electronic patient record.  An “electronic patient record” is simply an electronic or digital form of a health record.  This includes the following examples and their abbreviations/acronyms:  electronic medical record (EMR), electronic dental record (EDR), electronic health record (EHR), and personal health record (PHR).  A word about acronyms is appropriate now, since the US Federal Government Agencies, including the Office of the National Coordinator for Health Information Technology (ONC), are enamored with acronyms and even use acronyms in their definitions of other acronyms and even as part of other acronyms.  On the ONC website, for instance, there are five web pages of Health Information Technology (HIT) acronyms (see are the different forms of electronic patient records?  An Electronic Medical Record (EMR) is simply an electronic form of the paper medical charts classically used in a clinician’s office.  An EMR contains the medical and treatment history of the patients in a single practice. It allows clinicians to track clinical/financial/other data over time, it easily identifies patients due for preventive screenings or checkups, and it allows the clinician to check certain patient parameters—such as blood pressure readings or vaccinations, and to potentially monitor and improve the overall quality of care within that practice.  The major problem with an EMR is that the information in an EMR does not travel easily out of the practice.

An Electronic Dental Record (EDR) is simply the dental equivalent to the EMR, and describes what almost all dental professionals who are keeping “electronic records” are currently keeping.  It contains the dental and treatment history of patients in one practice (although this may be a large group practice with multiple clinicians).  It has the same problem as an EMR in that information in the EDR doesn’t travel easily out of the practice and in addition it typically does not integrate with other medical data.

An Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.  Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports (per the Healthcare Information and Management Systems Society- HIMSS).  The EHR focuses on the total health of the patient in that it reaches out beyond the health organizations (clinicians’ offices or hospitals) that originally collect the information. They are “built” to share information with other health care providers and the information “moves” with the patient between health facilities/providers.  In addition, EHRs are designed to be accessed by all persons involved in a patient’s care, including the patients themselves.  Indeed, that is an explicit expectation in the Stage 1 definition of “meaningful use” of EHRs (“meaningful use” is a term developed by the ONC to describe use sufficient to apply for funds set aside to increase EHR adoption).  An EHR would ideally include all dental, medical, pharmacy, chiropractic, etc. records in essentially “real time” and be “qualified” and “certified” as such.

A “qualified” EHR, per Section 3000, Definitions, of Subtitle A, Part 1, of Title XIII in the American Recovery and Reinvestment Act (ARRA) of 2009,includes:
“An electronic record of health-related information on an individual that-
(A) Includes patient demographic and clinical health information, such as medical history and problem lists
(B) Has the capacity—
(i) to provide clinical decision support
(ii) to support physician order entry
(iii) to capture and query information relevant to health care quality
(iv) to exchange electronic health information with, and integrate such information from other sources.”

Many advantages have been touted for EHRs.  Among these are their ability to consolidate all dental, medical, pharmacy, chiropractic, etc. records in a single “location”; their ability to allow emergency departments to quickly be aware of any life threatening conditions, even if patient is unconscious; the ability of a patient to log on to their own record and see the trend of lab results over the last year for instance, which can help motivate them to take their medications and keep up with the lifestyle changes that have improved the numbers; ability of the EHR to be stored “off site” securely so it is not lost in disasters (i.e. Katrina, tornados, fires, etc.); lab results run last week are already in the record for a specialist to access without running duplicate tests; prescriptions, notes, and orders are legible; notes from a hospital stay can help inform discharge instructions and follow-up care, especially if the patient will be followed up in a different (more local) care setting; patients seeing new clinician / clinic do not have to enter their information or their child’s or carry paper copies with them; and public health officials and researchers can more readily be alerted to, respond to, and research illness trends (SARS, Swine Flu, influenza, etc.), treatment differences, outcomes differences, etc.

