version 2 - nnohaprovide key stakeholders, dental directors, executive directors, and information...

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

Version 2.0

Guide to the Future

table of contents

Introduction ......................................................................................................................................... 1

Meaningful Use for Oral Health .............................................................................................................. 2

Current Meaningful Use Objectives and Exclusions for Consideration ......................................................... 6

Core Set Objectives .............................................................................................................................. 7

Menu Set Objectives ............................................................................................................................. 8

Current Clinical Quality Measures for Oral Health ................................................................................... 10

Clinical Quality Measures for Oral Health .............................................................................................. 12

EHR Selection ................................................................................................................................... 17

EDR/EHR Selection Tool ..................................................................................................................... 18

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

Step 4: Review of Meaningful Use Clinical Quality Measures (CQMs) ................................................ 21

Step 5: Vendor Response to Meaningful Use Certification and Reporting Measures............................. 22

Step 6: Vendor Response to NNOHA’s Proposed CQMs for Oral Health .............................................. 22

Step 7: Vendor Response to EDR/EHR Practice-Specific Requirements ............................................. 23

Step 8: Vendor Response to Qualitative Requirements..................................................................... 25

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

Challenges Selecting and Implementing an EDR/EHR Solution ................................................................ 29

EDR/EHR Implementation Strategies .................................................................................................... 30

Conclusion: A Strategic Pathway to the Future ....................................................................................... 33

Appendix A1: Meaningful Use Vendor Survey Responses ........................................................................ 36

Appendix A2: Rating Chart: Vendor Response to EDR/EHR Practice-Specific Requirements........................ 38

Appendix A3: Rating Chart: Vendor Response to Qualitative Requirements ............................................... 52

Appendix A4: Rating Chart: Vendor Response to Vendor Solution Cost ..................................................... 53

Appendix A5: Rating Chart: Vendor Selection Criteria and Summary Ratings............................................. 55

Appendix A6: Vendor Background Information and Evaluations ............................................................... 55

Product Name: QSI Dental – Electronic Dental Record (EDR) ........................................................... 57

Product Name: Dentrix Enterprise/Sage Intergy .............................................................................. 62

Product Name: Mediadent ............................................................................................................ 72

Product Name: Open Dental and eClinicalWorks ............................................................................. 80

Appendix B: Sources of Information/Additional Resources ...................................................................... 87

Appendix C: Glossary .......................................................................................................................... 88

Appendix D: References ...................................................................................................................... 89

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

inTroducTion

The future of health care can be found in combining skillful providers with the technological tools that allow them to provide the best possible care for their patients. At the forefront of this combination is the concept 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 measured. The National Network for Oral Health Access (NNOHA) developed this white paper to present a strategic roadmap for achieving Meaningful Use for oral health and to provide critical steps that need to be taken to implement an EHR system that fully integrates Electronic Dental Records (EDR). This white paper will help oral health providers, staff, and patients understand the benefits of Meaningful Use incentives and serve as a guide to selecting an Electronic Dental and Health Record system.

NNOHA’s Health Information Technology (HIT) Workgroup (formerly HIT Committee) was established to 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 health programs and make recommendations to guide Health Centers in selecting technology solutions that are compatible with the systems used by both medical and dental staff. Through a Health Resources and Services Administration (HRSA) Cooperative Agreement, NNOHA strives to provide technical assistance to Health Centers seeking to provide, expand, or improve oral health services.

NNOHA’s HIT Workgroup goals are to:

■ Provide key stakeholders, Dental Directors, Executive Directors, and Information Technology (IT) decision makers with objective comparisons among the current leading EDR/EHR products.

■ Provide input to dental software developers on areas for improvement within existing applications to better meet the challenges of Meaningful Use compliance, Health Center patient care, and practice management of oral health programs.

■ Advocate for integration of a dental module within Electronic Health Records as a vital part of the product functionality offered to Health Centers.

■ Identify potential Meaningful Use measures for oral health.

■ Provide Dental Directors and Health Center oral health programs with practical resources for selecting, implementing, and optimizing HIT.

When a Health Center finds a system that best meets the needs of their organization, as well as Meaningful Use criteria, it allows for maximized resources, increased reimbursements, and improved patient care. This paper can serve as a guide in the process, and facilitate the Health Centers’ decision making process toward improved use of HIT.

1

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 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 Act funded centers, sub-recipients (e.g. sub-grantees) and look-alikes.

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 throughout this paper to refer to the above listed types of grant-supported entities.

