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Guide To The Future:

A Strategic Roadmap to Achieving Meaningful Use Objectives and Selecting an Integrated Electronic Dental Record (EDR)/Electronic Health Record (EHR) System to Improve Oral Health Access and Outcomes table of contents Introduction

Introduction...... 1 Meaningful Use for Oral Health...... 2 The future of health care can be found in combining skillful providers with the technological tools that allow Current Meaningful Use Objectives and Exclusions for Consideration...... 6 them to provide the best possible care for their patients. At the forefront of this combination is the concept Core Set Objectives...... 7 of Meaningful Use: terminology used by the Centers for Medicare and Medicaid Services (CMS) that means providers must show they are using certified Electronic Health Record (EHR) technologies in ways that can be Menu Set Objectives...... 8 measured. The National Network for Oral Health Access (NNOHA) developed this white paper to present a Current Clinical Quality Measures for Oral Health...... 10 strategic roadmap for achieving Meaningful Use for oral health and to provide critical steps that need to be taken Clinical Quality Measures for Oral Health...... 12 to implement an EHR system that fully integrates Electronic Dental Records (EDR). This white paper will help EHR Selection...... 17 oral health providers, staff, and patients understand the benefits of Meaningful Use incentives and serve as a EDR/EHR Selection Tool...... 18 guide to selecting an Electronic Dental and Health Record system. Step 1: Eligible Professional Assessment...... 19 Step 2: Vendor Background Information – Request for Information (RFI)...... 20 Step 3: Review of Meaningful Use Core & Menu Set Objectives...... 21 NNOHA’s Health Information Technology (HIT) Workgroup (formerly HIT Committee) was established to Step 4: Review of Meaningful Use Clinical Quality Measures (CQMs)...... 21 help guide safety-net oral health programs through HIT decisions and challenges as they emerge. EDR issues have remained a priority for the Workgroup, which is continuing to assess the EHR needs of Health Center oral Step 5: Vendor Response to Meaningful Use Certification and Reporting Measures...... 22 health programs and make recommendations to guide Health Centers in selecting technology solutions that are Step 6: Vendor Response to NNOHA’s Proposed CQMs for Oral Health...... 22 compatible with the systems used by both medical and dental staff. Through a Health Resources and Services Step 7: Vendor Response to EDR/EHR Practice-Specific Requirements...... 23 Administration (HRSA) Cooperative Agreement, NNOHA strives to provide technical assistance to Health Step 8: Vendor Response to Qualitative Requirements...... 25 Centers seeking to provide, expand, or improve oral health services. Step 9: Vendor Response to Vendor Solution Cost...... 26 Step 10: Vendor Selection Criteria and Summary Ratings...... 26 Discussion on Use of EDR/EHR Selection Tool, Vendor’s Self Scoring and General Disclaimer...... 28 NNOHA’s HIT Workgroup goals are to: Challenges Selecting and Implementing an EDR/EHR Solution...... 29 ■ Provide key stakeholders, Dental Directors, Executive Directors, and Information Technology (IT) EDR/EHR Implementation Strategies...... 30 decision makers with objective comparisons among the current leading EDR/EHR products. Conclusion: A Strategic Pathway to the Future...... 33 ■ Provide input to dental software developers on areas for improvement within existing applications to Appendix A1: Meaningful Use Vendor Survey Responses...... 36 better meet the challenges of Meaningful Use compliance, Health Center patient care, and practice Appendix A2: Rating Chart: Vendor Response to EDR/EHR Practice-Specific Requirements...... 38 management of oral health programs. Appendix A3: Rating Chart: Vendor Response to Qualitative Requirements...... 52 ■ Advocate for integration of a dental module within Electronic Health Records as a vital part of the Appendix A4: Rating Chart: Vendor Response to Vendor Solution Cost...... 53 product functionality offered to Health Centers. Appendix A5: Rating Chart: Vendor Selection Criteria and Summary Ratings...... 55 ■ Identify potential Meaningful Use measures for oral health. Appendix A6: Vendor Background Information and Evaluations...... 55 ■ Provide Dental Directors and Health Center oral health programs with practical resources for selecting, Product Name: QSI Dental – Electronic Dental Record (EDR)...... 57 implementing, and optimizing HIT. Product Name: Dentrix Enterprise/Sage Intergy...... 62 Product Name: Mediadent...... 72 When a Health Center finds a system that best meets the needs of their organization, as well as Meaningful Use Product Name: Open Dental and eClinicalWorks...... 80 criteria, it allows for maximized resources, increased reimbursements, and improved patient care. This paper can Appendix B: Sources of Information/Additional Resources...... 87 serve as a guide in the process, and facilitate the Health Centers’ decision making process toward improved use Appendix C: Glossary...... 88 of HIT. Appendix D: References...... 89

Appendix E: Credits...... 91 Terminology

1 “Health Center” is the term commonly used to refer to Community Health Centers, migrant health centers, health centers that treat the homeless, and centers that © National Network for Oral Health Access, August 2012 treat residents of public housing. 2 “Federally Qualified Health Center” or FQHC is a Medicare/Medicaid/CHIP term related to reimbursement, which includes Section 330 of the Public Health Service The information in this document was accurate at the time of this printing. As regulations and information regarding Health Centers Act funded centers, sub-recipients (e.g. sub-grantees) and look-alikes. are not static, NNOHA recommends readers verify any critical information with different state regulations and changes that may have 3 Authorizing Section 330 legislation has officially changed the term “Community Health Center” to the accepted term “Health Center” and that is the term used occurred since printing. throughout this paper to refer to the above listed types of grant-supported entities.

This publication was supported by Grant/Cooperative Agreement #U30CS09745 from the Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.

1 Guide to the Future Meaningful Use For Oral Health

Background

One only has to listen to the news or pick up a journal to know that the United States health care delivery system is highly fragmented. Dentists, physicians, and other health care specialists utilize separate records with patient’s health information residing in a broad mix of paper charts, ancient legacy systems, new web-based tools, and everything in between. This variation has resulted in a lack of coordination and effective data sharing among dental and other medical professionals, negatively affecting patient care. As a result, the federal government has invested billions of dollars to create a health information technology infrastructure. One important component of this support is the creation of financial incentives (stimulus funds) to encourage eligible professionals (EPs) and health care organizations to implement and use electronic health records (EHRs) effectively using a concept referred to as “Meaningful Use.”

■ NQF 1335: Title – Children who have dental decay or cavities. Meaningful Use has become an important consideration for Health Centers not only because it ■ NQF 1419: Title – Primary Caries Prevention Intervention as Part of Well/Ill Child Care could improve patient care, but because there are financial incentives available through the as Offered by Primary Care Medical Providers. American Recovery and Reinvestment Act of 2009 (ARRA). There are two important considerations when trying to interpret Meaningful Use: the requirements the health NNOHA will continue to develop or identify clinical quality measures for dental/oral health care with partners professional or care delivery organization must meet, and the technology in use by and stakeholders that could be ready for future years. the provider. In the simplest terms, “Meaningful Use” means providers need to show they are using certified EHR technology in ways that can be measured significantly in quality and in quantity (Health Resources and Services Administration, 2011). Stimulating EHR Implementation

Participating in the Meaningful Use incentive program has been a challenge for many Health Information Technology (HIT) has tremendous potential to transform the delivery of health care by EPs, especially dentists, who must meet the same eligibility requirements as other EPs integrating clinical, administrative and financial systems and other administrative tasks, and providing the in order to qualify for payments under the Medicaid Electronic Health Record Incentive infrastructure to support them. One of the essential clinical systems is the EHR. An EHR generally includes a Program. This also means that they must demonstrate all of the Meaningful Use objectives longitudinal collection of information on the health of an individual or the care provided. An EHR also provides plus some optional measures detailed later in this report. immediate electronic access to patient and population-level information by authorized users, decision support to enhance the quality, safety, and efficiency of patient care, and support of efficient processes for health care delivery (Melvin, 2008). Current Meaningful Use objectives and measures are based on medical practice, and require observation, assessment and recording of areas of health that may not be pertinent for dental practice. As a result, several Meaningful Use objectives contain exclusion criteria. Dental practices will have to evaluate whether their In April 2004, President George W. Bush called for widespread adoption of interoperable EHRs within ten years practice meets the exclusion criteria for each applicable objective. and issued an executive order that established the position of the National Coordinator for Health Information Technology within the Department of Health and Human Services (Melvin, 2008). A framework document released two months later described four main goals for achieving nationwide interoperability of HIT. These There is a significant gap between the current situation and achieving Meaningful Use objectives, making it goals included: (1) informed clinical practice, (2) interconnection of clinicians, (3) personalized care, and difficult for oral health providers and electronic dental record (EDR) vendors to participate in the national (4) improvements in population health (Thompson & Brailer, 2004). Collectively, these initiatives laid the initiative to increase the use of technology as a means to improve health care. NNOHA will continue to assist groundwork for an organized effort to drive adoption of interoperable HIT. However, other barriers still exist, Health Centers in Meaningful Use involvement by monitoring the capabilities of dental software vendors in including the initial high costs of investing in HIT, the ongoing maintenance required in all information systems, meeting Meaningful Use criteria and providing guidance in selection of EDR/EHR systems. NNOHA and other and short-term loss of productivity as staff adapt to new technology and systems. key stakeholders have identified oral health measures for Stage 2 and the proposed rule includes the following two oral health measures beginning with Calendar Year (CY) 2014:

Guide to the Future 2 3 Guide to the Future To stimulate the investment and use of EHRs, the federal government has established a combination of voluntary vital signs, patient demographics, drug and allergy lists, updated problem lists, and smoking status. In addition, EPs financial incentives and eventual penalties to encourage the Meaningful Use of EHR for Medicare and Medicaid must comply with five out of a “menu” of ten additional objectives. Some of the menu items include: performing providers. Stimulus funds, designed to increase the use of EHRs, is only one of many information technology drug-formulary checks, incorporating laboratory results into patient records, providing patients with reminders initiatives encouraged by the federal government. However, lack of Meaningful Use measures relating to oral for needed care, supplying relevant educational resources, and supporting transitions between care facilities or health may lead to a reduction in dental provider participation in the stimulus fund program for personnel (Centers for Medicare & Medicaid Services, 2012). EDR/EHR implementation and integration.

Up until now, the adoption of HIT has generally been slow in the United States. Recent research highlights HIT is becoming increasingly prevalent in medical offices and facilities. Like accelerated adoption of EMR/EHR systems. EMR/EHR system use among office-based physicians increased from President George W. Bush before him, President Barack Obama announced a plan 18% in 2001 to 57% in preliminary 2011 estimates (CDC, 2011). The federal Meaningful Use EHR incentive to computerize the medical records of all Americans by 2014 (Jones, 2009). The program intends to boost those numbers through millions of dollars in federal incentive payments. While much of functionality of comprehensive EHR systems goes far beyond the traditional the discussion to date has focused on physician practices and hospitals, it is notable that the incentive program was role of paper dental/medical records. In addition to providing ready access to made available to doctors of dental surgery and dental medicine as well. clinical documentation, these systems quickly transmit diagnostic test images and results to physicians so that the data can be reviewed and shared with patients. EDR/EHRs feature computerized provider order entry (CPOE), which The United States spends more on health care than any other country, yet performs far below many others in allows health care providers to send patient orders, such as those for laboratory quality measures that include life expectancy, equities in the access to care, and the inconsistency of care in tests and medications, electronically to appropriate parties. EDR/EHR systems demographic locations (Gaylin, et al., 2011). The use of information technology is recognized as having a major also provide decision support tools, including clinical reminders, drug allergy/ role in the transformation of health care in order to meet the Six Aims for Improvement as identified in the interaction alerts, drug-dose recommendations, and suggestions for diagnostic and Institute of Medicine’s Committee on the Quality of Health Care in America, Crossing the Quality Chasm (2001). treatment options (Hoffman & Podgurski, 2011). EDR/EHRs are revolutionizing The use of technology in health care will increase treatment and business efficiency, promote patient safety, business in the health care industry, allowing medical professionals to work faster, increase continuity of care, increase access to quality care, and reduce disparities in health care. Increasing evidence smarter, and more efficiently than ever before. shows that the future of health care will involve an integration of two historically separate modalities of health care, medicine and dentistry (Rudman, 2010). The level of communication necessary to increase the quality of care that will be generated by the integration of medical and dental services will have a much greater success rate with The American Recovery and Reinvestment Act of 2009 (ARRA) dedicated $27 billion to the promotion of the utilization of technology accessible by all providers. HIT. It provides payments of up to $44,000 per clinician under the Medicare incentive program and $63,750 per clinician under the Medicaid program (Hoffman & Podgurski, 2011). Meaningful Use regulations were issued in July 2010, delineating what hospitals and clinicians must do to be deemed meaningful users of EHR systems in 2011 To promote the use of technology, the Health Information Technology for Clinical Use Act (HITECH) allows and beyond. Those in compliance will be eligible for EHR incentive payments, registration for which began in for access to federal stimulus funds for Medicaid and Medicare providers who show Meaningful Use of electronic January 2011. Two additional phases of Meaningful Use requirements will be staged in three steps over the course information technology. Stage 1 of the Meaningful Use guidelines does not provide specific oral health measures of the next five years. that can be utilized by dental providers, thus delaying dentists from achieving Meaningful Use. Support for EDR/ EHR implementation by public dental organizations is evidenced in a 2010 collaborative letter from vested dental ■ Stage 1 (2011 and 2012) sets the baseline for electronic data capture and information sharing. organizations sent to the Centers for Medicare and Medicaid Services (CMS) (Tankersley, et al., 2010). The letter states that these organizations realize the value and potential for health care providers, including dentists, ■ Stage 2 expected to be implemented in 2014 under the proposed rule: “Meaningful Use” includes to participate in EHR implementation. The organizations echoed a recurring theme addressing concerns that face standards such as online access for patients to their health information and electronic health dental providers in their attempt to meet Meaningful Use requirements. The system requirements associated with information exchange between providers. EHR implementation place a potentially significant burden on solo and small group practices. Large dental groups are better equipped to implement these systems; however, practices with five or more providers, account for less ■ Stage 3 expected to be implemented in 2016: “Meaningful Use” includes demonstrating that the than 1.2% of all dental practices (Tankersley, et al., 2010). quality of health care has been improved (Centers for Medicare & Medicaid Services, 2012).

During Stage 1, EPs (e.g., dentists and other health center providers) are required to meet fifteen “core” objectives. Later in this report is a diagram that highlights the steps for determining eligibility for dentists (refer to Figure 1, “Eligible Professional Assessment Map for Dentists”). Several of these measures focus on basic data entry, including

Guide to the Future 4 5 Guide to the Future Clinical Quality Measure Barriers meeting the Meaningful Use requirements). The exclusion requirements for each objective are available at CMS’s website link: https://www.cms.gov/ehrincentiveprograms and also shown in the tables and figures below.

The following table lists all fifteen of the required Core Set objectives and also identifies if they are part of a dentist’s normal routine and if there are any known exclusions. The primary areas of contention for dental providers in meeting Meaningful Use are the clinical quality measures (CQMs). The CQMs are defined by the CMS as the processes, experiences, and/or outcomes of patient care that are measured through observations and treatment addressing one or more of the Six Aims for Improvement in Objective Measure Exclusion Dentist Routine Health Care (Heubusch, 2010). The use of quality metrics is recognized as the driver of improvements in health Record patient demographics More than 50% of patients’ None Yes (sex, race, ethnicity, date of birth, demographic data recorded care. Unless measures that address oral health are utilized, oral health care may be overlooked in the health care preferred language) as structured data reform initiative. The Department of Health and Human Services (HHS) recognizes oral health as one of the target areas in achieving optimal national health through its Healthy People 2020 publication (Healthy People, Record vital signs and chart More than 50% of patients An EP who either sees no Yes: Blood pressure changes (height, weight, blood 2 years of age or older patients 2 years or older, or No: Other vitals 2011). This recognition supports the inclusion of oral health quality metrics for Meaningful Use. NNOHA’s pressure, body-mass index, have height, weight, and who believes that all three Health Information Technology and Meaningful Use Workgroup has identified six clinical quality core measures growth charts for children) blood pressure recorded vital signs of height, weight, and other alternative measures for consideration by HHS as potential Meaningful Use measures that can be met by as structured data and blood pressure of their patients have no relevance oral health providers. A consideration for oral health-focused CQMs is important in development of a data format to their scope of practice that can be captured and stored in an EHR. It will then be necessary for such data to be electronically transmitted to CMS in a structured, standardized format. Maintain up-to-date problem list of More than 80% of patients None Yes current and active diagnoses have at least one entry recorded as structured data

CMS prefers to select CQMs endorsed by the National Quality Forum (NQF) for the Meaningful Use Maintain active medication list More than 80% of patients None Yes have at least one entry requirements. The NQF is a nonprofit organization established in 1999 whose membership is made up of public recorded as structured data and private sector entities with an interest in quality health care. The NQF’s mission is to improve the quality Maintain active medication More than 80% of patients None Yes of American health care by setting national priorities and goals for performance endorsements through national allergy list have at least one entry consensus standards for measuring and public reporting of performance. The NQF promotes the attainment of recorded as structured data national goals through education and public outreach programs (NQF, 2011). Currently, all the clinical quality Record smoking status for patients More than 50% of patients An EP who sees no patients Potential measures recognized by CMS for Meaningful Use are endorsed by the NQF. NNOHA has recognized the need 13 years of age or older 13 years of age or older 13 years or older for NQF endorsement and will support future endorsement efforts for oral health CQMs. have smoking status recorded as structured data

Provide patients with clinical Clinical summaries provided An EP who has no office Potential The average length of the endorsement process is three years; however, a consideration to expedite the process can summaries for each office visit to patients for more than visits during the EHR occur if measures are shown to be well-established, widely used, or meet an urgent national need (NQF, 2011). 50% of all office visits within reporting period The expedited consideration decreases the number of days for several of the steps in the process, but does not 3 business days decrease the criteria for evaluation. NNOHA is currently exploring an expedited process to include relevant CQM On request, provide patients More than 50% of An EP that has no requests Potential for oral health. with an electronic copy of their requesting patients receive from patients or their agents health information (including electronic copy within 3 for an electronic copy of diagnostic test results, problem business days patient health information list, medication lists, medication during the EHR reporting Current Meaningful Use Objectives and Exclusions for Consideration allergies) period

One of the requirements for receiving Meaningful Use reimbursements is to track several quality improvement Generate and transmit permissible More than 40% are An EP who writes fewer than Potential prescriptions electronically transmitted electronically 100 prescriptions during the objectives. The question asked most often by dentists regarding Meaningful Use is: “Do dentists have to meet all of using certified EHR EHR reporting period the required Core Set Meaningful Use objectives?” The answer is currently yes, with some explanation. CMS has a list technology of 15 required “Core Set” objectives and 10 additional “Menu Set” objectives. CMS states that, “To qualify for an Computer provider order entry More than 30% of patients An EP who writes fewer than Potential incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives. The remaining 5 objectives (CPOE) for medication orders with at least one medication 100 prescriptions during the may be chosen from the list of 10 Menu Set objectives” (Centers for Medicare & Medicaid Services, 2011). However, in their medication list have EHR reporting period at least one medication there are exclusions available that can be claimed during attestation (the online process where EPs prove they are ordered through CPOE

Guide to the Future 6 7 Guide to the Future Objective (cont.) Measure Exclusion Dentist Routine Objective (cont.) Measure Exclusion Dentist Routine Implement drug-drug and drug- Functionality is enabled for None Yes Perform medication reconciliation Medication reconciliation An EP who was not the Potential allergy interaction checks these checks for the entire between care settings is performed for more than recipient of any transitions reporting period 50% of transitions of care of care during the EHR reporting period Implement capability to Perform at least one test None Yes electronically exchange key clinical of EHR’s capacity to Provide summary of care record Summary of care record An EP who neither transfers Potential information among providers and electronically exchange for patients referred or transitioned is provided for more than a patient to another setting patient-authorized entities information to another provider or setting 50% of patient transitions nor refers a patient to or referrals another provider during the Implement one clinical decision One clinical decision None Yes EHR reporting period support rule and ability to track support rule implemented compliance with this rule Send reminders to patients (per More than 20% of patients An EP who has no patients Potential patient preference) for preventive 65 years of age or older or 5 65 years old or older or 5 Implement systems to protect Conduct or review a None Yes and follow-up care years of age or younger are years old or younger with privacy and security of patient security risk analysis, sent appropriate reminders records maintained using data in the EHR implement security certified EHR technology updates as necessary, and correct identified security Provide patients with timely More than 10% of patients An EP that neither orders Potential deficiencies electronic access to their health are provided electronic nor creates any of the information (including laboratory access to information within information listed at 45 CFR Report clinical quality measures For 2011, provide aggregate None Potential results, problem list, medication 4 days of its being updated 170.304(g) during the EHR (CQMs) to CMS or states numerator and denominator lists, medication allergies) in the EHR reporting period through attestation; for 2012, electronically submit *PH* Submit electronic Perform at least one test An EP who administers No measures. Note: NNOHA immunization data to immunization of data submission and no immunizations during has proposed additional registries or immunization follow-up submission the EHR reporting period CQMs for consideration that information systems (where registries can accept or where no immunization are relevant to oral health. electronic submissions) registry has the capacity to receive the information electronically

An EP must report on 5 out of 10 Menu Set objectives; 1 of the 5 must be a Public Health Objective (designated as *PH*) *PH* Submit electronic syndromic Perform at least one test An EP who does not collect Potential surveillance data to public health of data submission and any reportable syndromic Objective Measure Exclusion Dentist Routine agencies follow-up submission (where information on their patients public health agencies can during the EHR reporting Implement drug formulary checks Drug formulary check None Yes accept electronic data) period or does not submit system is implemented and such information to any has access to at least one public health agency internal or external drug that has the capacity to formulary for the entire receive the information reporting period electronically Incorporate clinical laboratory test More than 40% of clinical An EP who orders no lab Yes – available via results into EHRs as structured laboratory test results whose tests whose results are integration with an data results are in positive/ either in a positive/negative EHR (Intergy) To be able to report on these objectives, it is essential that practices utilize an EHR. The CMS Medicare and negative or numerical format or numeric format during Medicaid incentive programs provide a financial reward for the Meaningful Use of certified EHRs to achieve are incorporated into EHRs the EHR reporting period as structured data health and efficiency goals. The Office of the National Coordinator for Health Information Technology (ONC) regulations specify the technical capabilities that EHR technology must have to be certified and to support Generate lists of patients by Generate at least one listing None Yes providers in achieving the Meaningful Use objectives. In 2010, the ONC released this definition of “certified EHR specific conditions to use for of patients with a specific quality improvement, reduction of condition technology,” “a Complete EHR or a combination of EHR Modules, each of which (1) meets the requirements disparities, research, or outreach included in the definition of a Qualified EHR; and (2) has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria Use EHR technology to identify More than 10% of patients None Yes patient-specific education are provided patient-specific adopted by the ONC” (Federal Register, 2010). resources and provide those to education resources the patient as appropriate For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/ EHRIncentivePrograms.