A Personal Health Record (PHR), sometimes called a Patient-Controlled Health Record (PCHR), is a patient created electronic record that conforms to certain interoperability standards (the same as EHRs).  It can be drawn from multiple sources.  It is managed, shared, and controlled by the individual patient.  The patient may or may not choose to grant other entities access to it since it is controlled by the patient (unlike EHRs).  The intent is to allow PHRs and EHRs to interact if desired and allowed by the patient.

There are many factors currently “driving” the change to EHRs: Congress, The American Recovery and Reinvestment Act (ARRA) 2009 (including the Health Information Technology for Economic and Clinical Health Act [HITECH]), the President, Third Party Payers (Medicaid, insurance companies, etc.), technology and software vendors, Standards Organizations – DICOM, HL7, etc., public demand (in response to Hurricane Katrina, etc.), researchers, and Public Health organizations.  One of the most prevalent of these “driving forces” is the HITECH Act.  The objectives of the HITECH Act are to leverage health information technology (IT), so health care providers will have: accurate and complete information about a patient’s health so they can give the best possible care, whether during a routine visit or a medical emergency; the ability to better coordinate the care they give (especially important if a patient has a serious medical condition); a way to securely share information with patients and their family caregivers over the Internet (for patients who opt for this convenience); the chance to allow patients and their families to more fully take part in decisions about their health care. Per the framers of this legislation, this increased access to health information will help clinicians diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs.  This legislation also claims widespread use of health IT can make our health care system more efficient, reduce paperwork for patients and doctors, expand access to affordable care, and build a healthier future for our nation.

The “overseer” of the EHR in the U.S. is the Office of the National Coordinator for Health Information Technology (ONC).  This office was set up to support adoption of health IT and promotion of a nationwide health information exchange to improve health care. The ONC is part of the Office of the Secretary for the U.S. Department of Health and Human Services (HHS).  It is directed by the position of National Coordinator of the ONC and was created in 2004, through an Executive Order and legislatively mandated in the HITECH Act of 2009.  Dr. David Blumenthal is the current National Coordinator but he is stepping down in the spring of 2011.

Some important issues are how the EPR will be accessed and where it will be stored.  Individual PHRs will be kept by patients and stored by them (USB, CD, DVD, etc.).  For EHRs there are several potential options that have been proposed, including the National Health Information Network (NHIN), an as yet unidentified national repository, or within Health Information Exchanges (HIEs – which are specific regional/area/network repositories).

This has not yet been finalized as of this time but regardless it will require standards for interaccessibility of the data whether a single, central repository or multiple HIEs.

The NHIN was formed to create a common platform for health information exchange across diverse entities, within communities, and across the country.  Its purpose was to promote a more effective marketplace, greater competition, and increased choice through accessibility to accurate information on health care costs, quality, and outcomes.  In essence, this is what is generally thought of as the “ideal”- a single, national, all-inclusive database for all citizens.  An HIE on the other hand, is a state or regional program set up to ensure the development of health information exchange within and across their jurisdictions.  These are currently being advanced as a more readily implemented means of meeting the aggressive EHR implementation timelines.  Of course, in order for different HIE’s to be able to interact and “play well” with each other they all need to be “speaking the same language” and this requires accepted standards.  The standards that are relevant for EHRs include the Digital Imaging and Communication in Medicine (DICOM) standard which is the established standard for the exchange of digital information between medical imaging equipment (i.e. radiographs, photographs, digital models, cone beam computed tomographs, etc.) and other systems.  Hospitals have long used the DICOM standard in their radiology departments which allows any type of radiograph obtained at one hospital to be transported, accessed and used at any other hospital, regardless of their radiologic software program.  Another EHR standard in use is the Health Level 7 (HL7) standard, which is the established standard for data exchange, management and integration to support clinical patient care as well as the management, delivery and evaluation of healthcare service (ie billing, demographics, outcome measures, etc.).