© National Network for Oral Health Access, August 2012The information in this document was accurate at the time of this printing. As regulations and information regarding Health Centers are not static, NNOHA recommends readers verify any critical information with different state regulations and changes that may have occurred since printing.

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.

Guide to the FutureGuide 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.”

Meaningful Use has become an important consideration for Health Centers not only because it could improve patient care, but because there are financial incentives available through the

American Recovery and Reinvestment Act of 2009 (ARRA). There are two important considerations when trying to interpret Meaningful Use: the requirements the health

professional or care delivery organization must meet, and the technology in use by 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).

Participating in the Meaningful Use incentive program has been a challenge for many EPs, especially dentists, who must meet the same eligibility requirements as other EPs

in order to qualify for payments under the Medicaid Electronic Health Record Incentive Program. This also means that they must demonstrate all of the Meaningful Use objectives

plus some optional measures detailed later in this report.

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 practice meets the exclusion criteria for each applicable objective.

There is a significant gap between the current situation and achieving Meaningful Use objectives, making it difficult for oral health providers and electronic dental record (EDR) vendors to participate in the national initiative to increase the use of technology as a means to improve health care. NNOHA will continue to assist Health Centers in Meaningful Use involvement by monitoring the capabilities of dental software vendors in meeting Meaningful Use criteria and providing guidance in selection of EDR/EHR systems. NNOHA and other 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:

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■ NQF 1335: Title – Children who have dental decay or cavities.

■ NQF 1419: Title – Primary Caries Prevention Intervention as Part of Well/Ill Child Care as Offered by Primary Care Medical Providers.

NNOHA will continue to develop or identify clinical quality measures for dental/oral health care with partners and stakeholders that could be ready for future years.

Stimulating EHR Implementation

Health Information Technology (HIT) has tremendous potential to transform the delivery of health care by integrating clinical, administrative and financial systems and other administrative tasks, and providing the infrastructure to support them. One of the essential clinical systems is the EHR. An EHR generally includes a longitudinal collection of information on the health of an individual or the care provided. An EHR also provides 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).

In April 2004, President George W. Bush called for widespread adoption of interoperable EHRs within ten years 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 goals included: (1) informed clinical practice, (2) interconnection of clinicians, (3) personalized care, and (4) improvements in population health (Thompson & Brailer, 2004). Collectively, these initiatives laid the groundwork for an organized effort to drive adoption of interoperable HIT. However, other barriers still exist, including the initial high costs of investing in HIT, the ongoing maintenance required in all information systems, and short-term loss of productivity as staff adapt to new technology and systems.


To stimulate the investment and use of EHRs, the federal government has established a combination of voluntary financial incentives and eventual penalties to encourage the Meaningful Use of EHR for Medicare and Medicaid providers. Stimulus funds, designed to increase the use of EHRs, is only one of many information technology initiatives encouraged by the federal government. However, lack of Meaningful Use measures relating to oral

health may lead to a reduction in dental provider participation in the stimulus fund program for EDR/EHR implementation and integration.

HIT is becoming increasingly prevalent in medical offices and facilities. Like President George W. Bush before him, President Barack Obama announced a plan

to computerize the medical records of all Americans by 2014 (Jones, 2009). The functionality of comprehensive EHR systems goes far beyond the traditional role of paper dental/medical records. In addition to providing ready access to 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 allows health care providers to send patient orders, such as those for laboratory

tests and medications, electronically to appropriate parties. EDR/EHR systems also provide decision support tools, including clinical reminders, drug allergy/

interaction alerts, drug-dose recommendations, and suggestions for diagnostic and treatment options (Hoffman & Podgurski, 2011). EDR/EHRs are revolutionizing

business in the health care industry, allowing medical professionals to work faster, smarter, and more efficiently than ever before.

The American Recovery and Reinvestment Act of 2009 (ARRA) dedicated $27 billion to the promotion of 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 and beyond. Those in compliance will be eligible for EHR incentive payments, registration for which began in January 2011. Two additional phases of Meaningful Use requirements will be staged in three steps over the course of the next five years.

■ Stage 1 (2011 and 2012) sets the baseline for electronic data capture and information sharing.

■ Stage 2 expected to be implemented in 2014 under the proposed rule: “Meaningful Use” includes standards such as online access for patients to their health information and electronic health

information exchange between providers.

■ Stage 3 expected to be implemented in 2016: “Meaningful Use” includes demonstrating that the 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

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vital signs, patient demographics, drug and allergy lists, updated problem lists, and smoking status. In addition, EPs must comply with five out of a “menu” of ten additional objectives. Some of the menu items include: performing drug-formulary checks, incorporating laboratory results into patient records, providing patients with reminders for needed care, supplying relevant educational resources, and supporting transitions between care facilities or personnel (Centers for Medicare & Medicaid Services, 2012).