Guide to the Future 8 9 Guide to the Future Current Clinical Quality Measures Menu Measures NQF PQRI For Oral Health Pneumonia Vaccination for Patients 65 Years and Older 0043 111 Screening Mammography 0031 112 Dentists must report six CQMs that include three Core Set Colorectal Cancer Screening 0034 113 measures. The remaining three measures must be selected from Cervical Cancer Screening 0032 — a Menu Set of alternative measures. Clinical quality measure Chlamydia Screening in Women 0033 — reporting is a requirement; however no thresholds must be met. Controlling High Blood Pressure 0018 — Asthma: Pharmacologic Therapy 0047 53 There are 38 additional CQMs, listed later in this section, from which a dentist must select three. A maximum of nine CQM measures would be reported if the dentist needed to Asthma Assessment 0001 64 attest to the three required core, the three alternate core, and the three additional measures. Use of Appropriate Medications for People with Asthma 0036 — Childhood Immunization Status 0038 — Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 0055 117 The following table lists the current CQMs: Diabetes Mellitus: Urine Screening for Microalbumin 0062 119 Diabetes Mellitus: Hemoglobin A1c Poor Control 0059 1 Core Set Menu Set Comprehensive Diabetes Care: HbA1c Control (<8.0%) 0575 — Clinical Quality Metrics 3 are required (select alternative core 3 out of other clinical quality measures set measures if the core measure alternative measures are required Diabetes Mellitus: Foot Exam 0056 163 does not apply) Diabetic Retinopathy: Documentation of Retinopathy 0088 18 Diabetes Mellitus: High Blood Pressure Control 0061 3 Communication with the Physician Managing On-going Care 0089 19 Current CQMs: Core Set Measures (must select 3 measures) Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control 0064 2

EPs Must Report on Three Core Set Measures Dentist Routine Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 0055 117 Oral Antiplatelet Therapy Prescribed for Patients with CAD 0067 6 Hypertension: Blood Pressure Measurement Potential Beta-Blocker Therapy for CAD Patients with Prior MI 0070 7 Tobacco Use Assessment & Counseling Potential Beta-Blocker Therapy for Left Ventricular Dysfunction (LVSD) 0083 8 Adult Weight Screening and Follow-up No Drug Therapy for Lowering LDL-Cholesterol 0073 197 Use of Aspirin or Another Antithrombotic 0068 204 Alternate Core Set Measures for EPs Warfarin Therapy for Patients with Atrial Fibrillation 0084 200 (substitute when any of the above 3 do not apply) Blood Pressure Management Control 0073 201 Weight Assessment & Counseling for Children No Use of Aspirin or Another Antithrombotic 0068 204 and Adolescents ACE Inhibitor or ARB for Left Ventricular Dysfunction (LVSD) 0081 5 Influenza Vaccination for Patients > 50 years No Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ 0387 71 Childhood Immunization Status No Progesterone Receptor (ER/PR) Positive Breast Cancer Colon Cancer: Chemotherapy for Stage II Colon Cancer Patients 0385 72 *An alternate core set of 3 measures is substituted for any of the 3 core metrics where the measure does not apply to Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk 0389 102 the dental program. Clinical quality measure reporting is a requirement; however no thresholds must be met. Prostate Cancer Patients Major Depression: (a) Effective Acute Phase Rx Treatment and (b) Continuation 0105 9 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: 0004 — Current Menu Measures for All EPs (must select 3 measures): (a) Initiation, (b) Engagement

In addition to the three CQM selections described earlier, providers will need to select 3 more measures from the Prenatal Screening for Human Immunodeficiency Virus (HIV) 0012 — current Menu Set of 38 CQMs on the next page. Prenatal Anti-D Immune Globulin 0014 — Appropriate Testing for Children with Pharyngitis 0002 66 Low Back Pain: Use of Imaging Studies 0052 —

Guide to the Future 10 11 Guide to the Future Clinical Quality Measures For Oral Health Core Set Measures Numerator Denominator 4. Oral Cancer Risk Assessment & The number of patients who receive The number of patients who receive In Stage 1, the Core Set Clinical Quality Measures (CQMs) are not as pertinent to oral health as they could be. Counseling – Percentage of all patients soft tissue screening, oral cancer a comprehensive oral health exam who receive soft tissue screening, oral exam and counseling. (ADA code 0110) or a periodic recall NNOHA identified six measures that are particularly applicable to Health Center oral health programs (listed cancer exam and counseling. (ADA code 0120) oral health exam during the report period. below). These measures were selected based on: (1) ease of data gathering; (2) ability to report through the current coding system; and (3) impact on improving the oral health status of the patients. The following Core 5. Periodontal Disease Assessment – The number of patients age 18 years who have been screened for the Set Measures for Oral Health would be substituted when any of the current CQMs do not apply (please note: Percentage of patients age 18 years and older who have been screened presence of periodontal disease. and older who have been screened for for the presence of periodontal these measures are under review and have not been approved by CMS). The number of patients age 18 the presence of periodontal disease. disease. years and older who receive a comprehensive oral health exam (ADA code 0110) or a periodic recall Proposed Top Three Alternate Core Set Measures for Dentists (substitute when any of the DENTIST (ADA code 0120) oral health exam current CQMs do not apply) ROUTINE during the report period. Annual Oral Health Visit Yes 6. Completed Comprehensive The number of patients with a The number of patients that receive Treatment Plan – Percentage of all completed Phase 1 treatment a comprehensive oral health exam Topical Fluoride or Fluoride Varnish Treatment Yes dental patients for whom the Phase 1* within 12 months of initiation. (ADA code 0110) or a periodic recall treatment plan is completed within a (ADA code 0120) oral health exam Periodontal Disease Assessment Yes 12 month period. during the report period.

DENTIST Proposed Other Alternate Core Set Measures for Dentists ROUTINE *For the definition of “Phase 1” treatment, please refer to the “Fundamentals” Chapter of theOperations Manual for Dental Sealant Yes Health Center Oral Health Programs: http://www.nnoha.org/practicemanagement/manual.html.

Oral Cancer Risk Assessment & Counseling Yes

Completed Comprehensive Treatment Plan Yes Additional Menu Set Measures for Oral Health

These CQMs for oral health would provide a significant step toward measurable, valuable, uniform clinical quality The current Menu Set of 38 items is not applicable for oral health programs. Measures that have been recently oral health measures across all Health Centers. added to Stage 2 proposed rule or could be added in the future to the Menu Set that would be more applicable to oral health are listed below. (Please note: two of the following oral health measures, NQF 1335 and NQF 1419, were included in the Stage 2 proposed rule). Core Set Measures Numerator Denominator 1. Annual Oral Health Visit— The number of patients with one The total number of registered patients Menu Set Measures for Oral Health NQF Percentage of patients who had or more dental visits. at the Health Center. at least one dental visit during the Children who received preventive dental care 1334 measurement year (the last 12 months). Children who have dental decay or cavities (INCLUDED in STAGE 2) 1335

2. Topical Fluoride or Fluoride Varnish The number of patients age 14 years The number of patients age 14 Primary caries prevention intervention as part of well/ill child care as offered by 1419 Treatment – Percentage of patients age and younger with at least one topical years and younger who receive a primary care medical providers (INCLUDED in STAGE 2) 14 years and younger with at least one fluoride or Fluoride Varnish treatment comprehensive oral health exam topical fluoride treatment or fluoride (ADA code 1203). (ADA code 0110) or a periodic recall Total eligible patients who received preventive dental services (EPSDT) N/A varnish treatment documented (the (ADA code 0120) oral health exam last 12 months). during the report period. Total eligible patients who received dental treatment services (EPSDT) N/A Percentage of new dental emergency patient visits (scheduled and unscheduled, N/A 3. Dental Sealant – Percentage of The number of patients age 6 to 20 The number of patients age 6 to 20 walk-in) patients age 6 to 20 years that have years that received sealant treatment years who were treatment planned to sealants on 1st and 2nd permanent on 1st and 2nd permanent molars receive sealants at the examination. Percentage of pregnant patients that receive an oral exam or N/A molars. after examination. preventive dental treatment

Guide to the Future 12 13 Guide to the Future Please note the four oral health measures endorsed by NQF (Aug, 2011) are listed below. At the time of this publication, under the Medicaid EHR Incentive Program, dentists in many states can register and attest. If the state’s EHR Incentive Program has not yet launched at the time of the dentist’s registration, the ■  Annual dental visit file will be placed into a pending status until the state’s program launches. Once registered, dentists can attest that ■  Children who received preventive dental care they have adopted, implemented or upgraded certified EHR technology in their first year of participation to receive ■  Primary caries prevention intervention as part of well/ill child care as offered by an incentive payment. Medicaid incentives will be paid by the states and are required to issue incentive payments primary care medical providers (INCLUDED in STAGE 2) within 45 days of dentists successfully attesting. Adopt, implement or upgrade means: ■  Children who have dental decay or cavities (INCLUDED in STAGE 2) ■ Adopt – Acquire, purchase or install a certified EHR system.

■ Implement – Install or commence use of certified EHR technology All four measures need to be e-measure specified (Harris, 2011). An eMeasure is a health quality measure encoded and have started one of the following: in a health quality measure format (HQMF). eMeasure testing should be done on the major EDR/EHR vendor systems in use to ensure that reliability and validity. NQF endorsement implies that a measure has been tested and • A training program for the certified EHR technology; shown to have adequate rates of validity and reliability. NNOHA plans to move forward with plans to test these • Data entry of patient demographic and administrative data into the EHR; measures. Stage 2 of Meaningful Use will include new requirements, criteria associated with new objectives and measures, and changes to the scope and threshold of existing measures. EPs who attest to Stage 1 Meaningful Use in • Establishment of data exchange agreements and a relationship between 2011 will have until 2014 to meet Stage 2 Meaningful Use standards and receive incentive payments. NNOHA and the provider’s certified EHR technology and other providers (such as other key stakeholders endorse the new two following oral health measures for Stage 2 beginning with CY 2014: laboratories, pharmacies, or health information exchanges).

■ NQF 1335: Title – Children who have dental decay or cavities. ■ Upgrade – Expand the available functionality of certified EHR technology capable of meeting Meaningful Use requirements at the practice site, including staffing, ■ Description: Assesses if children aged 1-17 years have had tooth decay or cavities in the past 6 months. maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the Office of the National Coordinator (ONC) EHR certification criteria. ■ NQF 1419: Title – Primary Caries Prevention Intervention as Part of Well/Ill Child Care as Offered by Primary Some examples of upgrading the existing EHR technology are the addition of clinical Care Medical Providers. decision support, e-prescribing functionality, and computerized physician order entry.

■ Description: The measure will a) track the extent to which the PCMP or clinic (determined by the provider number used for billing) applies FV as part of the EPSDT examination and b) track the degree Several states are currently capable of supporting all activities related to participation to which each billing entity’s use of the EPSDT with FV codes increases from year to year (more children in the Medicaid EHR Incentive Program, including: varnished and more children receiving FV four times a year according to ADA recommendations for high-risk children). • Program eligibility • Registration • Attestation to adoption, implementation, and upgrade activities In the Medicare & Medicaid EHR Incentive Program Registration and Attestation System (the • Incentive program payments online registration system for receiving reimbursements), dentist must fill in the numerators and denominators for the Meaningful Use objectives and CQMs, indicate if they qualify In the first year of participation in the Medicaid EHR Incentive Program, dentists that choose to demonstrate for exclusions to specific objectives, and attest their eligibility by entering that data into eligibility based on adopt/implement/upgrade (AIU) activities will need to attest to the following: the Attestation System. An EDR/EHR system must provide a report of the numerators, denominators and other required information. • Purchase and installation of ONC certified EHR technology that is commercially available • Development or upgrade of custom EHR technology with subsequent certification by an ONC-ACTB To attest for the Medicare EHR Incentive Program in the first year of participation, a dentist • Integration of certified EHR technology modules will need to have met Meaningful Use for a consecutive 90-day reporting period. Incentive • Testing and training in the use of the certified EHR technology payments for the Medicare EHR Incentive Program will be made approximately 4 to 8 weeks after • Business process engineering to integrate the certified EHR technology into clinical workflow a dentist meets the program requirements and successfully attests.

Guide to the Future 14 15 Guide to the Future As part of initial registration with the CMS National Level Repository (NLR), providers have the opportunity EHR Selection to specify the CMS EHR Certification ID of their EHR system. Dentists will need to supply the CMS EHR Certification ID during the Meaningful Use attestation process and attest that this Certification ID reflects a system that is actually being adopted, implemented, or upgraded. The accuracy of the attestation as to the specific certified People sometimes use the terms “Electronic Medical Record” (EMR) or “Electronic Dental Record” (EDR) when EHR system is ultimately the responsibility of the provider. Providers will be instructed that it is their responsibility talking about Electronic Health Record (EHR) technology. Very often an EDR or EMR is just another way to to maintain all applicable records to support their attestations for a period of no less than six years in the event of a describe an EHR, and both providers and vendors sometimes use the terms interchangeably. For the purposes of post-payment audit. the Medicare and Medicaid Incentive Programs, EPs must use ONC certified EHR technology. The Certified HIT Product List (CHPL) provides the authoritative, comprehensive listing of Complete EHRs and EHR Modules that To support attestations to AIU of certified EHR technology in the first year of participation in the Medicaid have been tested and certified under the Temporary Certification Program maintained by the Office of the National EHR Incentive Program, providers would supply documentation that demonstrates either a binding financial Coordinator for Health IT (ONC). Certified EHR technology gives assurance to purchasers and other users that an commitment or actual expenditures on adoption, implementation, or upgrade of the EHR technology. The EHR system or module offers the necessary technological capability, functionality, and security to help them meet documentation from an EDR/EHR vendor should include product name and version in such a way that it can the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health be matched to a specific product or combination of products in the ONC’s web-based Certified HIT Product IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to List (CHPL). The following documentation should be retained and produced upon request: share information.

■ Signed contracts, purchase orders, or receipts for purchase or lease of commercial off-the-shelf certified EHR software or proof of subscription to hosted EHR software Currently there are no flawless EDR systems or EDR/EHR integrated solutions available on the market. Every system has imperfections in working with oral health programs. Some systems are more robust with different ■ Documentation of expenses incurred in development, testing, maintenance, and upgrade features than others; some are more user-friendly, but none meets every need for Health Center oral health of custom certified EHR systems or modules programs. The task becomes finding the best fit for each Health Center depending on their needs, current systems, ■ Proof of payment for professional services related to the selection, acquisition, installation, and resources. and setup of certified EHR technology and the successful integration of the certified EHR technology into the clinical workflow ■ Purchase agreements or receipts for computer hardware or software required to operate the In general, EHRs, although not evaluated by this workgroup, are not considered to be dental friendly, especially certified EHR system when it comes to flexible scheduling or graphics. However, EMR products are well ahead of dental products in ■ Documentation of expenses incurred in transitioning patient records to the certified EHR system terms of tracking disease outcomes and diagnosis. This is because dental practices, with the exception of oral ■ Contracts or proof of actual expenditures for testing and/or training for the certified EHR system surgery and hospital practices, do not usually use diagnostic codes for billing as do medical practices. In addition, scheduling for dental procedures is challenging in medical EHR products since dental scheduling is not as flexible. Note that the software must be in use in clinical practice to count as adoption as a part of meeting the adopt/ While medical appointments may be slotted for 15 to 30 minutes, the appointment time for dental services vary implement/upgrade requirements. Centers should also be prepared, in the event of post-payment audit, to with procedures, type of providers (general or specialist), and level of experience of the providers, such as new or demonstrate that the certified EHR technology is actually in use in the clinical setting. For a detailed seasoned graduates, students and residents. illustration of this process, view page C-5 of the New York State MEDICAID Health Information Technology Plan: http://www.health.ny.gov/regulations/arra/docs/medicaid_health_information_technology_plan.pdf. While using an integrated EHR sounds ideal, Health Centers have other issues to consider before this can be a reality. If a dental patient is not a medical patient at the Center, medical records or other relevant information are not readily available. In the process of deciding which EDR/EHR system to use for an oral health program, the Dental Director may not have a lot of flexibility, as oral health programs are generally on the same practice management system with the medical department so that all types of data tracking can be done by one department. Until a true health home is established, access to a patient’s medications or ailments will remain a challenge. With these thoughts in mind, NNOHA has developed an EHR Selection Tool described below. For more information about which EHR systems and modules are certified for the Medicare and Medicaid EHR Incentive Programs, please visit http://healthit.hhs.gov/.

Guide to the Future 16 17 Guide to the Future EDR/EHR Selection Tool Step 1: Eligible Professional Assessment

Each Health Center’s dentists should start by completing the eligible professional assessment and deciding to participate Now that it has been established that electronic health records (EHR) are a key piece of Meaningful Use and the in Meaningful Use. The eligible professional assessment flow chart, below in Figure 1, will help determine if a dentist is future of health programs in general, the next step for many entities will be determining the best technology for eligible for the MU incentive and payment schedule shown in Figure 2. their organization. The NNOHA EDR/EHR selection tool is a multistep process that will guide members and other interested stakeholders in evaluating and selecting an EDR/EHR for oral health programs and assist dentists Figure 1: Eligible Professional Assessment Map for Dentists (an eligible professional (EP)), in determining eligibility for the Medicare and Medicaid EHR incentive programs. Meaningful Use Eligibility Flowchart The selection tool is available to NNOHA members and other key stakeholders on the NNOHA website: How to Use This Flow Chart: Doctors of Dental Medicine or Oral Surgery are eligible professionals (EPs) and may be eligible for EDR/EHR http://www.nnoha.org/practicemanagement/hit.html incentive payments. A dental EP that qualifies to receive EDR/EHR incentive payments under Medicare or Medicaid will maximize their payments by choosing the Medicaid EHR incentive program. Follow the path of answering the question to determine eligibility and start by assuming the dental EP did not perform 90% of the dental services in an inpatient hospital or emergency room hospital setting. A dental EP who qualifies for both Medicaid and Medicare can only participate in one program. The NNOHA selection tool starts with guiding the dentist through a series of questions to determine eligibility for EDR/EHR incentive payments and financial impact. The guide also includes key criteria to identify which START EDR/EHR systems can achieve interoperability between EDR and EHR systems, meet national Meaningful Use HERE Were at least Do you Do you You are not eligible objectives and are capable of reporting NNOHA’s proposed clinical quality measures for oral health. 30% of dental NO practice predominantly NO treat Medicare NO to receive an services furnished in an FQHC or RHC patients and bill EDR/EHR incentive to Medicaid patients with a 30% needy Medicare Fee for payment under in an outpatient individual* patient Service for patient the Medicare or The four vendors that have been included in this process for consideration are: setting? volume threshold? services? Medicaid EHR incentive program. YES ■ QSI/NextGen – QSI EDR and NextGen EHR. YES YES

■ Open Dental/eClinicalWorks – Open Dental EDR and eClinicalWorks EHR. Please note You are not By successfully demonstrating Meaningful eClinicalWorks is a separate corporation. eligible to receive Use of a certified EDR/EHR technology, you an EDR/EHR may be eligible to receive an incentive under Are you a Doctor incentive payment the Medicare EHR incentive program. ■ Henry Schein/Vitera (formerly Sage) – Dentrix Enterprise and Sage Intergy EHR. of Oral Surgery or under the Medicare Please note Vitera is a separate corporation and has a HL7 interface to Dentrix Enterprise. Dental Medicine? NO or Medicaid payment EHR ■ Mediadent/SuccessEHS – Mediadent EDR and Success EHS EHR. incentive program.

YES The selection tool also includes clinical, financial and administrative requirements that have been grouped into categories and a vendor solution cost assessment. You are not eligible to receive * section 1903(t)(3)(F) of the Act defines needy Does your practice an EDR/EHR individuals as individuals meeting any of the following use an ONC certified incentive payment three criteria: (1) They are receiving medical assistance The Process EDR/EHR and report under the Medicare from Medicaid or Children’s Health Insurance Program the core and menu NO or Medicaid (CHIP); (2) they are furnished uncompensated care by Step Description of Steps set measures? payment EHR the provider; (3) they are furnished services at either incentive program. no cost or reduced cost based on a sliding scale. 1 Eligible Professional Assessment YES 2 Vendor Background Information - Request For Information (RFI) ACROMONYMS: EDR: Electronic Dental Record 3 Review of Meaningful Use Core & Menu Set Objectives By adopting, implementing or upgrading to or successfully demonstrating Meaningful Use of a certified EHR: Electronic Health Record FQHC: Federally Qualified Health Center 4 Review of Meaningful Use Clinical Quality Measures (CQMs) EDR/EHR technology, you may be eligible to receive an incentive under the Medicaid EHR incentive program. RHC: Rural Health Center 5 Vendor Response to Meaningful Use Certification and Reporting Measures 6 Vendor Response to NNOHA’s Proposed Clinical Quality Measures (CQMs) for Oral Health Verification of Provider Eligibility 7 Vendor Response to EDR-EHR Practice-Specific Requirements After the dentist determines eligibility status, the process continues by applying for the Medicaid EHR Incentive 8 Vendor Response to Qualitative Requirements Program by visiting the website of the CMS National Level Repository (NLR) and logging in with the required 9 Vendor Response to Vendor Solution Cost information, including National Provider Identifier (NPI) and CMS Certification Number (CCN). Visit the CMS 10 Vendor Selection Criteria and Summary Ratings site for more details: https://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage.

Guide to the Future 18 19 Guide to the Future The NLR website will collect required information on the applicant, such as name, e-mail address, business address, ■ Compelling Reasons to Select Solutions: Ask vendors to provide reasons for selecting their EDR/EHR telephone number, and the desired incentive program (Medicare or Medicaid, and state, if applicable). CMS will and imaging solution. then transmit to the State a list of applicants who selected the Medicaid EHR Incentive Program, along with the CMS Certification Number (CCN). ■ Meaningful Use (MU) Plans: Ask vendors to respond to plans to attain MU certification and provide tools, knowledge, and services available to assist in attaining MU incentives. Figure 2: Maximum EHR Incentive Payments (CMS, 2012) ■ Integration Capabilities: Ask vendors to respond to capabilities to integrate EDR/EHR with radiographic imaging and intraoral camera technologies, manage the images, access the images from within charting software, and optimize workflow.

■ Conversion Capabilities: Ask vendors about their approach and experience in planning, implementing, and testing conversion processes, including conversion of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality.

■ Ways to Purchase Solutions: Ask vendors to respond to different ways to purchase solutions, including ability to bundle or unbundle products, leasing, ASP/hosted solutions, use of channel partners/VARs, or bundled with dental supply contracts. Ask, why are such purchasing approaches valuable?

■ Demonstration of Vendor EDR/EHR Capabilities: Ask vendors to respond to a demonstration script and present the company financial performance, deployment time/effort/risks, customer references, EDR/EHR product features and functions including interoperability, health information exchange, and clinical decision support.