What’s the timeline of the EHR?  In his 2004 State of the Union address then President George W. Bush set as a goal for most Americans to have a universal EHR by the year 2014.  In 2009 the Congress passed the ARRA and HITECH legislation, which established further guidelines for the development, adoption and implementation of the EHR.  Per this legislation by 2010 the Rules, definitions (especially for “Meaningful Use”– a term used in the legislation), certification process and certification bodies were identified and developed.  In 2011 Stage 1 of the implementation process will be completed.  Stage 1 consists of “Data Capture” – the electronic capture of health care information in a standardized format.   In 2013 Stage 2, “Data Aggregation” – electronic exchange of the collected health information will occur in order to improve the quality of care.  In 2015 Stage 3, “Data Use for Outcome Impact” will occur as necessary to improve the quality, safety and efficiency of healthcare through clinical decision support (CDS) and patient management tools.  By 2016 full implementation (ie all healthcare providers will be fully using and all persons will have an EHR) will be completed.  The legislation initially provides for financial incentives if healthcare providers/organizations “qualify” but these quickly change to disincentives for those who do not comply.  For instance this year (2011) for healthcare providers who do not begin (ie “write” a certain percentage of their prescriptions) e-prescribing drugs their payments through Medicaid will be reduced.

This brings us to the Medicaid EHR Incentive Program legislated by the HITECH Act.  This program provides incentive payments to eligible professionals and eligible hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years.  There are minimum Medicaid patient volumes to be eligible, which differs by state.  The program is voluntarily offered by individual states and territories and begins as early as 2011, depending on state.  Eligible professionals (including dentists) can receive up to $63,750 in funds over six years if they choose to participate in the program and meet all requirements.  There are no payment adjustments under the Medicaid EHR Incentive Program.  By contrast, just to be confusing, the Medicare EHR Incentive Program provides incentive payments to eligible professionals and eligible hospitals that demonstrate meaningful use of certified EHR technology.  Participation in the Medicare Program can begin as early as 2011 with eligible professionals able to receive up to a maximum of $44,000 over five years under the Medicare EHR Incentive Program for treating patients that qualify under Medicare.  In addition, if the eligible professionals provide services in a Health Professional Shortage Area (HSPA) they qualify for additional incentives above the $44,000 maximum under the Medicare EHR Incentive Program.  For maximum incentive payment, Medicare eligible professionals must begin participation by 2012.  For 2015 and later, Medicare eligible professionals, etc. that do not successfully demonstrate meaningful use will have a “payment adjustment” (read reduced payment or penalty) in their Medicare reimbursement.  In order to qualify for these Medicaid / Medicare EHR Incentive Program eligible healthcare providers must use a certified EHR program and demonstrate meaningful use of the program for their patients.  For dentistry, as of this writing (early 2011), there is only one EHR dental software that meets the Federal guidelines and has been certified as such.

A reasonable question for most dentists might be “Who cares?”  There is no federal deadline for adoption of EHRs by dentists who do not submit claims to Medicare and since “I don’t mess with Medicare/Medicaid” it’s not going to effect me.  Unfortunately, although you may not “mess” with the public payer programs the legislation IS going to “mess” with you!  Specifically, new privacy and security provisions (on top of current HIPPA requirements) and accessibility requirements are among the ARRA / HITECH legislation provisions.  These include privacy and security provisions extended to “business associates” (for instance laboratories, etc.), breach notification requirements, health information privacy education requirements for your staff, a requirement to honor withholding of protected health information from a health plan when a patient pays for treatment “out of pocket”, a prohibition of the sale of protected health information, a requirement for patient authorization for marketing and fundraising-related activities, new accessibility requirements (to patient information- i.e. patients may request an electronic copy of their record and it must be provided and in a timely fashion), and finally it authorizes patients the right to request an “audit trail” of all access to their record (i.e. who, when, why anyone accessed their record for any reason!).  The “final rules” have not yet been established but it behooves you to stay aware of these upcoming requirements and be prepared to meet them before they are enforced.  Theoretically a “certified” EHR program takes these requirements and provisions into account so if one purchases and implements these programs in their practice they will be able to meet many of these provisions.  Unfortunately, for any “early adopter” dentists who wish to implement a certified EHR program for their practice, there is only one at this time.  Several companies, although not currently certified, have indicated they were aware of the situation and were planning to eventually introduce a certified program. So one should check with their practice management software company for updates or “modules” to meet these requirements and insist they provide them if they indicate they are not considering these issues.

