Although the HITECH Act includes dentists among the "eligible professionals" in line for federal stimulus money, some dental advocates are worried oral health might get short shrift in the push toward electronic health records.
Efforts are well under way to get medical care providers in position to earn incentives under Medicare and Medicaid if they adopt and make "meaningful use" of certified EHRs, but similar efforts on behalf of dentists are less organized and not as nationally focused, according to some dental advocates.
"Dentistry is included in the stimulus language, but in practical terms, the stimulus money for electronic records isn't going to have much of an impact on most dentists," said Paul Glassman, director of Community Oral Health at the University of the Pacific School of Dentistry in San Francisco.
"There's a process going on right now, largely spearheaded by California activists, to try to figure out what can be done to change that," Glassman said. "State government, statewide foundations, academics and at the national level the ADA (American Dental Association) are trying to figure out how dentistry can have more of an impact in the move toward EHRs. We're working on answering questions like what are the barriers and what can be done about them," Glassman said.
'Meaningful Use' in the Dentist's Office
A big part of the equation for getting some of the $19 billion in federal money aimed at encouraging the use of EHRs involves meaningful use of technology. Much has been said and written about how IT might be meaningfully used in other parts of the health care spectrum, but not much about meaningful use in dental care.
In response to questions about dental care's role in the federal stimulus package, two representatives from federal agencies -- Joe Kuchler from CMS and John Glaser from the Office of the National Coordinator for Health IT -- collaborated on answers.
CMS and ONC are working closely in implementing HITECH, but their responsibilities differ. CMS is responsible for issuing a regulation defining meaningful use, while ONC has lead responsibility for establishing certification standards for EHR products.
CMS plans to issue its definition of meaningful use by the end of this year and ONC plans to have EHR certification process and criteria regulations written and approved by late spring next year.
"To be eligible for the HIT incentive payments, all providers will have to use a certified EHR," Kuchler and Glaser said, adding, "There are not many EHRs with dental modules -- though the VA's EHR system, called VistA, has one. CMS and ONC hope that by defining meaningful use as it pertains to oral health, the EHR vendor community will respond by creating EHR products to market to dentists to meet their needs."
Medicare/Medicaid Dental Coverage
Most dentists are probably not going to be as driven as their medical counterparts to acquire and use interoperable EHRs because of the stimulus package. The incentives aren't lined up the same way.
Except for a few dental-related services necessary as part of some other medical procedure or consideration, Medicare excludes dental services. So the financial incentive of increased Medicare reimbursement is largely moot for dentists.
Dentists who treat a significant number of low-income patients are probably the most likely to gain from health IT provisions in the federal stimulus package.
The American Recovery and Reinvestment Act specifies that health care providers -- including dentists -- who make meaningful use of EHR technology and whose patient load includes at least 30% Medicaid beneficiaries are eligible for Medicaid incentive payments. Dentists who practice predominately at federally qualified health centers, and whose patient encounters are at least 30% "needy individuals," are similarly eligible for the Medicaid incentive payments. "Needy individuals" are Medicaid or Children's Health Insurance Program enrollees, those who are deemed needy under FQHC sliding fee scales (which are tied to federal poverty levels), and those who receive uncompensated care services from hospitals.
The interoperability and the government's definition of meaningful use of EHRs is largely irrelevant for many dentists, Glassman said.
"Most dentists are in small practices and they deal with patients who walk in their door, and they don't really have much interaction with other parts of the health care system -- other providers or hospitals. Because of that, there isn't a huge need for systems that interoperate," Glassman said.
"That's not necessarily a good situation, but that's the situation we're in," Glassman said.
Dental Educators On the Stump
The American Dental Education Association earlier this year urged U.S. dental schools to advocate for health IT funding through ARRA. In a letter to dental school deans, association officials wrote that "most dentists and dental school clinics face significant impediments in qualifying for significant ARRA EHR incentives for the following reasons:
- There are no EHR incentives for dentists under Medicare.
- There is a 30% Medicaid population requirement for Medicaid EHR incentives.
- Additionally, ARRA EHR certification standards could delay EHR incentives to dentists who do qualify under the 30% Medicaid population requirement.
- The method for determining Medicaid EHR incentives for eligible professionals could underestimate costs for a dentist."
The letter concluded:
"If dental school clinics do not receive adequate and timely funding for implementation of EHR technology, they will be left out of the nation's health IT infrastructure, thereby undermining the overarching objective of the ARRA HIT provisions to improve the quality of all health care services in the United States."
Pipeline Project Under Way
Although it's been a top-down process in other parts of the medical field, where larger, better-funded physicians groups and hospitals have been early adopters, the move toward interoperable digital records in dentistry may be fueled from the bottom up. If clinics and dentists who cater to low-income patients are the early adopters -- spurred by federal incentives and program grants -- mainstream dentists may follow.
One such grant effort is flourishing in California. The Pipeline, Profession & Practice: Community-Based Dental Education program is a five-year program designed to help increase access to dental care for underserved populations. In round one of the program, the Robert Wood Johnson Foundation and the California Endowment funded 15 U.S. dental schools to develop community-based clinical education programs for five years. Round two began in March 2008, awarding eight more dental schools funds to carry out similar programs. The program has two goals:
- Provide dental care to the most vulnerable populations; and
- Increase recruitment and retention of low-income and underrepresented minority dental students in California.
University of the Pacific has been involved in the Dental Pipeline for seven years.
"Digital records will definitely become standard practice in dentistry," Glassman said, "but it's going to take more than new electronic systems to bring oral health into the bigger picture. Ultimately, I think we need to be altering our system of care and coordination of care if we're going to be able to be getting to parts of our nation that aren't getting good oral care."
"Ultimately, we're going to need more coordinated efforts that involve dental and other providers working together, not separately," Glassman said.