Step 3: Review Of Meaningful Use Core & Menu Set Objectives

Step three of the selection tool continues with an assessment of meeting specific Meaningful Use requirements. The Health Center should review the Core and Menu Set objectives and determine which objectives align with the dental routine. NNOHA has provided an initial assessment for review earlier in this paper. Step 2: Vendor Background Information – Request For Information (RFI)

The process continues by identifying EDR/EHR vendors that the Health Center is considering and requesting Step 4: Review Of Meaningful Use Clinical Quality Measures (CQMs) both company background information and product information. The Health Center’s evaluation and selection team should learn what basic and advanced functions the EDR/EHR systems perform, how these systems will Step four continues with an assessment of meeting specific Meaningful Use clinical quality measure (CQM) improve efficiency, understand the various deployment models (e.g. ASP – Application Service Provider, SaaS- requirements that were discussed earlier in this paper. Dentists must report from the table of 44 clinical quality Software-as-a-Service), and learn industry terminology. At least three EDR/EHR vendors should be considered for measures which includes, 3 Core Set, 3 Alternate Core Set, and 38 additional CQMs. evaluation. Research the vendor’s financial status, technical capabilities, customer satisfaction, and gain a general sense of what these systems cost. The following information should be considered for the RFI request. The 3 Core Set CQMs are Hypertension, Smoking Cessation, and Adult Weight Screening. The 3 Alternate Core CQMs are Weight Assessment for Children, Flu Vaccinations for Patients over 50, and Childhood Immunizations. ■ Company and Product Capabilities: Dentists must report on the 3 Core Set CQMs. If a dentist reports “0”s for one or more of the 3 “Required Core” – History of delivering EDR/EHR solutions CQMs, he/she must then report on up to 3 Alternate Core CQMs. Therefore, dentists may have to report on as – Client base (# of organizations) many as six Core CQMs. – Number of safety net/Health Center clients – Largest client (number of connected sites and number of users) Dentists must also select 3 additional CQMs from a set of 38 measures in addition to the core/alternate core measures. It is acceptable to have a ‘0’ denominator provided the dentist does not have an applicable population. ■ Implementation and Support Services: Ask vendors to respond to the approach to define and implement Several dentists will find the measures not relevant to their patient populations. However, they must still report systems to meet all requirements and resources assigned to customer support. Tools/approaches are on 3 of these measures with numerators and denominators where possible and “0”s for the others. utilized to help diagnose and resolve customer issues, with remote diagnosis and on-site.

Guide to the Future 20 21 Guide to the Future Step 5: Vendor Response To Meaningful Use Certification And Reporting Measures (cont.) Dentrix – EHR Solution QSI EDR – Mediadent – Open Dental – (Sage Intergy) NextGen EHR SuccessEHS eClinical Works Step five ascertains if the vendor response meets Meaningful Use certification and reporting requirements. To Dental sealant Yes Yes Yes Yes qualify for the program, a dentist must own or have access to certified EHR technology that has been certified by the Office of the National Coordinator for Health Information Technology (ONC). Dentists must also be able to Oral cancer risk assessment Yes Yes Yes Yes & counseling demonstrate Meaningful Use of that technology. The NNOHA HIT Workgroup engaged in a product evaluation of four leading electronic dental record systems that are committed to Meaningful Use and have EDR/EHR Completed comprehensive Yes Yes Yes Yes treatment plan solutions for Health Centers. As previously mentioned, the four vendors that participated in the NNOHA HIT survey are as follows: Children who received Yes Yes Yes Yes preventive dental care

■ QSI/NextGen – QSI EDR and NextGen EHR. Children who have dental Yes Yes Yes Yes decay or cavities (INCLUDED ■ Open Dental/eClinicalWorks – Open Dental EDR and eClinicalWorks EHR. Please note eClinicalWorks IN STAGE 2) is a separate corporation. Primary caries prevention Yes Yes Yes Yes intervention as part of well/ ■ Henry Schein/Vitera (formerly Sage) – Dentrix Enterprise and Sage Intergy EHR. Please note Vitera ill child care as offered by is a separate corporation and has a HL7 interface to Dentrix Enterprise. primary care medical providers (INCLUDED IN STAGE 2) ■ Mediadent/SuccessEHS – Mediadent EDR and Success EHS EHR. Please note that other EDR/EHR Total eligible patients who Yes Yes Yes Yes vendors may meet Health Centers’ requirements and would be included in this step. received dental treatment services (EPSDT) The responses to the survey are listed in Appendix A1. To verify if a vendor is ONC certified visit: http://onc-chpl.force.com/ehrcert. Percentage of new dental No Yes Yes Yes emergency patient visits (scheduled & unscheduled, walk-in) Step 6: Vendor Response To NNOHA’s Proposed CQMs For Oral Health Percentage of pregnant patients Yes Yes Yes Yes The NNOHA HIT Workgroup identified six Core Set Proposed Clinical Quality Measures (CQMs) for oral health that receive an oral exam or preventive dental treatment and additional alternative Menu Set measures for potential inclusion in dentists’ Meaningful Use reporting in the future. This step shows the vendor responses to NNOHA’s Request for Information (RFI) with commercially Periodontal disease Yes Yes Yes Yes assessment available products. All vendor responses stated they would be able to support the reporting of the proposed measures with current or future upgrades. NNOHA recommends that each Health Center’s evaluation team find out what is required to generate the reports with current versions of the product during vendor demonstrations.

Dentrix – EHR Solution QSI EDR – Mediadent – Open Dental – Step 7: Vendor Response To EDR/EHR Practice-Specific Requirements (Sage Intergy) NextGen EHR SuccessEHS eClinical Works Considering NNOHA’s proposed This step compares the vendor responses to EDR/EHR functional requirements. The NNOHA HIT Workgroup Clinical Quality Measures for members expanded the EDR/EHR functional requirements to more closely reflect the needs of Health Center oral health providers, would you providers and administrators. This is an initial set of EDR/EHR functional requirements. be able to support the reporting of these sets of measures: Functional requirements define a function of an EDR/EHR system or its components. A function is described as a set of inputs, the behavior, and outputs. These requirements are presented as a starting point for oral health Annual oral health visit Yes Yes Yes Yes programs to use in their system evaluation and selection process but they are not intended to be complete or Topical fluoride or fluoride Yes Yes Yes Yes inclusive. Customizing and prioritizing the requirements to meet the organization’s needs are essential. Meaningful varnish Treatment Use and other qualitative requirements have also been included and specify criteria that can be used to judge the Periodontal disease Yes Yes Yes Yes operation of a system or vendor. Non-functional requirements are often called “qualities of a system” (e.g., quality assessment goals, quality of service requirements).

Guide to the Future 22 23 Guide to the Future The Health Center would identify the gaps of the current system(s) and identify the final set of key capabilities Step 8: Vendor Response To Qualitative Requirements needed from new software and prioritize the list into “must-have” features and those that are just “nice to have.” This process serves as the foundation of the software selection. By knowing what the Health Center needs, the This step requires the Health Center to review and rate the vendor response to other qualitative requirements listed software selection team will better position the organization to control the selection process, rather than let in the table below. The Health Center would determine the vendor’s capability including EDR/EHR implementation, software vendors dictate the needs. support services, product differentiation, Meaningful Use plans, integration capabilities, conversion capabilities, and ways to purchase EDR/EHR solutions based on the response from the RFI and Each of the four vendors responded to their company’s ability to meet the requirements and the results are other sources of information. presented in Appendix A2. Approval ratings would be determined by the Health Center for each category that follows:

Consideration for Dental Imaging and Mobile Needs Now and In the Future

NNOHA recommends that Health Centers incorporate the advances in dental imaging and mobile solutions. An ■ Implementation and Support Services: integral part of any EDR is digital radiography. Common questions include what changes should be implemented — Implementation: Vendor’s response to the approach to define/implement systems to meet and when they should take place. The answer is “it depends.” There may be financial constraints that govern when all requirements. particular hardware can be purchased and which hardware is within the budget for the digital conversion. Several — Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help sources are available that discuss the benefits of each of the radiography technologies available in the market place diagnose and resolve customer issues, with remote diagnosis and on-site. (Comparison Study of Dental Sensors: http://dentalsensorstudy.com/). The roadmap to full realization of EDR should include this important consideration and sequence. ■ Compelling Reasons to Select Solutions: — Vendor’s reasons for selecting their EDR/EHR and imaging solution.

■ Meaningful Use (MU) Plans: Other questions that often arise for Health Centers are on the choice of hardware: laptops, tablets, desktops, — Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services thin clients, etc. Again the correct choice is “it depends.” Questions to consider include, Is the clinic space new available to assist in attaining MU incentives. construction or retrofitting existing operatories? Will infection control protocols be violated? Will the workflow be adversely affected? How will the function of the dental team change with the incorporation of this technology? ■ Integration Capabilities: How will patient education be presented, and are ergonomic configurations for the equipment and set up addressed — Vendor’s response to capabilities to integrate EDR/EHR with radiographic imaging and intraoral to minimize repetitive injuries? These decisions are universal for any Center contemplating this next step. Failure camera technologies, manage the images, access the images from within charting software, to address them can result in costly work-arounds or re-configurations later. and optimize workflow.

■ Conversion Capabilities: Increasingly, Health Center oral health programs are operating outside the four walls — Vendor’s response to their approach and experience to plan, implement, and test conversion of the traditional Health Center. Tele-medicine is becoming an important modality process. Including conversion of the data, mapping current processes to new processes, mapping of care. Dentists can consult with another specialist and determine an appropriate current system’s functionality to new functionality. care plan rather than requiring the patient to move through multiple locations ■ Ways to Purchase Solutions: and appointments. Mobile equipment is allowing for care delivery in schools, — Vendor’s response to different ways to purchase solutions, including ability to bundle or unbundle senior centers, or other temporary spaces. With this trend of care provision, it is products, leasing, ASP/hosted solutions, use channel partners/VARs, or bundled with dental supply important to discuss the ease of operations and connectivity of electronic records contracts and compelling reasons why such purchasing approaches are valuable. to remote locations. Will there be the opportunity to seamlessly send large dental images to the main servers, or will they be stored locally? Will real-time medical ■ Demonstration of Vendor – EDR/EHR Capabilities: information be available at the point of care delivery? What are the infrastructure — Vendor’s response to demonstration script and presentation of company financial stability, requirements for such systems to operate seamlessly and reliably? What are the deployment time/effort/risks, customer references, EDR/EHR product features and functions storage backup features? All these questions need to be carefully considered, including interoperability, health information exchange and clinical decision support. discussed and answered with the entire dental team before implementation.

NNOHA’s HIT Workgroup provided the ratings in Appendix A3 based on survey responses, but each Health Center is encouraged to conduct their own assessment. The vendor survey details are summarized in Appendix A3.

Guide to the Future 24 25 Guide to the Future Step 9: Vendor Response To Vendor Solution Cost Most contracts presented by EDR/EHR vendors are written to protect the vendor and not the Final Check List: Health Center. The Center should request Additionally, as a good reminder, the following checklist The NNOHA HIT Workgroup requested pricing information from each vendor and that data is language changes to make the intent of the should be considered and updated during the selection included in Appendix A4. The Workgroup did not provide ratings for this process step since contract more “equal;” however, some vendors process for an EDR/EHR. there are several different pricing models (e.g. monthly subscriptions, up-front license, may not be flexible about language changes. special discounting and financing options), and recommends that the Health Center There are several areas that the organization ■ Define EDR/EHR system and Meaningful Use carefully review each selection process while considering a vendor. The Workgroup should review closely such as “auto-renew” (MU) requirements does not recommend that price be the primary decision criteria; however it can be an clauses and a potential “out clause” if the vendor important tie breaker. Additionally, having three or four vendors compete for business does not meet contract terms and conditions. ■ Clinical and care management and treatment planning requirements may create a more competitive pricing dynamic. ■ Front-office requirements (on premises) Prior to making a final decision, ensure the team ■ Back-office requirements (billing and finance) The RFI process should include a detailed price quote from vendors including has thoroughly scored and ranked the vendor deployment costs, maintenance and support costs and total cost of ownership costs, solutions that have been evaluated. Request the ■ Image capture equipment inclusive of all costs associated with the system. This includes software licenses, interface leading vendor candidate to provide at least two ■ Integration among above customer references that are very similar to the development, special customization, support, training, and other fees. The vendor should ■ Identify key stakeholders & decision makers specify any networking or third-party hardware equipment needed to run the system. practice specialty and user needs/requirements. ■ Develop business model and Return on Investment (ROI) Recognize that there are many pricing options and it is important to compare responses on Typical questions to ask the references include, an equivalent basis. the challenges they faced during implementation, ■ Estimate funding needs and other key resources the responsiveness to service and support issues, ■ Identify alternative vendors The sample vendor price-rating chart is located in Appendix A4 and suggested for Health Centers to use in end-user satisfaction, and access to user groups. ■ Research basic and advanced software capabilities evaluating vendor proposals. Note, service and support issues should be explored fully especially when there are several ■ Vendor selection vendor systems and components. The Health ■ Request for Information (RFI) Center should be clear about what vendor Step 10: Vendor Selection Criteria And Summary Ratings ■ Define criteria for selection organization is responsible for responding in a timely manner to system problems. ■ Demonstrations/Presentations The online selection tool process continues with the calculation of the final ratings from steps 7, 8 and 9 based ■ Check references/Site visit on vendor selection criteria and final team weights. A sample vendor rating chart is shown in Appendix A5. ■ Evaluate and select the best alternative The highest rated vendor results indicate the preferred vendor solution for consideration that meets the given ■ Negotiate the best deal possible requirements and falls within the organization’s budget. The selection team should have a convincing proposal where the benefits of new EDR/EHR software outweigh the costs and the new solution will solve the operational ■ Request a detailed price quote workflow problems. Benefits include Meaningful Use incentive payments, improved patient care, streamlined ■ Provide necessary data for a price quote workflow, and increased productivity. ■ Ensure quotes are complete: software, service, training, etc. ■ Compare all quotes on an equivalent basis Narrowing the list of EDR/EHR vendors is an important step. The Health Center should explain to the final list ■ Request the vendors’ software license agreement (SLA) of vendors what is expected from them during the selection process and give them a timeline. Once the final ■ Financing vendor(s) have been selected, the Health Center should update the contracting guidelines between the Health Center and EHR vendor(s). Negotiating this type of contract can be time consuming and complicated. Obtaining ■ Philanthropy sources legal advice is strongly recommended. Several EDR/EHR vendor contracts contain basic information such as ■ Meaningful Use incentives licensing, pricing, included services and support. Unlike a standard contract, an EHR vendor contract typically ■ Capital and operational funds includes complex legal language related to Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements, indemnification, and other non-EHR related terms.

Guide to the Future 26 27 Guide to the Future Discussion On Use Of EDR/EHR Selection Tool, Vendor’s Self The individual vendors responded to the selection criteria first presented in NNOHA’s 2008 Guide To The Future white paper. Newly added Meaningful Use requirements have been added. Some of these criteria, while very Scoring And General Disclaimer detailed, do leave room for interpretation by both vendor and end-user. While NNOHA wants this paper to be a useful guide, there is still no substitution for in-depth discussions with vendors and live demonstrations.

The ultimate decision on EDR/EHR vendor selection lies within the Health Center and their due diligence Demonstrations will certainly lead to discussions on how a particular technology can be incorporated into the work processes. While most Health Centers function within predetermined criteria, there are unique factors that may flow and physical configuration in a particular operatory. Reviewing demos is perhaps the most critical step in the lead a Health Center to choose one vendor over another. NNOHA has identified several products that meet the software selection process. Health Centers should provide each vendor with a few “demo scripts” to detail specific unique criteria of Health Center oral health programs; all vendors presented here are already in full use at Health workflows (e.g. patient registration, charting, and billing) that they want to see in the demo. For each vendor, the Centers across the country. The question that remains to be answered, is which product will be the best match review team could use a “demo scorecard” to record the evaluation. Some questions might include: What are the for a particular Health Center. different licensing models? Do you require using a third party vendor? What type of work station configuration is required? How will the software be installed/updated, locally or on a remote server?

Four EDR vendors were contacted regarding the capabilities of their respective software in meeting Meaningful Use criteria. Research results show that most EDRs currently are inadequate for meeting Meaningful Use criteria Another example of a demo script could be the reporting or billing structure. All systems can bill for their services, and few vendors have achieved ONC certification from an ONC-Authorized Testing and Certification Body but the pathway, checks and balances, and numbers of clicks needed to get a claim out the door vary. All systems (ATCB); however some vendors have plans to meet Meaningful Use requirements in the near future (NORC, have the ability to report on the data they collect, but for many the raw data is imported into reporting software 2011). such as Crystal Reports, BridgeIT, or a similar package. Aligning data collection and data entry processes with reporting needs can be complex. EHR and Practice Management system vendors build database structures that are designed for operational efficiency to retrieve and review data related to a specific patient and their encounter and With the integration of medical and dental programs, Meaningful Use requirements, and patient-centered billing data. Many times these database structures do not lend themselves to reporting efficiency. Data warehousing medical home initiatives, the selection of the electronic health record system is shared between the various and tools designed specifically for reporting needs improve these capabilities. Again, the Health Center should departments. Additionally, clinical departments as well as their support systems such as the finance, information be asking the vendor to demonstrate key features, improvements in workflows and all Heath Center key decision technology, and practice management departments should all participate in the selection of the product that makers should be involved. will be used, since many of their workflows will be changed with the introduction of an EHR.

Technology is evolving very quickly to respond to the specific needs of the end user. Each software upgrade carries with it improvements that enhance the product’s usability. Technology does not stand still and as new Challenges Selecting And Implementing An EDR/EHR Solution features become available, portions of or scoring in this report will become outdated.

The EDR systems vendors have made some significant progress upgrading their solutions since the 2008 publication of NNOHA’s Guide to the Future. However, there are still areas for product differentiation such as:

■ Most EDR products have patient education modules. Unfortunately, most of these modules are in English, some may have few Spanish versions. None of the current products are useful to other ethnic groups. ■ Voice-activation is a useful feature of an EDR but may not be the selling point to Health Centers with many bilingual employees. ■ Electronic signatures and electronic medical history forms are one of the features of an EDR; however, they may not be as valuable to a Health Center where most patients are immigrants who may not read or write, even in their own languages.

Guide to the Future 28 29 Guide to the Future ■ ePrescription (computer-generated prescriptions created by the health care provider and sent directly ■ Identify and implement the EDR/EHR system and new workflow through staff training to the pharmacy) is an excellent tool for all providers but it may not be an incentive for practices in ■ Monitor the EDR/EHR workflow and adjust as required to optimize efficiencies small rural towns or other areas where the local pharmacies may not be as technologically ready. ■ Integration with digital imaging systems is becoming less of a problem as most digital image software A typical comprehensive implementation program would include digital imaging, an EDR/EHR system, and manufacturers are striving to easily interface with ANY EHR system. Digital X-Ray integration with integration and or migration of the existing practice management system. There are a number of implementation EDR products may still be an issue to consider. paths to consider from an all-at-once “big bang” approach by implementing digital imaging and EDR/EHR at all practice locations, to an incremental approach that starts with dental imaging first at a single practice location followed by the EDR/EHR integration and Go-Live. The “big bang” implementation has often led to implementation Ideally, the oral health program should be able to select its own EDR product that serves the needs of the dental failure if it was not carefully planned and staff adequately trained on the new systems. Health providers and, the decision of an EDR product should not depend on the selection of an EMR on the medical Centers should discuss with the dental imaging and EDR/EHR vendors the incremental side. Dental Directors will have to use persuasive skills to ensure that the clinical, financial and administrative approach to system implementation. Generally within six to nine months, dental imaging requirements of the oral health program are included with medical requirements of the Health Center. and EDR/EHR systems can be implemented smoothly. NNOHA recommends a gradual, incremental approach to ensure success. Another strategy that some Health These are only a few key challenges facing a Health Center. This white paper provides a strategic framework for Centers have adopted is to go with the EHR portion first, and then bring on the selecting an EDR/EHR system and moving forward to achieving Meaningful Use of EDR/EHR systems. digital imaging feature. Any approach should allow for adequate training of staff, especially if the Health Centers have long-term staff that may not be as technologically savvy and adept.

EDR/EHR Implementation Strategies The following illustrates an incremental implementation approach. It outlines the vision of a digital dental practice and a migration path to get there, identifies the users and beneficiaries, the critical decisions that will be made, business and clinical benefits to be achieved, the process used to define the technologies and Strategic HIT Investment vendors, the migration path, and the risks and mitigation strategies associated with this transformation. Before the introduction of Meaningful Use, the goal of EDR/EHR implementation was to digitize the traditional office practice workflow and make the traditional process of caring for a patient more efficient by replicating the paper workflow on the computer. The traditional approach will no longer suffice to meet the demands of Phase 1: Dental Imaging the transformation of care delivery. The strategic roadmap to Meaningful Use of EHRs starts with redesigning practice workflows. The workflow steps a Health Center team could take include: This phase will transition the organization from a film operation to a digital solution that will capture, store, and provide access to X-rays and pictures ■ Evaluate and document the current clinical, administrative and financial workflows taken throughout the practice. This capability will improve operational performance, reduce costs, provide advanced imaging tools for oral health ■ Involve clinical and administrative staff in the workflow analysis and redesign and early disease detection in an environmentally-friendly manner, and ■ Review workflow diagrams and supporting documentation of current workflows to ensure better serve patients in the community. they encompass all of the practice’s locations

■ Identify areas of improvement and waste in the workflows A typical dental imaging solution would include integrated imaging components that provide quick, accurate, flexible ways to capture, store, manage, and access ■ Redesign workflows to improve clinical and office functionality and ensure the EDR/EHR X-rays and pictures. Technologies include film-based scanners, direct and indirect system selection and training will ensure successful transition intraoral/extraoral imaging systems and sensors, and image management software.

Guide to the Future 30 31 Guide to the Future Benefits and Return on Investment Benefits and Return on Investment

The initial capital outlay for a digital X-ray unit is higher than for a conventional film-based equivalent. However, An integrated dental imaging and EDR/EHR solution will provide additional benefits such as: once this initial investment has been depreciated, all subsequent X-ray exposures are practically free of charge and this pays dividends throughout the long economic life of the digital X-ray systems. ■ Access to clinical data across medical and dental providers resulting in lower cost and fewer errors. There are several benefits with the addition of digital imaging: ■ More effective decision-making by clinicians and patients. ■ Attainment of desired outcomes through prevention, early detection, and intervention. ■ The proposed digital solutions will provide quality diagnostic images, lower radiation exposure to the ■ Less time associated with maintaining accurate, thorough, and legible documentation. patient, eliminate hazardous developer chemicals, and reduce staff and patient wait time for images. ■ Ability to easily view multiple diagnoses, and planned and completed dental treatments. ■ The digital patient images are saved automatically to the patient database and can be viewed chair side for patient education or at a remote location for a second consult. In addition, the new Meaningful Use incentive program associated with Medicare and ■ The Health Center can economize on labor costs and realize a reduction in expenditures Medicaid will provide up to $63,750 for each dentist. This program will help Health on consumables. Centers improve their operation, improve access to care for patients with needs, and ■ The digital solution will also unlock new sources of earnings potential. For instance, improve financial performance by increasing reimbursement. the darkroom can be devoted to other productive purposes.