There are some other implications of this push for EHR adoption for dentistry.  These include e-Prescribing (submitting prescriptions digitally online) ability and monitoring, the adoption of the Systematized Nomenclature of Dentistry (SNODENT- designed by the ADA for use in the electronic health and dental records environment it is essentially a single accepted “dictionary” of dental terms in order to standardize/digitize everything “dental”), a requirement of Diagnosis Codes for payment (long common in Medicine, the ADA is currently updating claim forms to include up to four diagnosis codes since some large dental insurers are adding diagnosis codes to claim requirements), and requirements by insurers, Dental Boards, etc. that all images, notes, models, letters, billing, etc. be provided in a standardized digital format.It is also wise to remember some of the other intents of an EHR according to the Government are their supposed ability to “decrease costs”, potentially due to their intended ability to monitor “quality measures” and adjust healthcare practices “appropriately” (through further legislation, payment adjustments, fees, etc.).  They will also provide for “Lifetime” radiation exposure monitoring since certified EHRs will have the capability of recording radiation exposure data and reporting it.  This could potentially be a big “issue” for those dentists taking or prescribing cone beam computed tomographs (CBCTs) since the Federal Department of Agriculture (FDA- under which the HHS resides), per their  “Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging” issued in February of 2010, is looking closely at “CT”’s.  Per this publication approximately 89% of the yearly exposure of the U.S. population is due to “CT”’s despite the fact they account for only 26% of the total of all imaging procedures.  Although “Medical” Imaging is used by the FDA in the title dentistry is definitely included as evidenced by the fact Table 1 of this publication specifically includes “Dental X-ray”.  Of particular interest to orthodontists and pedodontists is the point the publication stresses the deleterious impact of ionizing radiation on younger individuals is greater than that for adults.

Since the Government will be promoting and advertising the EHR heavily in all provider settings patients will quickly expect dental offices to be EHR compliant as this becomes commonplace in the other “healthcare” settings they are exposed to.  According to the ONC more than 21,000 providers had initiated registration for the EHR Incentive Programs during the first month it was available (January, 2011) and more than 45,000 additional providers had requested information or registration help from Regional Extension Centers during this same time.  In addition, it is quickly becoming obvious that third party payers will require offices to interact with them in an EHR compliant fashion (since it will save them money/resources), due to potential legal implications many malpractice/liability insurers may require their clients to be EHR compliant, privacy/security regulations will essentially require it (for instance each office must have a “Privacy & Security Officer”- per DHHS Guideline 45 CFR, Part 146), pharmacies/DEA will likely require, and lastly new (or updates to) imaging hardware/software will require DICOM compatibility.

Lastly, on a personal note, if and when one is contemplating their own PHR options it is useful to take into account the findings of a “Roundtable on PHRs” the ONC conducted and published in their blog of Dec. 3rd, 2010.  At the PHR Roundtable, four panels of experts and industry representatives explored the growth of PHRs, focusing on the nature and adequacy of privacy and security protections.  The key message to come out of this roundtable was that PHRs grow in value when people find them useful and trustworthy.  A key message from the Roundtable was that PHRs grow in value when people find them useful and trustworthy. Their usefulness grows as they are able to readily pull information from EHRs and other sources of clinical information, as well as from monitoring devices and mobile applications. The usefulness increases even more as that information can be organized to help people with their particular health care concerns and inform clinical decision-making.