Up until now, the adoption of HIT has generally been slow in the United States. Recent research highlights accelerated adoption of EMR/EHR systems. EMR/EHR system use among office-based physicians increased from 18% in 2001 to 57% in preliminary 2011 estimates (CDC, 2011). The federal Meaningful Use EHR incentive program intends to boost those numbers through millions of dollars in federal incentive payments. While much of the discussion to date has focused on physician practices and hospitals, it is notable that the incentive program was made available to doctors of dental surgery and dental medicine as well.

The United States spends more on health care than any other country, yet performs far below many others in quality measures that include life expectancy, equities in the access to care, and the inconsistency of care in demographic locations (Gaylin, et al., 2011). The use of information technology is recognized as having a major role in the transformation of health care in order to meet the Six Aims for Improvement as identified in the Institute of Medicine’s Committee on the Quality of Health Care in America, Crossing the Quality Chasm (2001). The use of technology in health care will increase treatment and business efficiency, promote patient safety, increase continuity of care, increase access to quality care, and reduce disparities in health care. Increasing evidence 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 utilization of technology accessible by all providers.

To promote the use of technology, the Health Information Technology for Clinical Use Act (HITECH) allows for access to federal stimulus funds for Medicaid and Medicare providers who show Meaningful Use of electronic information technology. Stage 1 of the Meaningful Use guidelines does not provide specific oral health measures 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 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, to participate in EHR implementation. The organizations echoed a recurring theme addressing concerns that face dental providers in their attempt to meet Meaningful Use requirements. The system requirements associated with 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 than 1.2% of all dental practices (Tankersley, et al., 2010).

Guide to the FutureGuide to the Future 76

clinical QualiTy Measure Barriers

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 Health Care (Heubusch, 2010). The use of quality metrics is recognized as the driver of improvements in health care. Unless measures that address oral health are utilized, oral health care may be overlooked in the health care 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, 2011). This recognition supports the inclusion of oral health quality metrics for Meaningful Use. NNOHA’s Health Information Technology and Meaningful Use Workgroup has identified six clinical quality core measures and other alternative measures for consideration by HHS as potential Meaningful Use measures that can be met by oral health providers. A consideration for oral health-focused CQMs is important in development of a data format 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.

CMS prefers to select CQMs endorsed by the National Quality Forum (NQF) for the Meaningful Use requirements. The NQF is a nonprofit organization established in 1999 whose membership is made up of public and private sector entities with an interest in quality health care. The NQF’s mission is to improve the quality of American health care by setting national priorities and goals for performance endorsements through national consensus standards for measuring and public reporting of performance. The NQF promotes the attainment of national goals through education and public outreach programs (NQF, 2011). Currently, all the clinical quality measures recognized by CMS for Meaningful Use are endorsed by the NQF. NNOHA has recognized the need for NQF endorsement and will support future endorsement efforts for oral health CQMs.

The average length of the endorsement process is three years; however, a consideration to expedite the process can occur if measures are shown to be well-established, widely used, or meet an urgent national need (NQF, 2011). The expedited consideration decreases the number of days for several of the steps in the process, but does not decrease the criteria for evaluation. NNOHA is currently exploring an expedited process to include relevant CQM for oral health.

Current Meaningful Use Objectives and Exclusions for Consideration

One of the requirements for receiving Meaningful Use reimbursements is to track several quality improvement objectives. The question asked most often by dentists regarding Meaningful Use is: “Do dentists have to meet all of the required Core Set Meaningful Use objectives?” The answer is currently yes, with some explanation. CMS has a list of 15 required “Core Set” objectives and 10 additional “Menu Set” objectives. CMS states that, “To qualify for an incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives. The remaining 5 objectives may be chosen from the list of 10 Menu Set objectives” (Centers for Medicare & Medicaid Services, 2011). However, there are exclusions available that can be claimed during attestation (the online process where EPs prove they are

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.