Payback for EDR/EHR is typically two years without incentives for Meaningful Digital Film Use. The combination of a digital imaging platform and the integrated EDR/EHR Fixed costs • Sensor and imaging software • Film & Film Processor will enable Health Centers to improve care, reduce errors and risk, lower costs, • Personal computer system • Darkroom and enhance the ability to serve populations for which they were not previously Variable costs • Barrier envelopes/sleeves • X-ray films and cassettes able to provide care. Due to the fact that this will establish a foundation to improve • Maintenance/repair costs • Chemicals the financial and operational performance of a Health Center for years to come and • Labor costs for film processing there will be a rapid payback, there has never been a better time to find the right and cleaning EDR/EHR solution. NNOHA can provide the tools and resources to guide Health • Maintenance/repair costs Centers through this process.

Note that there are maintenance and repair costs associated with both digital and film X-ray systems. Digital maintenance and repair costs may be higher; however, they may be covered under a warranty or extended maintenance agreement. Conclusion: A Strategic Pathway To The Future

Phase 2: Office Automation The American Recovery and Reinvestment Act of 2009 (ARRA) includes a provision designed to improve the coordination of patient care, reduce costs and improve health outcomes. This provision is referred to Digital software solutions can transform the organization from a paper-based as “Meaningful Use,” and the Centers for Medicare and Medicaid have implemented the Medicare and operation to an environment that leverages digital solutions to improve Medicaid EHR Incentive Programs that provide a financial incentive for the “meaningful use” of certified EHR workflow, reduce costs, help the practice address payment reform, and increase technology to achieve health and efficiency goals. Through participation in the program and meaningfully revenues by qualifying for Meaningful Use incentives. The digital software using an EHR system, providers will achieve benefits beyond financial incentives, such as reduction in solution is comprised of an EDR/EHR to help the clinicians capture patient errors, availability of records and data, reminders and alerts, clinical decision support, and e-prescribing/refill information, enable e-prescribing, and be able to track and communicate with automation (Centers for Medicare & Medicaid Services, 2011). This paper has been developed to assist oral patients regarding treatment options/patient history, and the EPM to continue to health programs participate in Meaningful Use by providing a roadmap to assessing, selecting provide capability for scheduling, reminders, and billing. and implementing an EHR that includes electronic dental records in their clinics.

Guide to the Future 32 33 Guide to the Future Health Centers must create a strategic vision and develop a strategic plan for the identification and ■  Policymakers and funders can encourage the development and acceptance of comprehensive oral implementation of an efficient and effective EDR that is integrated into the overall HIT system. The selection health measures and an integrated approach to oral and general health. Health Centers continue to and implementation of an EDR/EHR solution is critical to driving improvements in the quality of care through provide a testing ground for integrating care between the dental, medical, and mental health settings, better coordination and improvements in patient safety. Thorough and careful planning is needed to participate through the successful use of EDR/EHR systems. in the meaningful use incentives. ■  Dental Directors have an opportunity to supplement capital costs with Meaningful Use incentive Before embarking on Meaning Use, Health Centers should consider the following strategic roadmap questions: payments, create a long term strategic framework and solid foundation for the implementation of an EDR/EHR solution that will report Meaningful Use objectives among Health Center oral health • What are the implications of participating in Meaningful Use? programs and streamline the workflow. • Are the dentists eligible for Meaningful Use incentives?

• What external organizations can assist in the early planning, implementation and achievement With the Health Center’s requirements defined and these questions answered, the organization can start of Meaningful Use of EDR/EHR systems? building a “short list” of EDR/EHR vendors and evaluate each system in-depth, positioning the organization for • What features and capabilities should be included beyond the NNOHA suggested requirements? the “era of Meaningful Use.” Meaningful Use and health information technology are critical to delivery system • What is the Center’s capital and operating budget for an EDR/EHR solution? reform supporting and driving sustained improvement in patient outcomes. The end goal is not only to have an • What EDR/EHR selection process and deployment model should be used? efficient, quality practice, but also to improve the health of every community.

These questions, along with information regarding eligibility for the incentive program, EDR/EHR and vendor CMS recently announced the second stage of the three-stage process and two new CQMs for oral health. This selection criteria, and lists of vendors that have certified EDRs are addressed in this paper. Obtaining Meaningful is great news. NNOHA will provide additional updates to Meaningful Use Stages 2 and 3, and continue to Use incentives for EDR/EHR systems can provide the necessary funding, and can be a strategic step toward support EDR/EHR adoption. The proposed rule announced by ONC identifies standards and criteria for the strengthening the connections between oral health and general health. Utilizing the NNOHA EDR/EHR certification of EHR technology, so dentists can be sure that the systems they adopt are capable of performing selection tool will assist Health Centers in understanding this process. the required functions to demonstrate either stage of Meaningful Use that would be in effect starting in 2014.

NNOHA Is Committed To Guiding Stakeholders In The Strategic Roadmap Process:

■  EDR/EHR vendors are important players in furthering Meaningful Use reporting for oral health through upgrading existing products or developing new products that meet the unique needs of Health Center oral health programs. While several vendors have made progress in adding new features to existing products, this sector of the HIT market remains largely untapped and currently uses products or workflow processes that are inadequate in meeting the needs of oral health providers. There are specific gaps for electronic dental chart systems, practice management systems, and digital radiography and other imaging products that if addressed, could help to spread HIT adoption in Health Center dental settings. There is also a need to better integrate these products in a cost-effective approach both within the Health Center oral health program and between the dental and medical side of Health Centers. The EDR opportunity for vendors is a large opportunity in the Health Center market. Over a billion dollars of ARRA funding is targeted to Health Centers and the Affordable Care Act provides another 11 billion in funding to the existing 1,080 Federally Qualified Health Centers over the next 5 years.

Guide to the Future 34 35 Guide to the Future Appendix A1: Meaningful Use Vendor Survey Responses Dentrix – Other EHR System: QSI – NextGen Mediadent – Open Dental – Vitera Intergy EHR Software SuccessEHS eClinicalWorks (formerly Sage Intergy) Meaningful Use Vendor Survey Responses The EDR/EHR vendor responses to Meaningful Use requirements: Maintain up-to-date problem Yes Yes Yes Yes list of current and active diagnoses Dentrix – Other EHR System: QSI – NextGen Mediadent – Open Dental – Vitera Intergy EHR Software SuccessEHS eClinicalWorks Maintain active medication list Yes Yes Yes Yes (formerly Sage Intergy) Maintain active medication Yes Yes Yes Yes Meaningful Use Requirements allergy list

Is your EDR/EHR system No No No Yes – Smoking status for patients Yes Yes Yes Yes certified by an ONC-Authorized eClincalWorks 13 years of age or older Testing and Certification Body version 9.0 is Provide patients with clinical Yes Yes Yes Yes (ONC-ATCB) and reported to certified ONC? summaries for each visit OpenDental EHR Provide patients with electronic Yes Yes Yes Yes version 11.0 is copy of health info ONC certified Generate and transmit Yes (Planned for 2012) Yes Yes Yes Comments: If Dentrix Enterprise If QSI EDR If Mediadent is Currently both permissible prescriptions integrates with an ONC- is integrated integrated with are ONC-ATCB electronically ATCB certified EHRs, (e.g., with NextGen SuccessEHS certified. One vendor is Sage Intergy Ambulatory which is ONC- Computer provider order entry Yes Yes Yes Yes V7.0 ID: 07282011-4815-8, EHR, ATCB certified, eCW Certification for medication orders another vendor is version 5.6 SP1 ID: CC-1112- ID: CC-1112- Implement drug-drug Yes (Planned for 2012) Yes Yes Yes MicroMD EMR v7.5, ID: which is ONC- 909422-1 then 955447-1 interaction checks CC-1112-524956-3 then ATCB certified, dentists can Open Dental register for MU dentists can register for MU ID: CC-1112- Certification Capability to electronically Yes Yes Yes Yes incentive. incentive. 345777-1, then ID: 08182011- key clinical info among dentists can 1177-6 providers and patient- register for MU authorized entities incentive. Dentists can register for MU Implement one clinical Yes Yes Yes Yes incentive. decision support rule and ability to track compliance If no, does your company plan Yes Yes Yes Currently with this rule to obtain certification/Other Dentrix Enterprise is QSI Dental is QSI Dental is certified Comments: currently working towards currently working currently working Protect privacy and security Yes Yes Yes Yes modular certification. towards modular towards modular of patient data in the EHR certification. certification. Report clinical quality Yes Yes Yes Yes measures to CMS or states Core Set Objectives: (see Oral Health Proposed Can you meet the Core Objectives for Meaningful Use for Stage 1 measure? Measures)

Patient demographics (sex, Yes Yes Yes Yes Menu Set Objectives: race, ethnicity, date of birth, Can you meet the Menu Set for Meaningful Use for Stage 1 measure? preferred language) Drug formulary checks Yes (Planned for 2012) Yes Yes Yes

Vital signs and chart changes Yes Yes Yes Yes Incorporate clinical laboratory No, captured in EHR Yes Yes Yes (height, weight, BP, BMI, test results into EHRs as growth charts for children) structured data

Guide to the Future 36 37 Guide to the Future (cont.) Menu Set Objectives: EDR/EHR Vendor Dentrix Enterprise QSI EDR Mediadent Open Dental Can you meet the Menu Set for Meaningful Use for Stage 1 measure? & Sage Intergy & NextGen EHR & SuccessEHS & eClinicalWorks

Generate lists of patients by Yes (Planned for 2012) Yes Yes Yes Key Requirements Rating (1-5, or Not Rating (1-5, or Rating (1-5, or Rating (1-5, or specific conditions to use Clinical Care Management Applicable) Not Applicable) Not Applicable) Not Applicable) for quality improvement, and Treatment Planning reduction of disparities, Requirements research, or outreach Standard high quality workflow 3 (ePrescribe will be 5 5 5 Use EHR technology to identify Yes Yes Yes Yes for charting, information available in 2012) patient-specific Education access, image access, and resources and provide those ePrescribe to the patient Treatment planning module 5 5 5 5 Perform medication Yes (Planned for 2012) Yes Yes Yes reconciliation between Lab tracking of cases 5 5 5 5 care settings Recall tracking 5 5 5 5 Provide summary of care Yes Yes Yes Yes record for patients referred ePrescribing and Rx printing 3 (ePrescribe will be 5 5,3 5 or transitioned to another available in 2012) provider or setting Ability to manage and annotate 5 5 5 5 radiographs Send reminders to patients Yes Yes Yes Yes for preventive and f/u care Clinical charting and 5 5 5 5 integrating images with Provide patients with Yes Yes Yes Yes intraoral cameras and electronic access to their radiographic imaging on health Information (lab one screen results, problem list, meds Periodontal charting with 5 5 5 5 Submit electronic No Yes Yes Yes voice activation immunization data to (when used with Providers can easily access 5 5 5 5 registries or immunization SuccessEHS) production and collection information systems reports for any specified time frame Submit electronic syndromic No Yes Yes Yes Insurance predeterminations 5 3 5 5 surveillance data to public (when used with entered with ease, also health agencies SuccessEHS) tracking of predeterminations

Software accurately estimates 5 5 5 5 Appendix A2: Rating Chart: Vendor Response to EDR/EHR Practice-Specific Requirements patient’s and insurance provider’s portion of bill

Ability to integrate “outside” 5 5 5 5 Each of the four vendors responded to their company’s ability to meet the practice-specific requirements and are listed below financing programs, e.g. based on their integrated EHR solution. Following each requirement, the vendor provided a rating corresponding with the CareCredit statement from the following that most accurately reflects the relevant offerings from the company: Software can perform or incorporate programs that Rating: provide for the following 5 – Currently is able to meet this requirement with a commercially available product that is in use within live customer environment (*vendor response based 4 – Currently is able to meet this requirement with commercially available product that is not yet in use within live customer on lowest rating): environment • electronic statements, 5 5 5 5 3 – Soon will be able to meet this requirement with a product that is under development and expected to be commercially • online eligibility verification, 5 5 5 4 available within 3 months • electronic remittance advice 5 5 3 5 (detailed explanation of 2 – Will be able to meet this requirement with a product that is under development and expected to be commercially available benefits that automatically within 1 year enters insurance payments 1 – Is not able to meet this requirement; there are no plans to meet this requirement within 1 year to software ledger)

Guide to the Future 38 39 Guide to the Future Key Requirements Rating (1-5, or Not Rating (1-5, or Rating (1-5, or Rating (1-5, or Key Requirements Rating (1-5, or Not Rating (1-5, or Rating (1-5, or Rating (1-5, or Clinical Care Management Applicable) Not Applicable) Not Applicable) Not Applicable) Clinical Care Management Applicable) Not Applicable) Not Applicable) Not Applicable) and Treatment Planning and Treatment Planning Requirements Requirements

Software must integrate clinical 5 5 5 5 Customizable treatment plans 5 5 5 5 and financial information based on treatment priority order/clinical findings Clinical charting should easily 5 5 5 5 facilitate entry of planned and Ability to create alternative 5 5 5 5 completed treatment, as well treatment plans based on as conditions clinical findings

A comprehensive display of 5 5 5 5 Ability to print incomplete 5 5 5 5 treatment completed and treatment plans by: provider, planned is displayed procedure or user defined criteria Treatment plans can be 5 5 5 5 constructed in phases Ability to transmit treatment 5 2 5 5 plans electronically to Onscreen treatment planning 5 5 5 5 third party carriers for virtual charting – is available pre-determinations Ability to automatically 5 5 5 5 Procedures performed and 5 5 5 5 calculate insurance benefits pending are tracked. A report and patient financial liability of either can be produced when entering procedures A treatment plan broken 5 5 5 5 on a treatment plan down by visit with financial Ability to monitor treatment 5 5 5 5 requirements, time spreads, plans by medical diagnosis & notes on a report for the such as diabetes patient is available Dental Lab tracking module Multiple treatment plans can 5 5 5 5 is available that interfaces be stored and generated for with the Appointment module one patient indicating the patient’s next The system provides the ability 5 5 5 5 scheduled appointment and to identify and retain deleted allowing dental staff to enter and/or changed treatment by patient dual identifiers and plan items location: • the dental lab where the 3 2 5 5 Printed treatment plans 3 5 5 5 clinical case is being sent indicate date, time, and user • the date when the case printing the treatment plan was picked up Explanatory notes can 5 5 5 5 • the date when the case is be stored with individual requested back treatment plan items • a description of the dental work being processed Dentist can utilize a “status” 5 5 5 5 • the signature or initials of to be applied to any treatment the staff member sending plan or its items out the case • the actual date the dental Treatment plans can be 5 5 5 5 lab work is returned constructed in phases including multiple treatment • the signature or initials of plans that can be stored and the staff member checking generated for one patient in the case

Guide to the Future 40 41 Guide to the Future An integrated patient 5 5 1 5 Productivity Measurement and Support Requirements education system based on practice defined fields and Average patient case fee 5 5 5 5 reports from Health Center (average production and oral health disparities targeting collection per patient over specific systemic illness, oral a date range by provider) conditions, or financial classes. is calculated Referral report showing 5 5 5 5 Ability to create templates with 5 5 5 5 referred, treatment planned, treatment plans and chart treatment performed, fees notes that allow charting by and collections is available exception to minimize typing The system quantifies the 5 5 5 5 Ability to display or generate 5 5 5 5 number of active patients next appointment, recall using practice-defined criteria information of “active”

The system has an integrated 5 5 5 5 Historical reporting of 5 5 5 5 recare/recall system capable transactions available by of generating multi-lingual user-defined date parameters patient reminders The system calculates 5 (when interfaced 5 5 5 Built in ability to create 5 5 5 5 unduplicated patients for with medical) treatment completion reports UDS reporting and user defined outcome measures such as: Ability to assign an “effective 1 (able to import provider 5 5 5 • # of completed treatment date” to provider schedule schedules) plans templates and maintain several templates simultaneously for • # of children with sealed 4 (using Intergy) the same provider permanent molars • # of infants and toddlers Ability to track the number 5 2 5 2 receiving fluoride varnish of vacation, sick, personal, (except CE -1) • # of parents receiving continuing education and anticipatory guidance holiday time taken by providers • # of diabetics receiving (and support staff) over the periodontal therapy course of the year

Productivity Measurement and Support Requirements Ability to track via a virtual 4 (using Intergy or separate 2 5 5 sign-in/sign-out time clock third party software) System has a built-in way to 5 5 5 5 staff members’ punctuality. track and report broken, failed, or canceled appointments Ability to monitor access and according to user defined efficiency using the following criteria measures: • track the average time 5 5 1 5 System tracks lost production 5 5 5 5 in days to the third next and unscheduled treatment available appointment for from broken appointments routine care • track the average amount 5 System provides patient 5 5 5 5 of time a patient waits to be listing for confirmation of seated for their appointment appointments (with comments on financial information if • track the average amount of 5 applicable) time of a patient visit from when the check in to when All statistics and reports 5 5 5 5 they check out available by location of • monitor patient’s satisfaction 1 treatment, provider, or with their dental visit via combination thereof an electronic patient satisfaction survey

Guide to the Future 42 43 Guide to the Future Tooth and Periodontal Charting Report detailing incomplete Ability to chart supernumerary 5 5 5 5 treatment plans so patients 5 5 5 5 teeth in primary and can be contacted permanent dentitions. Software seamlessly 5 5 5 5 Ability to view radiographs on 5 5 5 5 communicates that a patient the same screen as the area has been checked in and being charted. is ready to be seated Changes in schedule 5 5 5 5 Ability to see the date of the 5 5 5 5 seamlessly appears on exam on the tooth charting operatory screen and periodontal charting/ Periodontal Screening and Seamless communication from 5 5 5 5 Reporting (PSR) as part of treatment areas to front desk the data collected. Field for Primary Dental 5 5 5 5 Ability to overlay the full mouth 5 5 5 2 Provider Name, Field for periodontal exam or PSR PCP name findings over the tooth charting Field for patient status (Active, 5 5 5 5 for a better general synopsis. Discharged, Deceased, or Ability to conduct a PSR 5 5 5 5 Transferred) independent of a full mouth periodontal examination. Budget plans for payments 5 5 5 5

Ability to utilize voice 5 5 5 5 Can perform or incorporate recognition, voice activated programs that provide: software to record periodontal • electronic statements 5 5 5 5 findings during a full mouth • online eligibility verification 5 5 5 5 periodontal exam or PSR. • electronic remittance advice 3 5 2 5 (detailed explanation of Customizable practice-defined 5 5 3 5 benefits that automatically full mouth periodontal exam enters insurance payments templates. to software ledger) By appointment type/global 5 5 5 1 Office Administration Requirements days indicator that does not allow appointment booking Automatically generates letters 5 5 5 5 prior to 6 months (annual) to patients or specialists (e.g. welcome letters with office Ability to view financial story 5 5 5 5 policies) (including payment history) as if it was in the central Voice activated dictation 3 (Intergy or third party 5 (Perio 1 5 business office solutions like Microsoft Charting only) Voice) Ability to import and edit fee 5 5 5 5 On screen alerts: recall alerts, 5 5 5 5 schedules medical alerts, financial alerts, etc. COMPLETE report writer 5 5 5 5 that can generate any report Check-in and check-out with 5 5 5 5 imaginable ease without having to access multiple screens Alert for bad debt (multiple 5 5 5 5 company options, internal Tracking of missed and 5 5 5 5 vs. external) canceled appointments Non-covered service codes for 5 5 5 5 List of patients available to fill 5 5 5 5 Medicaid to be able to force canceled appointments to patient

Guide to the Future 44 45 Guide to the Future Office Administration Requirements Automatic generation of a fee 5 5 5 5 upon entry of a procedure Can easily access production code and collection reports for any 5 5 5 5 specified time frame Ability to see the outstanding 5 5 5 5 balance from the Appointment (Appt. screen) Ability to easily and completely 5 5 5 5 Screen and Charting Form integrate clinical and financial information Claim form duplication for 5 5 5 5 resubmission Check-in and check-out with 5 5 5 5 ease without having to access Insurance aging and auditing 5 5 5 5 multiple screens of submitted, paid, or non- submitted claims Software seamlessly 5 5 5 5 communicates that a patient Insurance coverage 5 5 5 5 has been checked in and is breakdown per policy, ready to be seated employer, or company that list deductibles, maximums, Changes in schedule 5 5 5 5 % per category, etc. seamlessly appear on operatory screen Reflection of primary 5 5 5 5 Seamless communication from 5 5 5 5 insurance payment when treatment areas to front desk secondary claim is sent

Billing Requirements Changes estimated insurance 5 5 5 5 portion when entering charges Ability to support FQHC/ 5 5 5 5 Medicaid requirements to Single-screen posting of batch 5 5 5 5 bill by an encounter rate insurance payments (individual procedures roll up to an encounter rate) Supports electronic remittance 5 5 5 5 posting (with Intergy) Ability to calculate a sliding 5 5 5 5 fee scale for service based on Ability to transfer old balances 5 5 5 5 federal poverty guidelines to another responsible party Supports secure electronic 5 5 5 5 Open-item accounting for 5 5 5 5 billing to governmental payers insurance billing and tracking Ability to print insurance 5 5 5 5 forms for completed and Open-item insurance 5 5 5 5 planned services, including estimation Medicaid and American Dental Secondary insurance 5 5 5 5 Association (ADA) standard processing generated by dental claim forms primary insurance response Day sheet generation for 5 5 5 5 balancing the deposits and Ability to check insurance 5 5 5 5 viewing billings for the day eligibility, insurer coverage for proposed treatment in Aging dates reflect Current 5 5 5 5 real time (under 30 days), 30-60 days, 61-90 days, 91-120 days, and Account balance broken down 5 5 5 5 over 120 days by: previous balance, today’s treatment and fees, 3rd party Separate and combined aging 5 5 5 5 coverage information by provider, payer, contracts, grants, etc. Deductible and/or co-payment 5 5 5 4 owed; remaining coverage; Open item accounting for 5 5 5 5 expected payment from 3rd insurance billing and tracking party

Guide to the Future 46 47 Guide to the Future Statements Charge Entry edit: record additional provider name (e.g. 5 5 5 5 Statements reflect estimated dental hygienist); supervisor insurance benefit and patient 5 5 5 5 billing/dental hygienist balance; PPO, HMO coverage, productivity processing and eligibility handling Subscriber Billing 5 5 5 5 Dunning statements generated 5 5 5 5 Technical Requirements for billing Ability to run the application 5 5 5 5 Multiple cycles for billing 5 5 5 5 on thin client technologies statements (for example, aging date, alphanumeric by name, The system is available 5 (Health Choice Network) 1 5 5 etc.) through an Application Service Provider (ASP) option. Financial arrangements on 5 5 5 5 statements The system is HIPAA and 5 5 5 5 Joint Commission compliant Statements printed on request 5 5 5 5 for security and privacy, with for single patient well-documented backup and restoration procedures Printing statements in user- 5 5 5 5 defined order Ability to access the system 5 5 5 5 remotely via a virtual private Adding a statement comment network (VPN) from anywhere to a patient group with internet access