Objective Measure exclusiOn Dentist rOutine

Record patient demographics (sex, race, ethnicity, date of birth, preferred language)

More than 50% of patients’ demographic data recorded as structured data

None Yes

Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children)

More than 50% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data

An EP who either sees no patients 2 years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice

Yes: Blood pressureNo: Other vitals

Maintain up-to-date problem list of current and active diagnoses

More than 80% of patients have at least one entry recorded as structured data

None Yes

Maintain active medication list More than 80% of patients have at least one entry recorded as structured data

None Yes

Maintain active medication allergy list

More than 80% of patients have at least one entry recorded as structured data

None Yes

Record smoking status for patients 13 years of age or older

More than 50% of patients 13 years of age or older have smoking status recorded as structured data

An EP who sees no patients 13 years or older

Potential

Provide patients with clinical summaries for each office visit

Clinical summaries provided to patients for more than 50% of all office visits within 3 business days

An EP who has no office visits during the EHR reporting period

Potential

On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies)

More than 50% of requesting patients receive electronic copy within 3 business days

An EP that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period

Potential

Generate and transmit permissible prescriptions electronically

More than 40% are transmitted electronically using certified EHR technology

An EP who writes fewer than 100 prescriptions during the EHR reporting period

Potential

Computer provider order entry (CPOE) for medication orders

More than 30% of patients with at least one medication in their medication list have at least one medication ordered through CPOE

An EP who writes fewer than 100 prescriptions during the EHR reporting period

Potential

Guide to the FutureGuide to the Future 8 9

Objective (cOnt.) Measure exclusiOn Dentist rOutine

Implement drug-drug and drug-allergy interaction checks

Functionality is enabled for these checks for the entire reporting period

None Yes

Implement capability to electronically exchange key clinical information among providers and patient-authorized entities

Perform at least one test of EHR’s capacity to electronically exchange information

None Yes

Implement one clinical decision support rule and ability to track compliance with this rule

One clinical decision support rule implemented

None Yes

Implement systems to protect privacy and security of patient data in the EHR

Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies

None Yes

Report clinical quality measures (CQMs) to CMS or states

For 2011, provide aggregate numerator and denominator through attestation; for 2012, electronically submit measures. Note: NNOHA has proposed additional CQMs for consideration that are relevant to oral health.

None Potential

Objective Measure exclusiOn Dentist rOutine

Implement drug formulary checks Drug formulary check system is implemented and has access to at least one internal or external drug formulary for the entire reporting period

None Yes

Incorporate clinical laboratory test results into EHRs as structured data

More than 40% of clinical laboratory test results whose results are in positive/negative or numerical format are incorporated into EHRs as structured data

An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period

Yes – available via integration with an EHR (Intergy)

Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach

Generate at least one listing of patients with a specific condition

None Yes

Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate

More than 10% of patients are provided patient-specific education resources

None Yes

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*)

Objective (cOnt.) Measure exclusiOn Dentist rOutine

Perform medication reconciliation between care settings

Medication reconciliation is performed for more than 50% of transitions of care

An EP who was not the recipient of any transitions of care during the EHR reporting period

Potential

Provide summary of care record for patients referred or transitioned to another provider or setting

Summary of care record is provided for more than 50% of patient transitions or referrals

An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period

Potential

Send reminders to patients (per patient preference) for preventive and follow-up care

More than 20% of patients 65 years of age or older or 5 years of age or younger are sent appropriate reminders

An EP who has no patients 65 years old or older or 5 years old or younger with records maintained using certified EHR technology

Potential

Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies)

More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR

An EP that neither orders nor creates any of the information listed at 45 CFR 170.304(g) during the EHR reporting period

Potential

*PH* Submit electronic immunization data to immunization registries or immunization information systems

Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions)

An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically

No

*PH* Submit electronic syndromic surveillance data to public health agencies

Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data)

An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically

Potential

To be able to report on these objectives, it is essential that practices utilize an EHR. The CMS Medicare and Medicaid incentive programs provide a financial reward for the Meaningful Use of certified EHRs to achieve 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 providers in achieving the Meaningful Use objectives. In 2010, the ONC released this definition of “certified EHR technology,” “a Complete EHR or a combination of EHR Modules, each of which (1) meets the requirements 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 adopted by the ONC” (Federal Register, 2010).

For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.


currenT clinical QualiTy Measures For oral healTh

Dentists must report six CQMs that include three Core Set measures. The remaining three measures must be selected from a Menu Set of alternative measures. Clinical quality measure reporting is a requirement; however no thresholds must be met.

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 attest to the three required core, the three alternate core, and the three additional measures.

The following table lists the current CQMs:

cOre set Menu set

Clinical Quality Metrics 3 are required (select alternative core set measures if the core measure does not apply)

3 out of other clinical quality measures alternative measures are required

Current CQMs: Core Set Measures (must select 3 measures)

ePs Must rePOrt On three cOre set Measures Dentist rOutine

Hypertension: Blood Pressure Measurement Potential

Tobacco Use Assessment & Counseling Potential

Adult Weight Screening and Follow-up No

alternate cOre set Measures fOr ePs(substitute when any Of the abOve 3 DO nOt aPPly)

Weight Assessment & Counseling for Children and Adolescents

No

Influenza Vaccination for Patients > 50 years No

Childhood Immunization Status No

*An alternate core set of 3 measures is substituted for any of the 3 core metrics where the measure does not apply to the dental program. Clinical quality measure reporting is a requirement; however no thresholds must be met.