Immediately displays walk-out 5 5 5 5 The system is standards- 5 5 5 5 statement (i.e., what is owed based and hardware/software by patient and insurance) independent for digital radiography Claims – Ability to produce an 5 5 5 5 ADA and a UB04 form Access to the database 5 5 5 5 Encounter rate billing 5 5 5 5 for reporting purposes is for FQHC/wrap sites and made available through Ambulatory Patient Group a commercially available (APG) sites reporting tool UDS field capture capability 5 5 5 5 A tutorial is provided on how to 5 5 5 5 (race, religion, income etc.) export data from fields within the software to programs like 837I Institutional Electronic 3, 5 5 5 5 Crystal Reports Billing (available in some states) Reports and Microsoft Office 5 5 5 5 837D Fee for Service 5 5 5 5 applications are available Electronic Billing Integration with PM/EHR Systems 835 ERA Electronic 3 5 5 5 Remittance Posting Ability to interface demographic information 5 5 5 5 Patient Lockbox ERA posting 3 5 2 5 from EHR including one time population of database, using Ability to hold multiple Tax IDs 5 5 5 5 HL7 messaging standards

Ability to send electronic 5 5 5 5 Ability to receive diagnoses, 5 5 5 5 statement files to vendor allergies, and medication lists 3 (via ePrescribe (with some Pretreatment requests 5 5 5 5 interfaced from EHR planned for 2012) EHRs) capability Database is exportable/ 5 5 5 5 Charge Entry edit: ADA 5 5 5 5 importable or has Require Tooth, ADA Require interchangeability so that other Surface, ADA Require Quad applications can use the data

Guide to the Future 48 49 Guide to the Future Integrates Records Among Sites that are Geographically Disparate Imaging Requirements Ability to schedule one • Ability to easily present images to patient – while provider at multiple locations 5 5 5 5 5 5 5 — using the same provider in chair number • Fits into all working 5 5 5 — Online patient profile inquiry 5 5 5 5 environments without screen available at all sites disrupting usual work flow All statistics and reports 5 5 5 5 Integrated EDR document 5 5 5 5 available by location of scanning module is compatible provider, treatment performed with duplex scanner software or combination thereof allowing scanning of two sides of documents at once Offers keyboard “hot keys” 5 5 5 5 to quickly switch between X-Ray Units: N/A location sites for access to appointment schedules, • Convenient location and Use: 5 5 (QSI is X-ray 5 — patient records, etc. Wall, hand, stand, boom neutral)

One database links 5 5 5 5 • Ability to easily and 5 5 5 — geographically disparate sites effectively integrate with charting software Ability to operate the system in 5 5 5 5 • Adequate total filtration 5 5 5 — a mobile van with access to a is present central database

Imaging Requirements Meets The Joint Commission Standards Multiple users can access Meets TJC requirements for 3 5 5 (with 5 the same radiographs 5 5 5 5 medication reconciliation (via ePrescribe) application simultaneously between health records. programming interface to EHR) Ability to roll over “thumbnail” 5 5 5 5 views of scanned radiographs Meets TJC standards for dual 5 5 5 — and documents in a series patient identifiers to prevent or table format with “zoom clinical errors preview” option Meets TJC standards 5 5 5 5 Integrated EDR document 5 5 5 5 for limiting medication 3 (via ePrescribe (with API scanning module is compatible abbreviations (i.e., “dirty planned for 2012) to EHR) with duplex scanner software dozen”) and prevents allowing scanning of two sides users from entering these of documents at once abbreviations.

Intraoral Cameras N/A “Nice to Have” Additional Features and Software: Fee tickets (charge tickets 3 5 5 5 • Modern and innovative 5 5 5 — for tomorrow) design Work log billing follow-up 5 5 5 5 • Provides sharp images 5 5 5 — tasks (Denials, A/R, etc.) Sliding fee scale capability 5 5 5 5 • USB docking stations 5 5 5 — Reporting capability (charges, 5 5 5 5 • Can be easily connected 5 5 5 — payments, adjustments, to existing networks refunds, bad debt etc.) • Ability to easily present 5 5 5 — images to patient – while Place of service (Office, 5 5 5 5 in chair Hospital), facility name captured

Guide to the Future 50 51 Guide to the Future Appendix A3: Rating Chart: Vendor Response to Qualitative Requirements Approval Ratings– Reference Appendix A6: Vendor background information and evaluations (additional information to support the ratings) NNOHA’s HIT Workgroup provided the ratings below based on survey responses, but each Health Center is 5. Conversion Capabilities: 4 4 4 4 encouraged to conduct their own assessment. Details of the vendor survey are summarized in the table below. • Vendor’s response to their approach and experience Rating: to plan, implement, and 5 – Strongly Agree 2 – Disagree test conversion process. 4 – Agree 1 – Strongly Disagree Including conversion of the data, mapping current 3 – Neither Agree nor Disagree NA – Not Applicable processes to new processes, mapping current system’s Dentrix – Other EHR System: QSI – NextGen Mediadent – Open DentaL – functionality to new Vitera Intergy EHR Software SuccessEHS eClinicalWorks functionality. (formerly Sage Intergy) 6. Ways to Purchase Solutions: 4 3 3 4 Approval Ratings– Reference Appendix A6: Vendor background information and evaluations • Vendor’s response to (additional information to support the ratings) different ways to purchase solutions. Including ability 1. Implementation and Support 4 4 4 4 to bundle or unbundle Services: products, leasing, ASP/ • Implementation: Vendor’s hosted solutions, use response to the approach to channel partners/VARs, or define/implement systems bundled with dental supply to meet all requirements. contracts and compelling reasons why such • Support: Vendor’s resources purchasing approaches assigned to customer are valuable. support. Tools/approaches utilized to help diagnose 7. Demonstration of Vendor – 5 5 4 5 and resolve customer issues, EDR/EHR Capabilities: with remote diagnosis • Vendor’s response to and on-site. demonstration script 2. Compelling Reasons to 5 5 4 5 and presentation of Select Solutions: company financial stability, deployment time/effort/ • Vendor’s reasons for risks, customer references, selecting their EDR/EHR EDR/EHR product features and imaging solution. and functions including 3. Meaningful Use (MU) Plans: 4 5 4 5 interoperability, health information exchange and • Vendor’s response to plans clinical decision support. to attain MU certification and provide tools, knowledge, and services available to assist in Appendix A4: Rating Chart: Vendor Response to Vendor Solution Cost attaining MU incentives. 4. Integration Capabilities: 5 5 5 4 • Vendor’s response to Figure 3 below is only an example. The Health Center would review the vendor’s response to software and hardware capabilities to integrate costs, professional costs, internal IT and other support costs, and third party costs and include the number EDR/EHR with radiographic corresponding with the statement from the following rating scale that most accurately reflects the relevant offerings: imaging and intraoral camera technologies, manage Rating: the images, access the images from within charting 5 – Strongly Agree 2 – Disagree software, and optimize 4 – Agree 1 – Strongly Disagree workflow. 3 – Neither Agree nor Disagree NA – Not Applicable

Guide to the Future 52 53 Guide to the Future Figure 3: Sample Vendor Price Rating Chart Appendix A5: Rating Chart: Vendor Selection Criteria and Summary Ratings

Vendor 1 Vendor 2 Vendor 3 Vendor 4 A sample vendor rating chart is shown in Figure 4 below. The highest rated vendor results indicate the preferred Final Vendor Rating Enter Rating Enter Rating Enter Rating Enter Rating vendor solution for consideration that meets the given requirements and falls within the organization’s budget. (Example Only) (1-5, NA) (1-5, NA) (1-5, NA) (1-5, NA) Deployment Costs The selection team should have a convincing proposal where the benefits of new EDR/EHR software outweigh the costs and the new solution will solve the operational workflow problems. Vendor Software Costs Vendor Hardware Costs Figure 4: Sample Final Vendor Rating Chart Vendor Professional Services Costs Final Vendor Rating Vendor 1 Vendor 2 Vendor 3 Vendor 4 Internal IT and Other Support Costs Enter Vendor: Criteria & Weights for EDR/EHR Final Team Weights 3rd Party Costs Selection

Total Deployment Costs Functional Requirements Assessment from Step 7 50% 2.47 2.50 2.00 2.00 Maintenance and Support Costs (yrs. 1-5) Qualitative Requirements 25% 1.25 1.00 1.00 1.00 Vendor Software Costs Assessment from Step 8 Vendor Hardware Costs Total Cost Assessment from Step 9 25% 0.75 0.75 0.50 0.50 Vendor Professional Services Costs Total 100% 4.47 4.25 3.50 3.50 Internal IT and Other Support Costs 3rd Party Costs

Total Maintenance and Appendix A6: Vendor Background Information and Evaluations Support Costs

Total Costs (5 yrs.) The NNOHA HIT Workgroup engaged in a product evaluation of four leading electronic dental record systems that

Vendor Software Costs are committed to Meaningful Use and have EDR/EHR solutions for Health Centers. NNOHA thanks these EDR/EHR vendors for participating in the product demonstrations, responding to the Request for Information survey, and for Vendor Hardware Costs providing the information that follows. Vendor Professional Services Costs The EDR/EHR Vendors: Internal IT and Other Support Costs Vendors Electronic Dental Record (EDR) Electronic Health Record (EHR) 3rd Party Costs Henry Schein Dental Dentrix Enterprise Sage Intergy or Other certified EHR vendor Total Costs (5 yrs.) Mediadent and SuccessEHS Mediadent EDR SuccessEHS EHR Overall Rating Overall Rating Overall Rating Overall Rating (1-5, or NA) (1-5, or NA) (1-5, or NA) (1-5, or NA) Open Dental and eClinicalWorks Open Dental EDR eClinicalWorks EHR

Total Cost Assessment QSI Dental and NextGen QSI EDR NextGen EHR

Guide to the Future 54 55 Guide to the Future These EDR/EHR vendors were given sample dental system requirements and asked to demonstrate their product to the HIT Workgroup with these requirements in mind. Product Name: QSI Dental–Electronic Dental Record (EDR)

Demonstrations were conducted in September through November of 2011 via the Internet and at the annual Company: Quality Systems, Inc. (QSI, Inc.) NNOHA conference. Readers should keep in mind that the demonstrations were brief, approximately 1 hour, and Contact: Natalie Chamberlain, Regional Sales Executive - QSI Dental thus could not address all the issues, questions, and requirements comprehensively. Although the HIT Workgroup Address: 18111 Von Karman Avenue Suite 600, Irvine, CA 92612 has provided a narrative summary and evaluation of the key Health Center requirements, it should not be Office: 949.255.2600, Ext. 5292 interpreted as a “certification process.” Cell: 949.486.9198 Fax: 949.255.2605 Dental Directors and Health Center staff are encouraged to use this information as a basis for their own system Email: [email protected] selection and procurement process. The final decision on EDR/EHR venders lays with the Health Center and their Website: http://www.qsii.com/dental.shtml due diligence processes. The Workgroup’s overall impression of these products is that they share many similar key product features, each has its strengths and weaknesses, and there is no “one size fits all” solution. There is, however, a major difference between software designed for private practice and that geared for the Health Center market. Several private practice systems do not have product roadmap plans that meet EHR integration requirements; however, they have excellent practice management systems and EDRs that integrate with digital Vendor’s Statement Of Capabilities imaging products.

Quality Systems, Incorporated (CQI). and it’s NextGen Healthcare subsidiary develop and provide a broad range The EDR vendors were chosen based on their existing or potential market share in the Health Center setting, of computer-based business applications for United States hospital, physician and dental markets. These include capability of meeting Meaningful Use reporting requirements, and suitability for the Health Center market. These practice management, electronic health records, revenue cycle management and e-business applications. The focus vendors have integrated with other EHR ONC certified products, they have added new product features, added is on growing organically with a strong emphasis on reinvestment in new product and service development initiatives. Meaningful Use reports, and are developing future interoperable solutions that are Integrating the Healthcare Enterprise (IHE) standards compliant. IHE promotes the coordinated use of such established standards as DICOM, With over 35 years of experience implementing dental practice solutions, QSI represents the most comprehensive HL7 (both standards for transmission of electronic information) and web services to address specific clinical needs information technology product suite available for dental practice organizations in the marketplace today. During in support of improving patient care. the last three decades, QSI has built a reputation of anticipating changes in health care and delivering solutions that address those changes. QSI, throughout its entire history has remained focused on the needs of large, ambulatory group practice enterprises. Within the marketplace, QSI is the only vendor who, for more than 30 years, has consistently implemented and supported dental practice organizations that manage 100 or more clinical practice locations per single practice entity. Large enterprises require cost-effective, standardized, stable, reliable, secure solutions, which are compliant with state and federal regulations. QSI Dental has 80 employees and several third party relationships.

QSI has a history of delivering solutions that meet these requirements, and is a company that understands the need to deliver its products and services in a timely, flexible, and responsive manner to ensure the success of its customers’ clinical and business operations. QSI believes that our diverse and long-term client base demonstrate QSI’s ability to implement and support dental solutions for diverse practice requirements. Currently, QSI has implemented and supports clients of all practice size and types, from one location to more than 400 “live” practice sites managed by a single company - more than any other dental practice management company in the U.S. marketplace.

Guide to the Future 56 57 Guide to the Future ■  Client Base (# of organizations) QSI Dental has added several new product features as follows: • There are approximately 6,000 practice sites utilizing QSI and NextGen products of which approximately •  Synchronized Login from NextGen Application Launcher 2,000 utilize the QSI dental solution suite. •  Direct access from (EDR) application module to EPM & EHR •  EDR Toolbar options launch provider directly to: EHR Rx, ■  Number of Safety Net/Health Center Clients Allergies, Dental Home Page, ICS • There are approximately 180 safety net/Health Center clients utilizing the NextGen EPM/EMR suite of which •  Prescriptions from EHR post back into the dental record approximately 10% utilize the QSI electronic dental record. The NextGen product suite, including the QSI electronic dental record was recently purchased by the Illinois Primary Health Care Association •  Shared EHR/EDR allergy list for implementation at 30 of its member organizations. •  Encounter detail lookup •  Ability to assign diagnoses codes to dental procedures ■  Largest Client (number of connected sites) • Currently the largest (single) client supported by QSI has 450+ active locations utilizing the QSI dental practice The Workgroup did identify areas in product features that could be enhanced including insurance predeterminations, management solution. The largest (single) client utilizing both the electronic dental record and practice transmitting treatment plans, alternative treatment plans, thin client configuration for “Voice‐Activated” periodontal management solution has 165+ active locations and adds at least one new office location per month. charting, dental lab tracking, ASP option, clinical quality measure reporting for oral health and clinical and financial dashboards. Health Centers considering a thin client system integrating EDR with digital imaging products (X-ray and ■  Software-as-a-Service (SaaS) Technology visible imaging) should review licensing options and system performance. •  QSI also offers a SaaS solution. NextDDS takes advantage of Web 2.0 technology to provide the “anytime, anywhere” connectivity to vital patient data, information and records. NNOHA’s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: NNOHA HIT Workgroup Evaluation Highlights 3 – Completely satisfied 2 – Partially satisfied 1 – Not at all satisfied The QSI EDR and integrated NextGen EHR product offering has several new features and is considered a solid EDR/ EHR solution for Health Centers by the NNOHA Workgroup. QSI demonstrated an efficient integration of Ratings of Functional and Qualitative Requirements Rating the EDR and the company’s NextGen EHR product. Clinical Care Management and Treatment Planning Requirements 2 Productivity Measurement and Support Requirements 3 QSI’s many strengths include: user friendliness, HIPAA compliance for secure information exchange, billing, patient Tooth and Periodontal Charting 3 care, treatment planning, EDR training, service and support, and Meaningful Use reporting. The system has user- Office Administrative Requirements 3 definable fields throughout the application that are fully reportable. There is comprehensive training and support, Billing 3 federal and state regulation monitoring, and an understanding of FQHCs’ Migrant Healthcare, Homeless Healthcare, Statements 3 and government payors. Patient records and reports are easily accessed by location of treatment and provider. The Uniform Data System (UDS) reporting can be performed and there is a comprehensive understanding of billing for Technical Requirements 2 FQHCs, Medicaid, and sliding fee scales. Integration with Practice Management (PM) / EHR Systems 3 Integrates Records Among Sites that are Geographically Disparate 3 QSI Dental EDR is integrated with NextGen Ambulatory EHR and version 5.6 SP1 is ONC-ATCB certified for Meaningful Imaging Requirements 3 Use across the continuum of care. The benefits include: Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 “Nice to Have” Additional Features 3 •  HL7 protocols for information exchange •  Consolidated UDS and financial reporting Implementation and Support Services 3 •  Ambulatory EHR for allergies, medical history and scanned information Compelling Reasons to Select Solutions 3 •  Combined patient prescription history, medications management and drug Meaningful Use (MU) Plans 3 •  Patient prescriptions can be created using centralized EHR Integration Capabilities 3 •  Single practice management solution for entire clinic with centralized patient appointment scheduling, Conversion Capabilities 3 accounts receivable and billing management Ways to Purchase Solutions 2 •  Vendor neutral in terms of integrating digital radiography Demonstration of Vendor – EDR/EHR Capabilities 3

Guide to the Future 58 59 Guide to the Future Vendor Response To RFI Survey ■  Ways to Purchase Solutions •  Vendor’s response to different ways to purchase solutions, including ability to bundle or unbundle products, leasing, ASP/hosted solutions, use channel partners/VARs, or bundled with dental supply contracts and The RFI survey results for EDR/EHR system requirements are summarized below. compelling reasons why such purchasing approaches are valuable: – QSI Dental can be purchased directly or an approved VAR. If the CHC is currently using or plans on ■  Implementation and Support Services purchasing NextGen EPM/EHR for their Medical/Dental solution along with QSI EDR – an automatic 25% Implementation: Vendor’s response to the approach to define/implement systems to meet •   “Combined License” discount would be offered. There is no charge to interface QSI EDR to NextGen all requirements: EPM (Practice Management). Additional interfaces and costs would need to be quoted separately. – QSI’s implementation services provide health centers a comprehensive technical staff and implementation framework guides that will meet the health center expectations. ■  Pricing Scenario: •  Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help •  Vendor’s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. diagnose and resolve customer issues, with remote diagnosis and on-site: This is for software costs only – no hardware, no IT, no imaging: – QSI’s support services are available during normal business hours and are responsive to the – QSI EDR example: needs of the health center.

■  Compelling Reasons to Select Solutions •  Vendor’s reasons for selecting their EDR/EHR and imaging solution: – QSI’s singular development approach, solid financial position and advanced nature of dental clinical functionality. – QSI’s 35 plus years of experience in Dental software development.

■  Meaningful Use (MU) •  Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services available to assist in attaining MU incentives: – QSI EDR not yet certified, but as soon as certification is open for the Electronic Dental Record, QSI Dental will be applying for certification. QSI EDR is integrated with NextGen EHR 5.6 which is ONC certified.

■  Integration Capabilities • Vendor’s response to capabilities to integrate EDR/EHR with radiographic imaging and intraoral camera technologies, manage the images, access the images from within charting software, and optimize workflow: – QSI Dental is x-ray “neutral” and can bridge to most major brands of Digital x-ray hardware and software in the market – additional discussions are required to ensure the integrated bridge. QSI Image which is QSI’s imaging solution is also “neutral” to most Digital x-ray Hardware brands in the market – with the exception of Dexis. Additional discussions are required to ensure integration.

■  Conversion Capabilities •  Vendor’s response to their approach and experience to plan, implement, and test conversion process, including conversion of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality: – QSI provides complete data conversion as part of the implementation process. Information from present files is transferred to the QSI System using electronic and manual approaches. A QSI Data Conversion Specialist will review each alternative with you to select the most timely and cost-effective approach for the organization. – During the conversion process, electronic file images, copies or printed reports of all data are provided to QSI. Data are converted prior to training to facilitate system orientation through the use of familiar information.

Guide to the Future 60 61 Guide to the Future Dentrix Enterprise was first installed in September of 1999. In addition to being a full enterprise solution, Dentrix Enterprise offers an extensive array of HL7 interfaces with over 30 HL7 compliant medical practice management Product Name: Dentrix Enterprise/Sage Intergy and electronic health record systems. Whether a client is in need of a complete practice management system with a fully integrated electronic dental record or simply an electronic dental record interfaced with their medical practice Company: Henry Schein, Inc. Dentrix management/EHR system, Dentrix Enterprise has the right solution. Contact: Pam Reece, Director, Enterprise and Specialty Solutions Address: 727 East Utah Valley Drive, American Fork, Utah 84003 ■ Client Base (# of organizations) Office: 801.847.4320 Dentrix Dental Systems holds the number one market share position with a growing user base of over 3,000 Dentrix Cell: 801.319.2945 Enterprise installed sites, and more than 38,000 DENTRIX installed dental practices. According to both Clinical Email: [email protected] Research Associates (CRA) dental software surveys, Dentrix Dental Systems continues to maintain the highest level Website: http://www.dentrixenterprise.com customer satisfaction in the industry while growing the user base exponentially.

Contact: Randy Foley Office: 248.582.1529 NNOHA HIT Workgroup Evaluation Highlights Cell: 248.990.5653 FAX: 248.547.5640 The Dentrix Enterprise and integrated EHR product offering (e.g., Sage Software Email: [email protected] Intergy) has several new features and is considered a potential EDR/EHR solution for Health Centers by the NNOHA Workgroup. Dentrix demonstrated a solid EDR solution and identified several ONC-ATCB certified and HL7 compliant medical practice management and electronic health record systems. Health Choice Network (HCN) supported the demonstration of their technology partners, Sage Vendor’s Statement Of Capabilities Software (Intergy), Henry Schein (Dentrix/Dexis), and Microsoft (Amalga). During the past year, HCN continued to implement Meaningful Use-certified electronic Headquartered in American Fork, Utah, Henry Schein Practice Solutions, Inc. was established in 1986 with the health records (EHR) and oral health records Health Centers nationwide. HCN mission of developing an easy-to-use Microsoft Windows Dental Practice Management Software that met the guides its members to meaningful use of EHR as defined by the Office of the National practice and clinical management needs of the dental profession. More than two years were spent observing all of Coordinator for Health Information Technology. This includes meeting all of the the clinical and business functions performed in dental offices with the goal of developing automated, multi-tasking measures of the Stage 1 Meaningful Use Requirements. With the use of the integrated and comprehensive dental practice management software that also offered ease of use. This extensive research bridge, Amalga, Dentrix is able to integrate tightly with any EHR products. Amalga can be and software development resulted in the first DENTRIX System introduction in 1989. used to connect together many unrelated medical systems using a wide variety of data types in order to provide an immediate, updated composite portrait of the patient’s healthcare history. All of Amalga’s Dentrix Dental Systems was first to offer the dental profession the convenience and ease-of-use of the Microsoft components are integrated using middleware software that allows the creation of standard approaches and tools Windows Operating System, more than five years ahead of all other companies. Dentrix Dental Systems has been to interface with the many software and hardware systems. Amalga is designed to collect not only clinical data, listening to tens of thousands of user suggestions over our 20 year history of successful DENTRIX installations. but also financial and operational data for hospital administrators. Hundreds of advanced features have been added to create superb office workflow. Longevity and experience programming in the Windows environment explains Dentrix Dental Systems cutting edge response to the evolving Dentrix Enterprise has many strengths including: digital technologies, proven functionality and a high-quality product. •  Rapid access to patient demographics, insurance policies, financial transactions and clinical data •  Use current EMR to register and update patient records Dentrix Dental Systems, Inc./Henry Schein Practice Solutions, Inc. is a wholly owned subsidiary of Henry Schein, •  Import and export patient demographics with Admissions, Discharges, Transfers (ADT) Inc., an international corporation based in Melville, New York. As a healthcare supplier since 1932, Henry Schein •  Export procedure, charge and payment with Financial Management Transfers (DFT) is traded publicly on the NASDQ and is regarded as a corporation based on traditional values by both its customers •  Import and export appointments with Scheduling Transfers (SIU) and investors. In 2004, Henry Schein made the Fortune 500. In 2006, Henry Schein was named “most admired” •  Import provider and staff setup information with Master File in its industry by Fortune’s 2006 list of Most Admired Companies and has ranked number one in its industry in •  Electronic exchange of healthcare-related data social responsibility for five consecutive years.

Guide to the Future 62 63 Guide to the Future Dental practice management software such as Dentrix Enterprise and Dentrix can NNOHA’s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the receive modular certification. This, however, does not completely solve the problem RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: and Health Centers must invest in other systems that together meet all 15 core 3 – Completely satisfied objectives and measures. Dentrix Enterprise is currently working towards 2 – Partially satisfied modular certification. Dentrix, however, could be integrated with a certified 1 – Not at all satisfied EMR product such as Sage Intergy and meet the MU requirements, just like all other EDR products at the present time. Henry Schein Practice Ratings of Functional and Qualitative Requirements Rating Solutions is working with several groups, including the ADA, CMS, Clinical Care Management and Treatment Planning Requirements 2 Health Resources and Services Administration (HRSA), National Network Productivity Measurement and Support Requirements 3 for Oral Health Access (NNOHA) and the American Association of Tooth and Periodontal Charting 3 Oral and Maxillofacial Surgeons (AAOMS), to highlight the need for a Office Administrative Requirements 2 certification standard. Billing 3 Statements 2 Dentrix Enterprise has added several new product features as follows: Technical Requirements 3 •  Search Payment in Ledger Integration with Practice Management (PM)/EHR Systems 3 •  Multiple Referrals Integrates Records Among Sites that are Geographically Disparate 3 •  GURU Integration Imaging Requirements 3 •  Hid/Mask SSN Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 •  Enhancement to Perio Score “Nice to Have” Additional Features 3 •  eTrans 5.1 (Allow Edit of claim) Implementation and Support Services 3 •  Rate Code Feature Compelling Reasons to Select Solutions 3 •  Treatment Plan Fee Update Meaningful Use (MU) Plans 2/*3 Intergy •  Enhance Clinical Notes Feature Integration Capabilities 3 •  Note Spell Check Conversion Capabilities 3 •  DDX Integration Ways to Purchase Solutions 3 •  Enhance Treatment Planner (Presenter) Feature Demonstration of Vendor – EDR/EHR Capabilities 3 •  Enhance Document Center Feature •  Meaningful Use •  Auto-Log Off •  Emergency Access Vendor Response To RFI Survey •  Vital Signs/BMI Feature •  Oral Health Reports The RFI survey results for EDR/EHR system requirements are summarized below. •  Close/Block Operatory (Schedule Event) ■  •  Log Patient Information when Viewed Implementation and Support Services •  Implementation: Vendor’s response to the approach to define/implement systems to meet all requirements: •  5010 Mandate – For all new implementations, an account manager is assigned and accountable for the remote install, data conversion, HL7 installation and configuration, remote and onsite training and Go Live. Tiered implementation The Workgroup did identify areas in product features that could be enhanced, including ePrescribing and Rx packages are available based upon need including onsite implementation and installation services. printing, printed treated plans, dental lab tracking, voice activated dictation, electronic remittance advice/posting, – Includes an account manager, a certified software trainer, and (if applicable) an HL7 and/or data conversion low cost HL7 interface to other EMR/EHRs, clinical quality measure reporting for oral health, and clinical and technician. financial dashboards. – All Enterprise level technicians and account managers are fully trained on Enterprise. Enterprise trainers are fully certified on the Enterprise system. – Time requirements for projects vary but tend to include 20 hours of account management time and 40 hours of on-site training time. 7am – 5pm Mountain.

Guide to the Future 64 65 Guide to the Future •  Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help diagnose and ■  Integration Capabilities resolve customer issues, with remote diagnosis and on-site: •  Vendor’s response to capabilities to integrate EDR/EHR with radiographic imaging – HSPS provides a dedicated technical support team to provide remote support assistance for Dentrix Enterprise. and intraoral camera technologies, manage the images, access the images – Dentrix Enterprise support team offers: from within charting software, and optimize workflow: – Phone support assistance – Dentrix Enterprise maintains a true, two way integration with Dexis – Email support assistance for digital radiography. This integration allows clinicians to see x-rays – Click to chat from within the patient’s chart and allows billing staff to attach – Online live and recorded training sessions x-rays directly to claims for electronic billing. The Dexis imaging – Published online searchable knowledge base system is optimized to run alongside Dentrix Enterprise in a – Standard protocol for resolving customer issues thin-client wide area network with centralized data storage. – Initial troubleshooting with support technician – If unresolved, escalation to development team ■  Conversion Capabilities – Digital Radiography Support is handled directly by digital x-ray manufacturer. •  Vendor’s response to their approach and experience to plan, implement, and test conversion process, including conversion ■  Compelling Reasons to Select Solutions of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality: •  Vendor’s reasons for selecting their EDR/EHR and imaging solution: – All third party software systems can be converted into Dentrix – True Medicaid FQHC billing components including: Enterprise capturing most data fields such as patients, providers, – Automatic sliding fees appointments, prior clinical treatment, procedures, and notes, etc. – Wrap around for encounter rates billing The initial converted database is delivered in a test environment – Multiple alternative Medicaid fee schedules for data and mapping validation. All third party systems go through – Only true HL7 compliant EDR (ability to interface with ANY HL7 compliant software) – extends the ability of extensive testing with a test conversion followed by a validation conversion any integrated delivery network the capability of adding an electronic dental record to a fully certified EHR: for Go Live. – Self-contained UDS reporting – Process conversion and mapping is addressed onsite by a certified Dentrix Trainer. Account Managers and Implementation Engineers work with each customer – Number one electronic dental chart and dental practice management system used nationwide to assist in mapping current to new processes. – Leading electronic dental record in the CHC market – A Dentrix Enterprise account manager, data conversion technician, and Dentrix Trainer will access – Fully integrated digital x-ray component (Dexis) functionality differences and advise on appropriate data mapping solutions. Dentrix Enterprise also has – Fully integrated with the largest electronic dental claims clearinghouse webinar training available for additional training on functionality. – Open architecture SQL – Periodontal index and outcomes reporting ■  Ways to Purchase Solutions – Backing of the Henry Schein Inc. •  Vendor’s response to different ways to purchase solutions, including ability to bundle or unbundle products, leasing, ASP/hosted solutions, use channel partners/VARs, or bundled with dental supply contracts and ■  Meaningful Use (MU) compelling reasons why such purchasing approaches are valuable: •  Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services available to – Dentrix Enterprise is sold directly by HSPS (Henry Schein Practice Solutions) and offers multiple bundles assist in attaining MU incentives: and pricing tiers based on size and interface requirements. For example, a clinic that wishes to integrate – While there are no dental specific criteria specified for Meaningful Use certification, Dentrix Enterprise is dental and bill out of their medical software can purchase “an EDR only” bundle which essentially provides currently seeking modular certification via CCHIT. Dentrix have been in regular talks with ONC, CMS, ADA, and the HL7 interface at half price. Dentrix Enterprise does not currently provide a hosted model. However, other associations to push the need for a dental specific certification. Health Choice Network out of Florida does provide hosting services for health centers utilizing Dentrix Enterprise. Bundled dental supply contract are available when applicable. Average retail fee from Dentrix – Dentrix Enterprise interfaces with over 30 different medical systems, providing the NNOHA members a wide Enterprise for HL7 interfacing is $15,000 for bi-directional. Medical vendor fees will vary. variety of choices to select the right EHR that fits their needs. With access to a fully certified EHR interfaced to Dentrix Enterprise, a dental provider that meets the Medicaid thresholds meets Meaningful Use. The capability to utilize a dental specific module developed for oral health providers with any HL7 compliant medical EHR is a strength of Dentrix Enterprise. Dentrix software is based on over 20 years of research and constant work with dental customer partners to develop the best electronic dental record and practice management solution in the CHC and public health markets.

Guide to the Future 66 67 Guide to the Future ■  Pricing Methodology and Annual Maintenance Fees: For the Electronic Dental Record-only the Dentrix Enterprise application site license for 10 concurrent users per site •  Vendor’s response to pricing: includes the following products: HL7 Bidirectional Interface, Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO BILLING): Satellite Sites Each dental office that installs or runs the Dentrix Enterprise software at that location is required to obtain a separate Site License. Pricing models include a minimal five concurrent users per site or a ten concurrent user per site. Pricing models for either the five or ten concurrent user models also include an Electronic Dental Record only model or a full Electronic Dental Record with practice management model. The former will be interfaced to an HL7 compliant medical program whereas all billing is passed to the medical program and the latter model can be used where Dentrix Enterprise is used for billing as well as an EDR.

The EDR only model includes a bi-directional interface. Please note that a fee may be charged for the HL7 interface from your medical software for their side of the HL7 Interface. Digital X-rays, Intra-oral Imaging and Voice Charting are optional with all configurations.

The investment figures above are per site for up to 10 workstations, additional workstations are $500 each plus $60 per year for annual support & enhancements.

For the Electronic Dental Record only the Dentrix Enterprise application site license for 5 concurrent users per site includes the following products: HL7 Bidirectional Interface, Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO BILLING):

The investment figures above are per site for up to 5 workstations, additional workstations are $1,595 each plus $190 per year for annual support & enhancements.

For the Practice Management and Electronic Dental Record Model the Dentrix Enterprise application site license for 10 concurrent users per site includes the following products: Ledger (Billing), Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO HL7 Interface):

Guide to the Future 68 69 Guide to the Future Please note that some medical software packages require that an HL7 interface be licensed for their software as well. It is the responsibility of the medical software to send the appropriate HL7 messages and to process the ones that are sent from Dentrix. For the Practice Management Model a typical implementation that will enable you to have a one way interface of basic demographic data from your HL7 compatible medical software to Dentrix Enterprise is $4,995 plus an annual license of $1,200. A typical bidirectional interface with basic demographic information coming from the medical software and completed dental charges being sent to the medical software is $9,995 plus an annual license fee of $1,200. Additional fees may apply for additional systems and data fields such as, Appointments, Patient Visit Numbers and Clinical Notes.

Installation Installations need to be scheduled during a pre-installation conference call that will be held to assure a smooth transition to Dentrix Enterprise. Installation of the software performed over a telephone connection by our technicians including the creation of the data tables on your SQL Server, and testing the connectivity between the database, OS and application is included. On-site installation assistance from our Technical department for 40 hours on-site is available for $8,000 plus travel related expenses. Additional time is billed at the rate of $250 per hour plus travel. Weekend telephone installation is available at an additional cost of $6,000. The investment figures above are per site for up to 10 workstations; additional workstations are $500 each plus $60 per year for annual support & enhancements. Training $800 per eight-hour day, plus travel expenses from a Dentrix Certified Trainer. As an option, we provide a “Train For the Practice Management and Electronic Dental Record Model the Dentrix Enterprise application site license the Trainer Program” at our corporate facility in Utah or at your site. The course is a full week and will only include for 5 concurrent users per site includes the following products: Ledger (Billing), Office Manager, Family File, students from your organization. The “Train the Trainer Program” is $3,600 for the first person and $600 for each Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO HL7 Interface): additional person in the same class. Travel expenses are not included in the tuition.

Data Conversion There are three parts of a data conversion: •  Extraction of data from old system •  Manipulating the data to conform to a standard file format •  Building the database

The fee is $1,250 per database. The following items are not included in the above investments: •  Hardware, preparation of the computer site & on-site labor and/or installation The investment figures above are per site for up to 5 workstations, additional workstations are $1,595 each plus •  Third party software such as Microsoft 2003 Server, $190 per year for annual support & enhancements. Microsoft Terminal Server, Citrix, Microsoft SQL 2000/2005 & Microsoft Word HL7 Interface •  Custom software modifications The investment for the HL7 interface is included with the EDR only model and optional with the Practice •  Applicable state & local sales taxes Management Model. A typical bi-directional interface consists of basic demographic information coming from •  Travel expenses for training/on site install the medical software and completed dental charges being sent to the medical software. Other options include •  HL7 fees from medical system appointment data with visit numbers coming from the medical system and clinical notes being sent to the medical system.

Guide to the Future 70 71 Guide to the Future MediaDent is a Single Source Dental Solution and can provide all of the EDR AND Imaging software as well as all of the imaging devices (sensors, pans, cameras, scanners) and computer equipment necessary, if requested, and Product Name: Mediadent MediaDent will provide support for all of the software AND hardware. Only ONE support call is required for problem Company: SuccessEHS resolution. MediaDent is the only Health Center solution who owns, develops and supports all of the software required. No other Dental Health Center system can offer a Single Source Solution and they have to coordinate the purchase, Contact: Matt Holtzer, Chief Operating Officer/Director of CHC Sales implementation and support with at least two other companies to provide a similar solution. Office: 877.770.8514 Ext. 330 Cell: 770.337.8076 Fax: 770.867.5087 MediaDent Enterprise solution offers more extensive features than other solutions including provider, location, Email: [email protected] organizational and enterprise segregation. So depending upon whether a single database for each location is desired, one for each organization or even one for the entire membership, MediaDent can separate the patient’s demographics, Website: http://www.successehs.com accounts and charts in many ways.

■  Client Base •  SuccessEHS has over 6,000 providers with 20,000 users in 47 states utilizing our EDR, PM/EMR and billing products Vendor’s Statement Of Capabilities •  SuccessEHS serves over 10% of the Health Center market •  MediaDent EDR has over 3,500 users MediaDent Dental software is a wholly owned division of SuccessEHS and has been providing top-quality •  MediaDent has over 150 organizations using our enterprise/Multi-location EDR product products for over a decade. Our solutions continually help practices become more efficient, productive, and inevitably increase their bottom line. We’ve incorporated new groundbreaking technology into our ■  Number of Safety Net/Health Center Clients system. As a result, MediaDent can share dental patient data with HL7 compatible medical systems such •  SuccessEHS has over 190 Health Center organizations with over as Sage Intergy, SuccessEHS, Healthport, eClinicalWorks, GE Centricity, MSI, Epic, MediTab, and NextGen. 900 sites using our EDR and/or PM/EMR Software MediaDent can consolidate the data in multi-location organizations so that all patient data and images are •  Products serve over 2,100 Providers in the Health Center Market available at every clinic or configure an ASP/SaaS solution so that all the data is on a single server. With our latest API (Application Program Interface) development, the dentist can simply click on the Rx or Medical ■  Largest Client History icons in the MediaDent EDR which will open the active patient’s record in Intergy and SuccessEHS. •  EHS Turnkey customer with 518 users MMD is currently working with other EMRs and has the ability to develop a similar interface with almost any •  ASP/Hosted user with 350 users solution. In some EMRs, the dentist could also create an order computerized physician order entry (CPOE) for ■  MediaDent something like a biopsy and the dental treatment/progress notes can automatically replicate into the patient’s •  17 Locations with about 400 users summary as they are created. A CPOE is a process of electronic entry of dental practitioner instructions for •  10 Clients with 50+ Workstations in one location the treatment of patients under his or her care. •  1 Customer with 22 providers •  SuccessEHS operates its own multi-million dollar MediaDent is offered on both a server-based solution for those who maintain their own network with an IT data center that currently serves over 10,000 department, as well as an ASP/hosted solution (SaaS) where MediaDent or the client’s IT department could licensed users across the United States host and maintain the server, and all that is needed is a 1.5 Mbps or better broadband connection at each location. MediaDent works with any combination of thin client/terminal and/or fat client/PCs. MediaDent is the ONLY dental EDR and imaging provider that can also offer a hosted solution with digital imaging and utilize digital sensors, digital pans, intraoral cameras and phosphor plate scanners without the requirement to setup a “store and forward” configuration with multiple servers.

Guide to the Future 72 73 Guide to the Future Ratings of Functional and Qualitative Requirements Rating NNOHA HIT Workgroup Evaluation Highlights Clinical Care Management and Treatment Planning Requirements 2 Productivity Measurement and Support Requirements 3 The Mediadent and integrated SuccessEHS product offering is considered a potential EDR/EMR solution for Health Centers by the NNOHA Workgroup. Mediadent demonstrated an excellent EDR solution and when integrated with Tooth and Periodontal Charting 2 SuccessEHS, an ONC certified EHR, dentists can register for Meaningful Use incentives. SuccessEHS 6.0 is a Office Administrative Requirements 2 CCHIT Certified ® 2011 Ambulatory EHR, and additionally certified for Child Health, with a 5-star usability rating; Billing 3 this product received certification as a Complete EHR on September 30, 2010. The clinical quality measures Statements 2 certified include: NQF 0421, NQF 0013, NQF 0028, NQF 0041, NQF 0024, NQF 0038, NQF 0043, NQF 0031, and Technical Requirements 3 NQF 0034. Dental customers can benefit from the SuccessEHS hosting infrastructure, which includes Software as Integration with Practice Management (PM)/EHR Systems 3 a Service (SaaS), Turnkey and Hosted Turnkey setups. SuccessEHS is one of the few vendors to offer independent Integrates Records Among Sites that are Geographically Disparate 3 dental practitioners a fully cloud-based EDR, including imaging, via its SaaS hosting option. Imaging Requirements 3 Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 MediaDent has many strengths including: “Nice to Have” Additional Features 3 •  A Single Source Dental Solution that can provide all of the EDR and Imaging software as well as Implementation and Support Services 3 all of the imaging devices (sensors, pans, cameras, scanners) and computer equipment. Compelling Reasons to Select Solutions 3 •  Solid technological infrastructure and strong support staff Meaningful Use (MU) Plans 2 •  SaaS hosting option; offers both hosted and server-based system WITH IMAGING capabilities Integration Capabilities 3 •  Robust reporting capabilities in the core EDR product, and also Data Miner custom report writer •  A high level of integration and Open Architecture Conversion Capabilities 3 Ways to Purchase Solutions 3

The Workgroup did identify areas in product features that could be enhanced including integrated patient Demonstration of Vendor – EDR/EHR Capabilities 3 education, electronic remittance advice/posting, monitoring patient satisfaction with dental visit, voice activated dictation, customizable periodontal exam templates, clinical quality measure reporting for oral health, and clinical Vendor Response To RFI Survey and financial dashboards. The RFI survey results for EDR/EHR system requirements are summarized below. NNOHA’s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: ■  Implementation and Support Services 3 – Completely satisfied •  Implementation: Vendor’s response to the approach to define / implement systems to meet all requirements: 2 – Partially satisfied – MediaDent assigns a Project Manager to work with the dental group to provide engineering support 1 – Not at all satisfied and implementation support for the EDR and Imaging solution. The Project Manager will evaluate the configuration that is in place at each location and provide recommendations as to any additional equipment or software that is required that is not provided by MediaDent so that the clinic achieves a successful implementation. MediaDent has standard specifications that will be sent to the IT group working with the dental clinic and will typically include 10-15 hours of project management time for most installations. – Once the design is agreed upon, the Project Manager will coordinate with the IT staff to assist in the installation of the MediaDent software on the server(s) after verifying remote access of some sort for project assistance. MediaDent will schedule a technician to come to the customer site(s) for additional assistance, as necessary, and will also provide on-site assistance for installation support and testing of the imaging devices, as necessary. Once all of the installation services are completed, MediaDent will coordinate with the clinic’s EMR provider to implement the HL7 interface. If the member uses SuccessEHS or Sage Intergy, MediaDent will also configure for the API interface. After all of these steps have been completed, MediaDent will schedule the training and typically include 10-15 hours for most installations plus one day per site if the clinic(s) are planning to use sensors or pans. – Training: MediaDent will assign an Implementation Specialist to the project. There are a number of different ways training services are provided and MediaDent will develop the best method for each clinic. Typically, MediaDent will work with each Dental Director before any on-site training to create their specific