Current Menu Measures for All EPs (must select 3 measures):

In addition to the three CQM selections described earlier, providers will need to select 3 more measures from the current Menu Set of 38 CQMs on the next page.

Menu Measures nQf PQri

Pneumonia Vaccination for Patients 65 Years and Older 0043 111

Screening Mammography 0031 112

Colorectal Cancer Screening 0034 113

Cervical Cancer Screening 0032 —

Chlamydia Screening in Women 0033 —

Controlling High Blood Pressure 0018 —

Asthma: Pharmacologic Therapy 0047 53

Asthma Assessment 0001 64

Use of Appropriate Medications for People with Asthma 0036 —

Childhood Immunization Status 0038 —

Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 0055 117

Diabetes Mellitus: Urine Screening for Microalbumin 0062 119

Diabetes Mellitus: Hemoglobin A1c Poor Control 0059 1

Comprehensive Diabetes Care: HbA1c Control (


clinical QualiTy Measures For oral healTh

In Stage 1, the Core Set Clinical Quality Measures (CQMs) are not as pertinent to oral health as they could be.

NNOHA identified six measures that are particularly applicable to Health Center oral health programs (listed 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 Set Measures for Oral Health would be substituted when any of the current CQMs do not apply (please note: these measures are under review and have not been approved by CMS).

These CQMs for oral health would provide a significant step toward measurable, valuable, uniform clinical quality oral health measures across all Health Centers.

Additional Menu Set Measures for Oral Health

The current Menu Set of 38 items is not applicable for oral health programs. Measures that have been recently 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).

*For the definition of “Phase 1” treatment, please refer to the “Fundamentals” Chapter of the Operations Manual for Health Center Oral Health Programs: http://www.nnoha.org/practicemanagement/manual.html.

cOre set Measures nuMeratOr DenOMinatOr

4. Oral Cancer Risk Assessment & Counseling – Percentage of all patients who receive soft tissue screening, oral cancer exam and counseling.

The number of patients who receive soft tissue screening, oral cancer exam and counseling.

The number of patients who receive a comprehensive oral health exam (ADA code 0110) or a periodic recall (ADA code 0120) oral health exam during the report period.

5. Periodontal Disease Assessment – Percentage of patients age 18 years and older who have been screened for the presence of periodontal disease.

The number of patients age 18 years and older who have been screened for the presence of periodontal disease.

who have been screened for the presence of periodontal disease.The number of patients age 18 years and older who receive a comprehensive oral health exam (ADA code 0110) or a periodic recall (ADA code 0120) oral health exam during the report period.

6. Completed Comprehensive Treatment Plan – Percentage of all dental patients for whom the Phase 1* treatment plan is completed within a 12 month period.

The number of patients with a completed Phase 1 treatment within 12 months of initiation.

The number of patients that receive a comprehensive oral health exam (ADA code 0110) or a periodic recall (ADA code 0120) oral health exam during the report period.

Menu set Measures fOr Oral health nQf

Children who received preventive dental care 1334

Children who have dental decay or cavities (INCLUDED in STAGE 2) 1335

Primary caries prevention intervention as part of well/ill child care as offered by primary care medical providers (INCLUDED in STAGE 2)

1419

Total eligible patients who received preventive dental services (EPSDT) N/A

Total eligible patients who received dental treatment services (EPSDT) N/A

Percentage of new dental emergency patient visits (scheduled and unscheduled, walk-in)

N/A

Percentage of pregnant patients that receive an oral exam or preventive dental treatment

N/A

PrOPOseD tOP three alternate cOre set Measures fOr Dentists (substitute when any Of the current cQMs DO nOt aPPly)

Dentist rOutine

Annual Oral Health Visit Yes

Topical Fluoride or Fluoride Varnish Treatment Yes

Periodontal Disease Assessment Yes

PrOPOseD Other alternate cOre set Measures fOr Dentists Dentist rOutine

Dental Sealant Yes

Oral Cancer Risk Assessment & Counseling Yes

Completed Comprehensive Treatment Plan Yes

cOre set Measures nuMeratOr DenOMinatOr

1. Annual Oral Health Visit—Percentage of patients who had at least one dental visit during the measurement year (the last 12 months).