Guide to the Future 74 75 Guide to the Future workflows, fee schedules, progress notes, appointment book as well as a number of other features. Basic – With our latest API (Application Program Interface) development, the dentist can simply click on the setup will be completed prior to on-site, and MediaDent can provide any number of days for each clinic Rx or Medical History icons in the MediaDent EDR which will open the active patient’s record in Intergy based on their needs. and SuccessEHS. MediaDent is currently working with other EMRs and has the ability to develop a similar – Infrastructure/Disaster Recovery – MediaDent is a MS SQL 2008 and Windows Server 2008 product interface with almost any solution. The user will be limited to whatever permissions they are allowed, but it which can be setup as a server based solution or in a thin client configuration. MediaDent can also be setup will pull up the patient’s medical record in the EMR, and the dentist will be able to review their medication in a virtual environment and uses VMWare 4.0. MediaDent recommends redundancy for all aspects of the history and allergies as well as create a new prescription. In some EMRs, the dentist could also create an system, especially for data storage and have successfully implemented RAID 1 and 5 server systems as well order (CPOE) for something like a biopsy as well and the dental treatment/progress notes can automatically as redundant virtual servers in a data center. Furthermore, MediaDent offers a remote replication service replicate into the patient’s summary as they are created. This feature is not an HL7 interface where messages so that a clinics data is being duplicated in a real-time environment instead of just performing a backup at have to transfer, but is a “live” link between MediaDent and the EMR. the end of the day. A complete systems specification sheet is available to each customer to explain all of the – MediaDent is offered as both a server-based solution for those who maintain their own network with an IT details and the Project Manager will assist the IT group with their implementation. department, as well as a hosted solution (SaaS) where MMD or your IT department can host and maintain – Implementation Hours – Our Implementation group is available from 8am through 7pm Eastern the server and all you need is a 1.5 Mbps or better broadband connection at each location. MediaDent works M-F and can also schedule after hours installations as late as 9pm Eastern. with any combination of Thin Client/Terminal and/or Fat Client/PCs. MediaDent is the ONLY dental EDR and imaging provider that can also offer a hosted solution with digital imaging and utilize digital sensors, digital •  Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help diagnose and pans, intraoral cameras and phosphor plate scanners without the requirement to setup a “store and forward” resolve customer issues, with remote diagnosis and on-site: configuration with multiple servers. – MediaDent has a support staff of over 20 people who can assist the dental staff with any aspect of the – Mediadent provides robust integration capabilities and the powerful management tools you need to EDR, Imaging or HL7 software as well as any of the imaging devices that are provided. MediaDent utilizes effectively link your medical and dental data. And because our software solutions were designed to handle a triage system where when the customer calls, will usually speak with a Level 1 tech who can answer any number of clinics and workstations, all tasks can be centralized, paving the way for increased clinic basic questions. If the issue is more advanced, it will be referred to a Level 2 tech that specializes in a efficiency. more specific area. If it turns out to be a more advanced issue, it will be referred to one of our engineers. Each of our techs has the ability to remotely access the system, with the customer’s permission, with either • Additional reasons why MediaDent should be your choice: NetSupport or RDP. In addition, MediaDent sometimes uses Go To Meeting for x-ray diagnostics. Most often, – MediaDent is a Single Source Dental Solution and can provide all of the EDR AND Imaging software as well the issues can be resolved remotely, but MediaDent does provide on-site support for issues such as with as all of the imaging devices (sensors, pans, cameras, and scanners) and computer equipment necessary, a digital pan. The company offers loaner sensors and cameras in the event that a unit still under warranty if requested, and provides support for all of the software and hardware, implementation and support with at needs further evaluation. MediaDent also partners with Dell to provide on-site network support. least two other companies to provide a similar solution. – Support Hours – Our support group is available for 8am to 7pm Eastern M-F except official company – MediaDent currently has a more advanced API interface with Sage Intergy and SuccessEHS than any other holidays. In addition to support during regular office-hours, our after-hours support is from 7pm to 8am FQHC solution and is the only company able to provide a direct integration for prescriptions and medical Eastern Monday through Sunday by leaving your name, company name, number and a description of the history. MediaDent is a division of SuccessEHS and has a signed business development agreement with Sage problem you have encountered. A support representative will return the call as soon as possible. for co-development of the products which other companies do not offer. – MediaDent is written for Microsoft SQL 2008 R2, Windows Server 2008 R2 and is deployed using VM Ware ■ Compelling Reasons to Select Solutions in our own Data Center. The solution is currently operational including with digital x-rays and no development is required. MediaDent can deploy the solution within 30 days of agreement. • Vendor’s reasons for selecting their EDR/EHR and imaging solution: – The MediaDent HL7 interface offers a higher level of integration than most other systems and will be – MediaDent Dental software has been providing top-quality products for over a decade. These solutions able to continually improve the linkage because of the Open Architecture of our SQL database as medical continually help practices become more efficient, productive, and inevitably increase their bottom line. systems evolve and the Federal government expands its requirements. MediaDent uses a live port transfer We’ve incorporated new groundbreaking technology into our system. As a result, MediaDent can share methodology (real time) which includes all of the HL7 details within one message, and other systems dental patient data with HL7 compatible medical systems such as Sage Intergy, SuccessEHS, Healthport, like Dentrix use the zpt segment (optional) with a file transfer methodology which takes up to 15 or more eClinicalWorks, GE Centricity, MSI, Epic, MediTab, and NextGen. MediaDent can consolidate the data in messages to transfer the same data. multi-location organizations so that all patient data and images are available at every clinic or configure an ASP/SaaS solution so that all the data is on a single server. – MediaDent Enterprise solution offers more extensive features than other solution including provider, location, organizational and enterprise segregation. So depending upon whether you want a single database – The medical practice management to MediaDent link transfers the patient demographics to the dental for each location, one for each organization or even one for the entire membership, MediaDent can separate system and creates a corresponding dental record automatically. Any additions or changes to the patient the patient’s demographics, accounts and charts in many ways. record in MPM automatically update the dental record. The interface works with Medicaid, Sliding Fee Schedules and private pay plans. You would typically use the appointment book in MPM which also – MediaDent is the ONLY dental solution which offers both hosted and server-based system WITH IMAGING automatically updates the MediaDent scheduler, and any changes made after the initial appointment, such capabilities. This includes the ability deploy digital sensors and pans on thin clients/terminals without using as cancellations or no shows, will also automatically update the EDR system. You would typically use the hard drives or servers. NO fat clients or servers are required with our hosted/SaaS solution. However, if the MPM Reason/Procedure Codes to schedule the appointment and indicate what procedures the dental member already has PCs/fat clients, MediaDent will still be able to utilize their existing equipment and can clinic is expecting to perform. After treatment is completed, the encounter and transaction information will implement a system with a mixture of terminals and PCs as needed. transfer back to the medical software so that all the billing, both insurance and private, will be performed – MediaDent offers robust reporting capabilities in the core EDR product, but also offers Data Miner custom from MPM. Furthermore, all UDS encounter information is consolidated into the medical system to simplify report writer which allows the user to easily create a custom report using any field in the system. Again, the reporting. No more keeping duplicate databases or manually consolidating UDS information. SQL database gives us this capability.

Guide to the Future 76 77 Guide to the Future – MediaDent provides excellent support and utilizes many advanced features to quickly answer customer ■ Ways to Purchase Solutions issues and update systems. MediaDent incorporates NetSupport to access your system within seconds to • Vendor’s response to different ways to purchase solutions, including ability to bundle or unbundle products, save you and us valuable time. MediaDent can receive support requests by phone, website or email, and all leasing, ASP/hosted solutions, use channel partners/VARs, or bundled with dental supply contracts and calls are triaged and logged into our customer system. Updates can be automatically download to the server compelling reasons why such purchasing approaches are valuable: very quickly, usually in a matter of just a few minutes and workstations simply log off and log back on the – MediaDent EDR and Imaging can be purchased direct and the company has several partnerships and get the updates. dealers who refer business to the company. There are four primary modules that are available – Practice Management, EDR/Charting, Digital Imaging and HL7/API Interfaces. In addition to software, MediaDent sells ■ Meaningful Use (MU) digital x-rays sensors, phosphor plate scanners, digital pans, intraoral cameras, signature pads, document • Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services available to scanners and almost any Dell brand equipment for your network. MediaDent provides the complete solution assist in attaining MU incentives: and offers the installation and implementation services for the system as well as the necessary training and – Currently, there are no certifications available for an EDR as an independent module. As soon as a testing support to allow the user to succeed. All of these products can be implemented in either a traditional server/ procedure for EDR is defined by one of the certifying agencies such as CCHIT or Drummond, MediaDent PC configuration or setup as an ASP/Hosted system with terminals instead of PCs and no servers. The ASP will complete the certification process. In the meantime, MediaDent, in conjunction with whichever medical solution can be hosted by MediaDent or the client if they have a capable IT Department. solution the organization uses, would be part of the certification of that medical software. As long as the dental – MediaDent has established HL7 interfaces with many of the medical software solutions including providers use the medical software for any functions, such as prescriptions, they should be eligible SuccessEHS, Sage Intergy, eClinicalWorks, NextGen, MSI, GE Centricity, McKesson Practice Partners and for MU incentives. Healthport. HL7 allows patient demographics (ADT) and appointment information (SIU) to flow from the – In addition, MediaDent is the dental division of SuccessEHS who does have a certified product as outlined medical software to MediaDent and billing/encounter information (DFT) to flow from MediaDent back to the below and can be offered to any FQHC who needs to change to a qualifying solution. medical software. Both MediaDent and the medical software usually have a fee for the HL7. In addition, – SuccessEHS is 2011/2012 compliant and was certified as a Complete EHR on September 30, 2010, by the MediaDent has an API interface with SuccessEHS and Sage which allows the dentist to use the medical Certification Commission for Health Information Technology (CCHIT®), an ONC‐ATCB, in accordance with software prescription, medication, allergy and medical history modules. MediaDent is also in development the applicable Eligible Provider certification criteria adopted by the Secretary of Health and Human Services. with several other vendors at this time. Typically, there is a slight additional charge for this interface as well. The 2011/2012 criteria support the Stage 1 Meaningful Use measures required to qualify eligible providers – MediaDent is the only company that offers all the components that you will need to implement a complete and hospitals for funding under the American Recovery and Reinvestment Act (ARRA). dental solution. All software, services and hosting is owned, developed and maintained by MediaDent. In addition, MediaDent can provide all of the imaging components required by most dental practices. MediaDent ■ Integration Capabilities offer a complete solution instead of a grouping of products from various companies. All other solutions • Vendor’s response to capabilities to integrate EDR/EHR with radiographic imaging and intraoral camera combine one company’s EDR with another company’s imaging along with a third company’s x-ray devices. technologies, manage the images, access the images from within charting software, and optimize workflow: MediaDent is also the only company that hosts their solution directly. – MediaDent has developed a complete imaging software solution that is fully integrated with the EDR/Chart ■ Pricing Methodology and Annual Maintenance Fees: software. MediaDent owns the software and provides all of the installation, implementation and support that is necessary for the product. All images are taken and viewed within our MediaDent software and all images are viewable within the chart as well as full screen mode which allows the provider to optimize their productivity. Software: (Depends on number of users and sites) A workflow will be defined by our implementation specialists to best match your clinic procedures. The •  MediaDent EDR Licenses $1,000 to $1,500 per license imaging solution works with several sensors and intraoral cameras, most phosphor plate scanners and almost •  MediaDent Imaging Licenses $300 to $ 900 per license all digital pans. In addition, the images are able to be exported or emailed in an encrypted format directly •  HL7 Interface (ADT, SIU and DFT) $6,000 per organization from MediaDent. The ability to automatically attach and transmit an image to submit to insurance for either •  API Interface (prescriptions, medical history) $2,500 per organization (if applicable) pre-authorization or payment is also built into the MediaDent software with our NEA module. •  Data Miner Custom Report Writer $995 per authoring license ■ Conversion Capabilities •  Scanner Software $395 per member • Vendor’s response to their approach and experience to plan, implement, and test conversion process. •  RCC Channel Communication Software $195 per imaging client workstation Including conversion of the data, mapping current processes to new processes, mapping current systems functionality to new functionality: ASP Hosting: (Depends on number of users and sites) – MediaDent has successfully converted data from most dental practice management systems including •  Hosting Fee for Data Center $30 to $60 per month per license Dentrix, EagleSoft, PracticeWorks, SoftDent and many more. Each situation is different and our Project Hardware: Manager will assist the IT staff in the evaluation. In most cases, MediaDent is able to transfer the demographics, appointment book and treatment history, but usually cannot get the pending treatment •  Digital Sensor – Size #1 $5,995 each plans, notes and images. If a dental clinic is converting from standalone dental software that has not been •  Digital Sensor – Size #2 $6,995 each interfaced with their medical solution, it is usually best to not convert the data and instead, link to the •  USB Interface Unit $1,295 each medical software which will populate the patient and appointment records so that all of the patients IDs •  Digital Pan with Stand $29,995 each match. The old system will be used as reference. Sometimes MediaDent will just convert the appointment •  Soredex Optime Phosphor Plate System $9,995 each book, but each case is evaluated independently.

Guide to the Future 78 79 Guide to the Future Vendor’s Statement Of Capabilities •  Document Scanner $495 each •  Signature Pad $350 each Open Dental is a comprehensive software package that offers very robust solutions for many different kinds of clinics. •  Unigrip Sensor Holders Kit $120 each Open Dental has an efficient workflow, a powerful database, and many well-designed tools for data management. As the only open source dental software in the world, it provides users with the assurance that the software belongs Services: firmly to the users and to the entire dental community. Open Dental is also the only PC dental software that has been •  Implementation $150 per hour certified as an EHR. Open Dental can directly create 837 dental, medical, and institutional claims, and has HL7 •  Installation $750 per day plus travel expenses interfaces for use with medical software, in particular, eClinicalWorks. Open Dental’s outstanding customer support •  Training $800 per day plus travel expenses and unmatched responsiveness to user needs have resulted in a rapidly growing, enthusiastic user base. •  Digital Pan Installation and Freight $1,995 per pan plus travel expenses ■  Client Base (# of organizations): Support: •  Open Dental is in use at approximately 4,000 locations. •  EDR $15 per month per license •  Imaging $10 per month per license ■  Number of Safety Net/Health Center Clients: •  HL7 (with API if used) $100 per month per member •  This information is not tracked, but is estimated at 100 locations.

Network Hardware: ■  Largest Client (number of connected sites and number of users in one organization): •  Customized Proposal Upon Request •  12 sites with approximately 100 users.

■  ASP Hosting: •  It can be hosted off-site in a variety of different ways. ■ Pricing Scenario •  Open Dental does not yet offer that service directly. •  Vendor’s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. This is for software costs only – no hardware, no IT, no imaging: – Assumes 8 total workstations, an HL7 interface to medical software, 3 days of training and standard 10 hours of implementation services. – Software Purchase: $21,900 plus $180 per month support – ASP: $2,800 plus $1,400 per month for software, support and hosting Company: eClinicalWorks

Dental Contact: Kelli Smith, Business Development Address: 2 Technology Drive, Westborough, MA 01581 Office: 508.836.2700 Ext. 15902 Email: [email protected] Product Name: Open Dental and eClinicalWorks Website: www.eClinicalWorks.com Company: Open Dental

Contact: Jordan Sparks, DMD, President Vendor’s Statement Of Capabilities Address: 1462 Commercial St. SE, Salem, OR 97302 Office: 503.363.5432 Directly interfacing eClinicalWorks with Open Dental practices improve patient safety and streamline workflows by removing Fax: 503.485.5202 manual, double entry of patient data, and increase care team collaboration by sharing information across systems. Email: [email protected] Website: http://www.opendental.com/contact.html eClinicalWorks has developed a “tight” interface with Open Dental for charting and treatment in an ambulatory setting. The dental interface will provide dental functionality for those ambulatory medical clinics that offer dental services, leveraging the strengths of the eClinicalWorks application in the following areas:

Guide to the Future 80 81 Guide to the Future •  Centralized scheduling of appointments accessed by location of treatment and provider. UDS reporting can be performed and there is a comprehensive •  Centralized billing of all clinic activity understanding of billing for Health Centers, Medicaid, and sliding fee scales. •  Sharing of relevant clinical information at the point-of-care •  Medication management, reconciliation, and allergy/interaction checking Open Dental and eClinicalWorks are both ONC-ATCB certified for Meaningful Use across the continuum of care. at the time medications are prescribed Open Dental has several new features and benefits including: •  e-Prescribing via Surescripts (if the practice chooses to install a Surescripts) •  Easy to access and share data ■  Client Base (# of organizations) and number of safety net/Health Center clients: •  Tutorials on-line cover the minimal setup functions •  eClinicalWorks: actively implementing 400 Health Centers across the country •  Support complete patient records (HIPAA compliant) • Open Dental: Approximately 60 are live with Open Dental •  Comprehensive billing system with e-claim support •  Dashboard includes several practice parameters in graphical format ■  Largest Client (number of connected sites and number of users in one organization): •  Batch insurance payments •  5 sites with approximately 25 users

The Workgroup did identify areas in Open Dental and eClinicalWorks product features that could be enhanced ■  ASP Hosting: including dental imaging integration (both radiographic and visible imaging), eligibility verification, periodontal •  Yes, currently limited to new clients charting, electronic remittance advice/posting, clinical quality measure reporting for oral health, and clinical and ■  Pricing Methodology: financial dashboards. •  Subscription based pricing model: Client engages directly with Open Dental for support and training •  No up-front cost to use the open dental integrated model in eClinicalWorks. Standard provider licensing NNOHA’s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the pricing applies RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: 3 – Completely satisfied ■  Annual Maintenance Fees: 2 – Partially satisfied •  $75 per provider per month to Open Dental 1 – Not at all satisfied

Ratings of Functional and Qualitative Requirements Rating NNOHA HIT Workgroup Evaluation Highlights Clinical Care Management and Treatment Planning Requirements 3 Productivity Measurement and Support Requirements 3 The Open Dental and eClinicalWorks (eCW) solution is a tightly integrated product. Both products are considered Tooth and Periodontal Charting 3 a solid EDR/EHR foundation solution for Health Centers by the NNOHA Workgroup. eClinicalWorks has more Office Administrative Requirements 2 than 1,600 employees dedicated to this one product, the 1,600:1 ratio is the highest employee-to-product ratio in Billing 2 the industry. This, coupled with eCW’s 24x7 support structure makes eCW well positioned to move forward with Statements 3 NNOHA’s initiative. Technical Requirements 3 Integration with Practice Management (PM)/EHR Systems 3 Open Dental and eCW demonstrated an efficient integration of the two products. Open Dental is also the only PC Integrates Records Among Sites that are Geographically Disparate 3 dental software that has been certified as an EHR and provides users with the assurance that the software belongs firmly to the users and to the entire dental community. By interfacing eClinicalWorks with Open Dental, practices Imaging Requirements 2 improve patient safety and streamline workflows by removing manual, double entry of patient data, and increase Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 care team collaboration by sharing information across systems. “Nice to Have” Additional Features 3 Implementation and Support Services 3 Open Dental and eClinicalWorks has several strengths including: user-friendliness, HIPAA compliance for secure Compelling Reasons to Select Solutions 3 information exchange, billing, patient care, treatment planning, training, service and support, and meaningful Meaningful Use (MU) Plans 3 use reporting. The system has user-definable fields throughout the application that are fully reportable. There is Integration Capabilities 3 comprehensive training and support, federal and state regulation monitoring, and an understanding of Health Conversion Capabilities 3 Centers’ Migrant Healthcare, Homeless Healthcare, and government payers. Patient records and reports are easily Ways to Purchase Solutions 3 Demonstration of Vendor – EDR/EHR Capabilities 3

Guide to the Future 82 83 Guide to the Future Vendor Response To RFI Survey – As the only open source dental software in the world, it provides users with the assurance that the software belongs firmly to the users and to the entire dental community. Open Dental is also the only PC dental software that has been certified as an EHR. Open Dental can directly create 837 dental, medical, The RFI survey results for EDR/EHR system requirements are summarized below. and institutional claims, and has HL7 interfaces for use with medical software, in particular, eClinicalWorks. The outstanding customer support and unmatched responsiveness to user needs have resulted in an ■  Implementation and Support Services enthusiastic user base that is growing rapidly. • Implementation: Vendor’s response to the approach to define / implement systems to meet all requirements: • eClinicalWorks: • Open Dental: – eClinicalWorks is the leader in the ambulatory Electronic Medical Records (EMR) and Practice Management – Hours of operation are M-F 5am-5pm, Sat 7-11am Pacific, and after hours for emergencies. Open Dental (PM) industry. Focused exclusively on the design and deployment of its comprehensive EHR and Practice usually does not provide a lot of implementation support, depending instead on local resources. Management Solution, eCW has been working with large practice groups and community-wide projects as • eClinicalWorks: well as medium, small, and solo practices, regardless of specialty or number of locations since 1999. – The Implementation Process begins when eClinicalWorks receives the signed contract from the client. At – eClinicalWorks is the vendor of choice for community health centers across the Nation with more than 400 that time, an eClinicalWorks Project Team will be assigned to your account and the eCW Project Manager practices. Of these clients, approximately 75% are providing Dental Services to their patients. It made sense will contact you to begin planning the implementation in detail. Issues to consider at this time are: workflow for eClinicalWorks to partner with Open Dental and build an integrated product. Most of the eClinicalWorks analysis, IT requirements, interface requirements, data migration, system architecture, training, Community Health Center client base is moving toward this integrated product. and Go-Live. Special requirements and custom features are discussed in detail at this time as well. – Benefits: • Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help diagnose and – Support Patient Centered Medical Home model of care resolve customer issues, with remote diagnosis and on-site: – Supports Meaningful Use • Open Dental: – Supports Clinical Decision Support – The Open Dental user manual is entirely online. Open Dental has a staff of 21 to handle phone support and – Simplified/ease of reporting for UDS, as it keeps your patients in one database and alleviates duplication escalated issues. Open Dental will usually connect remotely to help train and troubleshoot. The integration – Minimized up front and ongoing costs with one unified system with image programs is software based. If customers have issues with sensors, Open Dental will refer them to their imaging hardware vendor. ■  Meaningful Use (MU) • eClinicalWorks: • Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services available to – eClinicalWorks has over 2000 hosted clients nationwide, who currently reap the benefits of eCW’s Disaster assist in attaining MU incentives: Recovery/Business Continuity Solutions. Now, organizations who host their own server infrastructure have the • Open Dental: ability to utilize eClinicalWorks existing framework for business continuity as well, and at a fraction of the cost – Open Dental is a fully certified ambulatory EHR and continues to make enhancements that will help of third party disaster recovery programs. customers demonstrate Meaningful Use. – On-line support at the My eClinicalWorks (https://my.eclinicalworks.com) is available 24 hours a day. – It is a requirement to use the full EHR version of Open Dental. No provider will be able to turn on the reporting – The Customer Service and Technical Support site is a full-service portal that has numerous resources for features until they have paid an amount equivalent to the lesser of the following three time periods: 12 months, clients and is the preferred method for contacting technical support for application-related issues. back to October 1, 2010, or back to the date Open Dental was first used. This requirement may be met by – The eClinicalWorks Customer Service and Technical Support Portal is located at: https://my.eclinicalworks. paying the monthly fees until 12 months have passed, or by paying up front. com, giving clients the ability to contact support staff, download documentation and training manuals, view • eClinicalWorks: training videos, view notifications about the eClinicalWorks product, access eCW newsletters, and obtain – eClinicalWorks is fully certified in accordance with the applicable certification criteria for Eligible Providers industry updates, etc. adopted by the Secretary of Health and Human Services. Certification Date: October 1, 2010. – eClinicalWorks Customer Support is located in Westborough, MA and consists of more than 700 professional customer support representatives. ■  Integration Capabilities – Customer Telephone Support Hours: M-F 7am-8pm, Eastern (excl. holidays) • Vendor’s response to capabilities to integrate EDR/EHR with radiographic imaging and intraoral camera – Telephone access to Technical Assistance: 1-508-475-0450 technologies, manage the images, access the images from within charting software, and optimize workflow: – Customers can log their support requests through the Internet 24 X 7 at https://my.eclinicalworks.com. • Open Dental: – eClinicalWorks uses eClinicalWorks Remote Support (eRS) to resolve any eClinicalWorks-related issues – Open Dental has one-way bridges to nearly every imaging software product on the market. At typical the client may have. eRS results in a faster and more satisfying customer support experience. bridge launches the imaging software and brings up the same patient as is displayed in Open Dental. Image management is almost always done from within the imaging software. ■  Compelling Reasons to Select Solutions – Open Dental Images module has some basic imaging capabilities which can handle scanning, importing, • Vendor’s reasons for selecting their EDR/EHR and imaging solution: cropping, and storing images. This is mostly targeted for documents, but can also easily be used with digital • Open Dental: photos which you can import from your camera. Please refer to the Open Dental website for further information – Open Dental is a comprehensive software package that offers very robust solutions for many different regarding third party imaging software that would be compatible for integration. kinds of clinics. Open Dental has an efficient workflow, a powerful database, and many well-designed http://www.opendental.com/manual/images.html tools for data management.