The number of patients with one or more dental visits.

The total number of registered patients at the Health Center.

2. Topical Fluoride or Fluoride Varnish Treatment – Percentage of patients age 14 years and younger with at least one topical fluoride treatment or fluoride varnish treatment documented (the last 12 months).

The number of patients age 14 years and younger with at least one topical fluoride or Fluoride Varnish treatment (ADA code 1203).

The number of patients age 14 years and younger who receive a comprehensive oral health exam (ADA code 0110) or a periodic recall (ADA code 0120) oral health exam during the report period.

3. Dental Sealant – Percentage of patients age 6 to 20 years that have sealants on 1st and 2nd permanent molars.

The number of patients age 6 to 20 years that received sealant treatment on 1st and 2nd permanent molars after examination.

The number of patients age 6 to 20 years who were treatment planned to receive sealants at the examination.


Please note the four oral health measures endorsed by NQF (Aug, 2011) are listed below.

■ Annual dental visit

■ Children who received preventive dental care

■ Primary caries prevention intervention as part of well/ill child care as offered by primary care medical providers (INCLUDED in STAGE 2)

■ Children who have dental decay or cavities (INCLUDED in STAGE 2)

All four measures need to be e-measure specified (Harris, 2011). An eMeasure is a health quality measure encoded 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 shown to have adequate rates of validity and reliability. NNOHA plans to move forward with plans to test these 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 2011 will have until 2014 to meet Stage 2 Meaningful Use standards and receive incentive payments. NNOHA and other key stakeholders endorse the new two following oral health measures for Stage 2 beginning with CY 2014:

■ NQF 1335: Title – Children who have dental decay or cavities.

■ Description: Assesses if children aged 1-17 years have had tooth decay or cavities in the past 6 months.

■ NQF 1419: Title – Primary Caries Prevention Intervention as Part of Well/Ill Child Care as Offered by Primary Care Medical Providers.

■ 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

to which each billing entity’s use of the EPSDT with FV codes increases from year to year (more children

varnished and more children receiving FV four times a year according to ADA recommendations for

high-risk children).

In the Medicare & Medicaid EHR Incentive Program Registration and Attestation System (the 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 for exclusions to specific objectives, and attest their eligibility by entering that data into the Attestation System. An EDR/EHR system must provide a report of the numerators, denominators and other required information.

To attest for the Medicare EHR Incentive Program in the first year of participation, a dentist will need to have met Meaningful Use for a consecutive 90-day reporting period. Incentive

payments for the Medicare EHR Incentive Program will be made approximately 4 to 8 weeks after a dentist meets the program requirements and successfully attests.

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 file will be placed into a pending status until the state’s program launches. Once registered, dentists can attest that they have adopted, implemented or upgraded certified EHR technology in their first year of participation to receive an incentive payment. Medicaid incentives will be paid by the states and are required to issue incentive payments within 45 days of dentists successfully attesting. Adopt, implement or upgrade means:

■ Adopt – Acquire, purchase or install a certified EHR system.

■ Implement – Install or commence use of certified EHR technology and have started one of the following:

• A training program for the certified EHR technology;

• Data entry of patient demographic and administrative data into the EHR;

• Establishment of data exchange agreements and a relationship between the provider’s certified EHR technology and other providers (such as

laboratories, pharmacies, or health information exchanges).

■ Upgrade – Expand the available functionality of certified EHR technology capable of meeting Meaningful Use requirements at the practice site, including staffing,

maintenance, and training, or upgrade from existing EHR technology to certified EHR

technology per the Office of the National Coordinator (ONC) EHR certification criteria.

Some examples of upgrading the existing EHR technology are the addition of clinical

decision support, e-prescribing functionality, and computerized physician order entry.

Several states are currently capable of supporting all activities related to participation

in the Medicaid EHR Incentive Program, including:

• Program eligibility • Registration • Attestation to adoption, implementation, and upgrade activities • Incentive program payments

In the first year of participation in the Medicaid EHR Incentive Program, dentists that choose to demonstrate

eligibility based on adopt/implement/upgrade (AIU) activities will need to attest to the following:

• 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 • Integration of certified EHR technology modules • Testing and training in the use of the certified EHR technology • Business process engineering to integrate the certified EHR technology into clinical workflow


As part of initial registration with the CMS National Level Repository (NLR), providers have the opportunity 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 EHR system is ultimately the responsibility of the provider. Providers will be instructed that it is their responsibility to maintain all applicable records to support their attestations for a period of no less than six years in the event of a post-payment audit.

To support attestations to AIU of certified EHR technology in the first year of participation in the Medicaid EHR Incentive Program, providers would supply documentation that demonstrates either a binding financial commitment or actual expenditures on adoption, implementation, or upgrade of the EHR technology. The documentation from an EDR/EHR vendor should include product name and version in such a way that it can be matched to a specific product or combination of products in the ONC’s web-based Certified HIT Product List (CHPL). The following documentation should be retained and produced upon request:

■ 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

■ Documentation of expenses incurred in development, testing, maintenance, and upgrade of custom certified EHR systems or modules

■ Proof of payment for professional services related to the selection, acquisition, installation, 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 certified EHR system

■ Documentation of expenses incurred in transitioning patient records to the certified EHR system

■ Contracts or proof of actual expenditures for testing and/or training for the certified EHR system

Note that the software must be in use in clinical practice to count as adoption as a part of meeting the adopt/implement/upgrade requirements. Centers should also be prepared, in the event of post-payment audit, to demonstrate that the certified EHR technology is actually in use in the clinical setting. For a detailed 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.

ehr selecTion

People sometimes use the terms “Electronic Medical Record” (EMR) or “Electronic Dental Record” (EDR) when talking about Electronic Health Record (EHR) technology. Very often an EDR or EMR is just another way to describe an EHR, and both providers and vendors sometimes use the terms interchangeably. For the purposes of 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 have been tested and certified under the Temporary Certification Program maintained by the Office of the National Coordinator for Health IT (ONC). Certified EHR technology gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.

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 features than others; some are more user-friendly, but none meets every need for Health Center oral health programs. The task becomes finding the best fit for each Health Center depending on their needs, current systems, and resources.

In general, EHRs, although not evaluated by this workgroup, are not considered to be dental friendly, especially when it comes to flexible scheduling or graphics. However, EMR products are well ahead of dental products in terms of tracking disease outcomes and diagnosis. This is because dental practices, with the exception of oral 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. While medical appointments may be slotted for 15 to 30 minutes, the appointment time for dental services vary with procedures, type of providers (general or specialist), and level of experience of the providers, such as new or seasoned graduates, students and residents.

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/.


edr/ehr selecTion Tool

Now that it has been established that electronic health records (EHR) are a key piece of Meaningful Use and the future of health programs in general, the next step for many entities will be determining the best technology for 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 (an eligible professional (EP)), in determining eligibility for the Medicare and Medicaid EHR incentive programs. The selection tool is available to NNOHA members and other key stakeholders on the NNOHA website: http://www.nnoha.org/practicemanagement/hit.html

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 EDR/EHR systems can achieve interoperability between EDR and EHR systems, meet national Meaningful Use objectives and are capable of reporting NNOHA’s proposed clinical quality measures for oral health.

The four vendors that have been included in this process for consideration are:

■ QSI/NextGen – QSI EDR and NextGen EHR.

■ Open Dental/eClinicalWorks – Open Dental EDR and eClinicalWorks EHR. Please note eClinicalWorks is a separate corporation.

■ Henry Schein/Vitera (formerly Sage) – Dentrix Enterprise and Sage Intergy EHR. Please note Vitera is a separate corporation and has a HL7 interface to Dentrix Enterprise.

■ Mediadent/SuccessEHS – Mediadent EDR and Success EHS EHR.

The selection tool also includes clinical, financial and administrative requirements that have been grouped into categories and a vendor solution cost assessment.

THE PROCESS

sTep 1: eliGiBle proFessional assessMenT

Each Health Center’s dentists should start by completing the eligible professional assessment and deciding to participate in Meaningful Use. The eligible professional assessment flow chart, below in Figure 1, will help determine if a dentist is eligible for the MU incentive and payment schedule shown in Figure 2.

Figure 1: Eligible Professional Assessment Map for Dentists

steP DescriPtiOn Of stePs

1 Eligible Professional Assessment

2 Vendor Background Information - Request For Information (RFI)

3 Review of Meaningful Use Core & Menu Set Objectives

4 Review of Meaningful Use Clinical Quality Measures (CQMs)

5 Vendor Response to Meaningful Use Certification and Reporting Measures

6 Vendor Response to NNOHA’s Proposed Clinical Quality Measures (CQMs) for Oral Health

7 Vendor Response to EDR-EHR Practice-Specific Requirements

8 Vendor Response to Qualitative Requirements

9 Vendor Response to Vendor Solution Cost

10 Vendor Selection Criteria and Summary Ratings

Verification of Provider Eligibility

After the dentist determines eligibility status, the process continues by applying for the Medicaid EHR Incentive Program by visiting the website of the CMS National Level Repository (NLR) and logging in with the required information, including National Provider Identifier (NPI) and CMS Certification Number (CCN). Visit the CMS site for more details: https://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage.