Guide to the Future 84 85 Guide to the Future ■  Conversion Capabilities ■  Pricing Scenario: • Vendor’s response to their approach and experience to plan, implement, and test conversion process, • Vendor’s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. including conversion of the data, mapping current processes to new processes, and mapping current This is for software costs only – no hardware, no IT, no imaging: systems functionality to new functionality: • Open Dental: • Open Dental: – 1 site @ $149 per month (per site charge). – Open Dental has built complex scripting tools that automate conversions from many other database – 3 providers @$60 per provider (per provider EHR charge). formats. Each conversion script presents unique challenges that the company continues to refine with each new customer conversion. • eClinicalWorks: – Data migration is typically done in two steps, namely the initial migration and the final migration. The initial migration is a preliminary, test migration which is conducted to ensure the highest quality Appendix B: Sources of Information/Additional Resources data transfer. It also allows the practice to test the data before it is migrated for the final time. The initial migration is done just after the eClinicalWorks software installation which is typically one–two weeks before the practice starts using eClinicalWorks software. During the initial migration, the data The following resources provide additional information regarding Meaningful Use and EDR/EHR selection and mapping is established between the current PM or EMR system of the practice and eClinicalWorks. implementation. – The purpose of final migration is to deliver the most recent data in eClinicalWorks and to ensure that the practice does not lose any data entered into the old system during the data transition. • NNOHA Website: http://www.nnoha.org/ • HHS Oral Health Initiative 2010: http://www.hrsa.gov/publichealth/clinical/oralhealth/hhsinitiative.html ■  Ways to Purchase Solutions • Vendor’s response to different ways to purchase solutions, including ability to bundle or unbundle products, • The Office of the National Coordinator for Health Information Technology (ONC) – Electronic Health Records leasing, ASP/hosted solutions, use channel partners/VARs, or bundled with dental supply contracts and and Meaningful Use: http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2 compelling reasons why such purchasing approaches are valuable: • CMS EHR Meaningful Use Overview: https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp • Open Dental: – There is no up-front cost for Open Dental. There is a monthly fee which covers telephone support and • CMS Attestation Guide: http://www.cms.gov/EHRIncentivePrograms/downloads/EP_Attestation_User_Guide.pdf frequent updates. After the short initial contract, the customer can continue to use the software even if • ONC Certified HIT Product List maintained: they discontinue support. There is no charge for any of the many included bridges to other programs, and generally no charge for HL7 interfaces. http://onc-chpl.force.com/ehrcert/EHRProductSearch?setting=Ambulatory • eClinicalWorks: • NQF’s Measure Evaluation Criteria / NQF endorsement process: – Open Dental has a direct agreement with eCW clients who are looking for an integrated dental solution http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx with eClinicalWorks. eCW has partnered with Open Dental to offer the integrated dental solution with http://www.qualityforum.org/News_And_Resources/Press_Kits/Endorsing_Measures.aspx eClinicalWorks EMR at a minimum subscription cost which the client pays directly to Open Dental on a monthly basis. eCW does not charge any interfaces charges related to Open Dental integration. • HHS Office of the National Coordinator for Health Information Technology – HIT Policy Committee Meaningful Use Also Open Dental directs all the clients on the required hardware to install Open Dental software. Workgroup: http://www.mahealthdata.org/Resources/Documents/cio/Halamka%20-%20Tang-Meaningful%20Use%20.pdf

■  Pricing Methodology and Annual Maintenance Fees: • ADA Website: http://www.ada.org • Open Dental: • ADA SCDI meetings, ADA SCDI membership to view proposed ANSI/ADA specifications and technical reports that – Subscription based pricing model: Client engages directly with Open Dental for support and training. are available for review and comment: http://www.ada.org/scdi – No up-front cost to use the open dental integrated model in eCW. Standard provider licensing pricing •  http://www.hitechanswers.net/ applies. HITECH Answers Website: – $149/month/site plus $10/month for every dentist beyond 3. Drops to $99/month after the first year. • University of Pittsburgh Department of Dental Informatics: http://www.dental.pitt.edu/informatics/ – EHR module is an additional $60/dentist/month. If using the medical software for MU, then this is • Tides CCI Publication: Healthcare Technology Resource Guide (Sample Contract): not needed. http://www.communityclinics.org/content/general/detail/804 – eCW: $75 per provider per month to Open Dental. • New York State Medicaid Health Information Technology Plan: http://www.health.ny.gov/regulations/arra/docs/medicaid_health_information_technology_plan.pdf • HRSA’s Oral Health IT Toolbox: http://www.hrsa.gov/healthit/toolbox/oralhealthittoolbox/index.html

Guide to the Future 86 87 Guide to the Future Appendix C: Glossary HL7 (Health Level 7) — An ANSI standard for healthcare-specific data exchange between computer applications. Application Service Provider — A business that manages and distributes software-based services and solutions to HL7 messages are used for interchange between hospital and physician record systems and between EMR customers over a network from a central data center. systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other materials. Clinical Decision Support — Computer programs designed to assist physicians and other health professionals with decision-making tasks, linking health observations (signs and symptoms) with health knowledge (best practices Interoperability — The ability of various HIT products to exchange information safely and securely, and to preserve and current research) to influence choices made by clinicians to improve care. the meaning of the data that is being shared.

CPOE (Computerized Provider Order Entry) — A computer application that allows a physician’s orders for diagnostic Office of the National Coordinator for Health IT (ONCHIT) — Provides counsel to the Secretary of HHS and and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead Departmental leadership for the development and nationwide implementation of an interoperable health information of being recorded on order sheets or prescription pads. The computer compares the order against standards technology infrastructure. for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems. Orders for pharmacy, laboratory, radiology, and treatment protocols are communicated over a computer SaaS (Software-as-a-Service) — SaaS is closely related to the ASP (Application Service Provider) and on demand network to the medical staff or to the departments/entities responsible for fulfilling the order. computing software delivery models. Applications are hosted by a service provider and made available to customers over a network, typically the Internet. DICOM (Digital Imaging and Communications in Medicine) — A widely used standard for representing and communicating radiology images and reports. Sources: • California HealthCare Foundation Glossary: DSS (Decision Support System) — Computer tools or applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples include drug interaction http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/H/PDF%20HITGlossary.pdf alerts at the time medication is prescribed and reminders for specific guideline-based interventions during the care • Selected Health Information Technology Terms: of patients with chronic disease. Information is presented in a patient-centric view of individual care and also in a http://www.pinellashealth.com/RHIO/Terminology_Master.pdf population or aggregate view to support population management and quality improvement. • US National Library of Medicine – National Institute of Health HIT Glossary: EDR (Electronic Dental Record) — EDR software provides clinical charting for dentists and eliminates paper http://www.nlm.nih.gov/nichsr/hta101/ta101014.html charts. Some common features of EDR software include exam results, patient images, treatment plan charts, and periodontal charts. Exams, treatment plans, procedures and images are viewed in the patient record on a display.

EHR (Electronic Health Record) — A real time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision making. An EHR is a medical record or any other Appendix D: References information relating to the past, present or future physical and mental health, or condition of a patient which resides in computers which capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing health care and health-related services. The EHR can also support the collection of • Centers for Medicare & Medicaid Services. (2011). CMS EHR Meaningful Use Overview. Retrieved on August 20, data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health 2011 from https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp disease surveillance and reporting. EHR records include patient demographics, progress notes, SOAP (Subjective, Objective, Assessment, and Plan) notes, problems, medications, vital signs, past medical history, immunizations, • Centers for Disease Control and Prevention. (2011). Electronic Health Record Systems and Intent to Apply for laboratory data and radiology reports. Meaningful Use Incentives Among Office-based Physician Practices: United States, 2001–2011. Retrieved on August 20, 2011 from http://www.cdc.gov/nchs/data/databriefs/db79.htm eRx (Electronic Prescribing) — A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local • Centers for Medicare & Medicaid Services. (2012).Medicare EHR Incentive Program, Physician Quality Reporting pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physicians System and e-Prescribing Comparison. Retrieved on April 26, 2012 from https://www.cms.gov/Outreach-and- access to patient specific information to screen for drug interactions and allergies. Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//EHRIncentivePayments-ICN903691.pdf

HIE (Health Information Exchange) — Provides the capability to electronically move clinical information between • Centers for Medicare & Medicaid Services. (2012). Stage 2 Meaningful Use NPRM Moves Toward Patient- disparate health care information systems to facilitate access to, and retrieval of, clinical data, thereby helping to Centered Care Through Wider Use of EHRs. Retrieved on April 26, 2012 from http://blog.cms.gov/2012/02/28/ provide safer, timely, efficient, effective, equitable patient-centered care. HIE is also known as a regional health stage-2-meaningful-use-nprm-moves-toward-patient-centered-care-through-wider-use-of-ehrs/ information organization (RHIO). The notion of HIE is the precursor to RHIO and is used interchangeably when discussing RHIOs. • Comparison Study of Dental Sensors. Retrieved on August 23, 2011 from http://dentalsensorstudy.com/

HIT (Health Information Technology) — The application of information processing involving both computer hardware • Federal Register. (2010). Retrieved on October 15, 2011 from and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge http://www.thefederalregister.com/d.p/2010-07-28-2010-17210 for communication and decision making.

Guide to the Future 88 89 Guide to the Future • Gaylin, D., Moiduddin, A., Mohamoud, S., Lundeen, K., & Kelly, J. (June 2011). Public attitudes about health • Tankersley, R., Wong, D., Snow, M., Birdwell, R., & McFarland, J. (March 2010). RE: Notice of Proposed information technology and its relationship to health care quality, costs, and privacy. HSR: Health Services Rulemaking: Medicare and Medicaid programs; electronic health record incentive program. Retrieved July 11, 2011 from Research.46 (3) 920-38. http://www.nnoha.org/goopages/pages_downloadgallery/download.php?filename=21405.pdf&orig_name=dqa_ltr_coalition_ mmehrincentiveprog.pdf&cdpath=/dqa_ltr_coalition_mmehrincentiveprog.pdf  • Harris, Y. & Leigh, J. (2011). Meaningful Use for Dentists: What it Means for Me? Retrieved on October 26, 2011 from http://www.nnoha.org/npohcpresentations/2011npohcpresentations.html • Thompson, T. & Brailer, D. (2004). The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Department of Health and Human Services. Retrieved On August 23, 2011, from • Health Resources and Services Administration (2011). What is “Meaningful Use”? Retrieved on October 15, 2011 http://www.providersedge.com/ehdocs/ehr_articles/The_Decade_of_HIT-Delivering_Customer-centric_and_Info-rich_HC.pdf from http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/mu.html

• Healthy People 2020. Retrieved on August 20, 2011 from http://www.healthypeople.gov/2020

• Heinrich, J. (2004). HHS’s Efforts to Promote Health Information Technology and Legal Barriers to Its Adoption. United States Government Accountability Office. Retrieved on August 23, 2011 from http://www.gao.gov/new.items/d08499t.pdf Appendix E: Credits

• Heubusch, K. (2010). Clinical quality measures for providers. Journal of AHIMA. 6a. Retrieved August 20, 2011 from http://journal.ahima.org/2010/09/15/clinical-quality-measures-for-provider-3/

• Hoffman, S & Podgurski, A. (2011). Meaningful Use and Certification of Health Information Technology: What about NNOHA Health IT (HIT) And Meaningful Use (MU) Workgroups Safety? Retrieved on August 25, 2011 from http://www.aslme.org/media/downloadable/files/links/1/7/17.Hoffman.pdf Members of NNOHA’s HIT Workgroup have volunteered their time researching and supporting this project. A special • Institute of Medicine. (2001). Crossing the Quality Chasm: a New Health System for the 21st Century. heartfelt “thank you” to the Meaningful Use Workgroup members for proposing and evaluating the Clinical Quality Washington, D.C., National Academy Press. Measures for Oral Health. • Jones, K.C. (2009). Obama Wants E-Health Records In Five Years. President-elect says medical information on all Americans should be digitized by 2014. Retrieved on August 25, 2011 from Huong N. Le, DDS, FACD Maggie Drozdowski Maule, DMD, MBA Noelle Parker http://www.informationweek.com/news/healthcare/212800199 NNOHA HIT Workgroup Chairperson Dental Director, Community Health Manager, Missouri Primary Care Dental Director, Asian Health Services Center, Inc. Association • Melvin, V. (2008). HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy. United States Government Accountability Office. Retrieved on August 21, 2011 from Steven Russell, MEEM, MSHA, CPHIT Lyn Blankenship Barbara Woods http://www.gao.gov/new.items/d08499t.pdf NNOHA HIT Consultant EHR Project Coordinator, Community Project Coordinator, Missouri Primary Director of Dental Services, Health Centers Care Association • National Network of Oral Health Access. (2011). NNOHA HIT and Meaningful Use (MU) Framework for Strategic Interests Eligible Professionals (Dentists), Adoption Incentives & EHR Implementation. Retrieved on August 26, 2011 Clifford Hames, DDS Mary Ellen Yankosky, RDH, BS from http://www.nnoha.org/advocacy.html Colleen Lampron, MPH VP, Chief Dental Officer/Chief Infection Vice Chair, New York State Oral Former Executive Director, National Control Officer, Health Coalition • National Quality Forum. (2011). Measure evaluation criteria and guidance summary tables. Retrieved on Network for Oral Health Access Hudson River HealthCare August 20, 2011, from http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx Terry Russell, RDH, MSHA Amanda Stangis, MPH Karen Dent, CDA, EFDA New York State Oral Health Coalition • National Quality Forum. (2011). Retrieved on August 20, 2011 from http://www.qualityforum.org/Home.aspx Director of Programs, California Oral Health Network Director, Dental Operations Administrator, Primary Care Association Missouri Primary Care Association Suncoast Community Health Centers • NORC. (2011). Quality Oral Health Care in Medicaid Through Health IT. Retrieved on September, 30, 2011 from http://www.norc.org/PDFs/QualityOralHealthCareMedicaid[1].pdf Andie Martinez Patterson, MPP Shannon Quirk, MSW Assistant Director of Policy, Oral Health Affairs Manager, • Robert Wood Johnson Foundation (2006). Health Information Technology in the United States: The Information California Primary Care Association Massachusetts League of Base for Progress. Retrieved on August 27, 2011 from http://www.rwjf.org/files/publications/other/EHRReport0609.pdf Community Health Centers Sonia Sheck • Rudman, W., Hart-Hester, S., Jones, W., Caputo, N., Madison, M. (2010). Integrating medical and dental records: Clinical Projects Coordinator, Ryan Krull a new frontier in health information management. Journal of AHIMA 81, (10) 36-39. Colorado Community Health Network Project Coordinator, Missouri Primary Care Association

Guide to the Future 90 91 Guide to the Future Steven T. Russell, MEEM, MSHA, CPHIT: Steven Russell is a Meaningful Use and HIT consultant for NNOHA and other health NNOHA Health Information Technology (HIT) Workgroup care organizations. He received his undergraduate engineering degree from Syracuse University and graduate degrees from Rochester Institute of Technology and Roberts Wesleyan College. His certifications include Professional in Healthcare IT, Program Management, Lean Six Sigma and Competitive Intelligence. Steven held the position of World Wide Manager Business Research NNOHA Health Information Technology (HIT) Workgroup members enumerated several specific objectives in their and Development Healthcare Information Systems at Carestream Health. At Eastman Kodak Health Group he held positions of vision for greater technology adoption in the Health Center oral health setting: Innovation & Integrated Solutions Manager, Manager of Technology Innovation, and Director of Strategic Planning for Dental Systems and received several patent awards. Steven has served on the ADA Standards Committee on Dental Informatics (SCDI) and other standards developing organizations. He has prepared grants in conjunction with the Unity Health System, Rochester • Foster integration of medical and dental information RHIO and Regional Extension Centers in New York State. He has also chaired panel reviews for the U.S. Department of HHS, • Increase the efficiency and accuracy of required reporting to HRSA Office of the National Coordinator Beacon Community Program that provides funding for the advancement of HIT, workflow redesign and care coordination and CMS Innovation grants that fosters health care transformation by finding new ways to pay for • Focus on all aspects of the patient’s health, including oral, systemic, mental and behavioral health and deliver care that improve care and health while lowering costs. Steven is an adjunct professor in the MS Health Information • Enhance dentist recruitment and retention Administration program at Roberts Wesleyan College, and also serves as the Access to Care Chair and Steering Board Member for the New York State Oral Health Coalition. • Gather and use data to support population health improvements • Evaluate the effectiveness of clinical interventions Special Recognition: The NNOHA HIT leadership extends a special recognition to the Roberts Wesleyan College, Master of Science • Enable quality of care improvement measurement Health Administration program staff and students for assisting in the research efforts for this project and increasing awareness of improving oral health for Health Centers across the nation. • Improve the quality of care for patients • Increase patient safety.

Thank you to the following individuals for their input and review of this white paper: Whether focused on clinical or public health, these goals are to improve patient outcomes, and it is widely recognized that these efforts are not scalable without the effective use of technology. Hyewon Lee, DMD Emily Jones, MPP Lisa A. Wald, MPH Lieutenant, U.S. Public Health Service Public Health Analyst Public Health Analyst Dental Consultant, Office of Strategic Office of Quality and Data, Office of Training and Technical Priorities (OSP), HRSA Quality Branch Assistance Coordination NNOHA Project Officer Bureau of Primary Health Care, HRSA Bureau of Primary Health Care, HRSA PRIMARY AUTHORS:

Huong N. Le, DDS, FACD (MA expected in 2012): Dr. Huong Le joined the Health Center world in 1989 after a few years in private practice. Since 2003, Dr. Le has served as Dental Director at Asian Health Services in Oakland, California. Dr. Le is a member NNOHA Staff: of the American Dental Association (ADA), California Dental Association (CDA) and Alameda County Dental Society where she Annette Zacharias Maria Smith, MPA Jennifer Hein is Immediate-Past President. She is a former member of CDA Policy Development Council, CDA and ADA delegation. Dr. Le is Executive Director Project Coordinator Operations Manager currently President-Elect of the National Network for Oral Health Access (NNOHA) and Immediate Past President of the Western [email protected] [email protected] [email protected] Clinicians Network (WCN). Dr. Le has appointments as an Associate Clinical Professor at University of California San Francisco (UCSF) School of Dentistry and Assistant Clinical Professor at A. T. Still School of Dental and Oral Health. She is California Assistant Mitsuko Ikeda Irene Hilton, DDS, MPH Barbara E. Bailey, RDH, PhD Director of Lutheran Medical Center– Advanced Education in General Dentistry (AEGD) residency programs. On behalf of NNOHA, Dr. Le has collaborated with the ADA, ASTDD, and other organizations on various projects related to EHR. In November, 2008, Project Director Dental Consultant Interim Executive Director NNOHA’s HIT Workgroup published its first white paper titled Guide to the Future: Using HIT to Improve Oral Health Access [email protected] [email protected] and Outcomes. Dr. Le received an Outstanding Clinician Award from NNOHA in 2007, Outstanding Contributor Award from the California Pipeline Program in June, 2009, and Outstanding Service Award in Community Partnership from UCSF School of Dentistry in July, 2009. Her oral health program at Asian Health Services, in collaboration with UCSF School of Dentistry, has recently been awarded a multi-year research grant by National Institute of Health (NIH). In March, 2009, she was appointed by The National Network for Oral Health Access (NNOHA) California Governor Arnold Schwarzenegger to serve on the state Dental Board of California. She is serving her second term on the board where she was recently elected to be Vice-President. Dr. Le also serves on California Managed Risk Medical Insurance The National Network for Oral Health Access (NNOHA), a 501(c)3 non-profit organization, was founded in 1991 by a group of Health Board (MRMIB) Dental Advisory Leadership Group, in California. She was also a member of the National Association of Community Center Dental Directors. They recognized that peer-to-peer networking, services, and collaboration could improve operations of Health Centers’ Dental and Behavioral Advisory Workforce Report Group in 2010. Dr. Le is a graduate of Baylor University, Health Center oral health programs that serve underserved populations. NNOHA has a diverse membership of safety-net oral health University of Texas Dental Branch in Houston, and General Practice in Hospital Dentistry Residency at Loma Linda VA Hospital. providers: Dental Directors, dental hygienists, and their support teams, who understand that inadequate access to oral health services Dr. Le is a Fellow of American College of Dentists. Dr. Le is working on her MA in Dental Education and is expected to receive her can adversely affect a person’s speech, appearance, health, and quality of life. To better serve these low-income individuals, NNOHA degree in December 2012. coordinates efforts to benefit community, migrant, and homeless Health Center oral health programs across the United States.

Margaret Drozdowski Maule, DMD, MBA: Dr. Margaret Drozdowski Maule received her undergraduate degree from St. Joseph’s NNOHA communicates with its members and supporters via: College and her graduate degree from the University of Connecticut School of Dental Medicine in 1998. She completed her residency training in Advanced Education in General Dentistry also at the University of Connecticut. She earned an MBA degree • An online forum where colleagues can post questions, share advice and network from Cornell University in May, 2011. Dr. Drozdowski Maule spent three years in private practice before joining Community Health • A quarterly newsletter in both electronic and hard copy formats Center, Inc. in Connecticut in September 2002. Since 2005, she has served as the Dental Director for the agency. Currently, Community Health Center, Inc has seven locations throughout the state of Connecticut operating 46 dental chairs, and over 150 • The www.nnoha.org website, which includes contact info, links, and reference materials, including the Dental Operations “mobile” dental delivery sites. Dr. Drozdowski Maule continues a general dentistry practice at the New Britain site. She has a faculty Manual and a dental forms library appointment at the University of Connecticut School of Dentistry and participates in clinical supervision of AEGD residents and 4th • The annual National Primary Oral Health Conference, where members can obtain Continuing Education credits, network, year dental students. In 2008, she was named as one of “40 under 40” outstanding graduates of the University of Connecticut. and learn the latest oral health best practices. Dr. Drozdowski Maule also serves on the NNOHA Board of Directors. For more information visit www.nnoha.org.

Guide to the Future 92 93 Guide to the Future The National Network for Oral Health Access (NNOHA)

The National Network for Oral Health Access (NNOHA), a 501(c)3 non-profit organization, was founded in 1991 by a group of Health Center Dental Directors. They recognized that peer-to-peer networking, services, and collaboration could improve operations of Health Center oral health programs that serve underserved populations. NNOHA has a diverse membership of safety-net oral health providers: Dental Directors, dental hygienists, and their support teams, who understand that inadequate access to oral health services can adversely affect a person’s speech, appearance, health, and quality of life. To better serve these low-income individuals, NNOHA coordinates efforts to benefit community, migrant, and homeless Health Center oral health programs across the United States.

NNOHA communicates with its members and supporters via: ■ An online forum where colleagues can post questions, share advice and network ■ A quarterly newsletter in both electronic and hard copy formats ■ The www.nnoha.org website, which includes contact info, links, and reference materials, including the Dental Operations Manual and a dental forms library ■ The annual National Primary Oral Health Conference, where members can obtain Continuing Education credits, network, and learn the latest oral health best practices. For more information visit www.nnoha.org.

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