Were at least 30% of dental

services furnished to Medicaid patients

in an outpatient setting?

START HERE

NO

YES

NO

NO

NO

YES

YES

YES

YES

NO

Are you a Doctor of Oral Surgery or Dental Medicine?

Does your practice use an ONC certified EDR/EHR and report the core and menu

set measures?

By adopting, implementing or upgrading to or successfully demonstrating Meaningful Use of a certified EDR/EHR technology, you may be eligible to receive an incentive under the Medicaid EHR incentive program.

Do you practice predominantly

in an FQHC or RHC with a 30% needy individual* patient

volume threshold?

You are not eligible to receive

an EDR/EHR incentive payment under the Medicare

or Medicaid payment EHR

incentive program.

You are not eligible to receive

an EDR/EHR incentive payment under the Medicare

or Medicaid payment EHR

incentive program.

Do you treat Medicare

patients and bill Medicare Fee for

Service for patient services?

You are not eligible to receive an

EDR/EHR incentive payment under the Medicare or Medicaid EHR

incentive program.

By successfully demonstrating Meaningful Use of a certified EDR/EHR technology, you may be eligible to receive an incentive under

the Medicare EHR incentive program.

* section 1903(t)(3)(F) of the Act defines needy individuals as individuals meeting any of the following three criteria: (1) They are receiving medical assistance from Medicaid or Children’s Health Insurance Program (CHIP); (2) they are furnished uncompensated care by the provider; (3) they are furnished services at either

no cost or reduced cost based on a sliding scale.

ACROMONYMS:EDR: Electronic Dental RecordEHR: Electronic Health RecordFQHC: Federally Qualified Health CenterRHC: Rural Health Center

Meaningful Use Eligibility Flowchart

How to Use This Flow Chart: Doctors of Dental Medicine or Oral Surgery are eligible professionals (EPs) and may be eligible for EDR/EHR 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 NLR website will collect required information on the applicant, such as name, e-mail address, business address, telephone number, and the desired incentive program (Medicare or Medicaid, and state, if applicable). CMS will then transmit to the State a list of applicants who selected the Medicaid EHR Incentive Program, along with the CMS Certification Number (CCN).

2120

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 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 improve efficiency, understand the various deployment models (e.g. ASP – Application Service Provider, SaaS- Software-as-a-Service), and learn industry terminology. At least three EDR/EHR vendors should be considered for 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.

■ Company and Product Capabilities: – History of delivering EDR/EHR solutions

– Client base (# of organizations)

– Number of safety net/Health Center clients

– Largest client (number of connected sites and number of users)

■ Implementation and Support Services: Ask vendors to respond to the approach to define and implement systems to meet all requirements and resources assigned to customer support. Tools/approaches are

utilized to help diagnose and resolve customer issues, with remote diagnosis and on-site.

■ Compelling Reasons to Select Solutions: Ask vendors to provide reasons for selecting their EDR/EHR and imaging solution.

■ 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.

■ 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 4: reView oF MeaninGFul use clinical QualiTy Measures (cQMs)

Step four continues with an assessment of meeting specific Meaningful Use clinical quality measure (CQM) requirements that were discussed earlier in this paper. Dentists must report from the table of 44 clinical quality measures which includes, 3 Core Set, 3 Alternate Core Set, and 38 additional CQMs.

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. Dentists must report on the 3 Core Set CQMs. If a dentist reports “0”s for one or more of the 3 “Required Core” CQMs, he/she must then report on up to 3 Alternate Core CQMs. Therefore, dentists may have to report on as many as six Core CQMs.

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. Several dentists will find the measures not relevant to their patient populations. However, they must still report on 3 of these measures with numerators and denominators where possible and “0”s for the others.

Figure 2: Maximum EHR Incentive Payments (CMS, 2012)


sTep 5: Vendor response To MeaninGFul use cerTiFicaTion and reporTinG Measures

Step five ascertains if the vendor response meets Meaningful Use certification and reporting requirements. To 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 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 solutions for Health Centers. As previously mentioned, the four vendors that participated in the NNOHA HIT survey are as follows:

■ QSI/NextGen – QSI EDR and NextGen EHR.

■ Open Dental/eClinicalWorks – Open Dental EDR and eClinicalWorks EHR. Please note eClinicalWorks is a separate corporation.

■ Henry Schein/Vitera (formerly Sage) – Dentrix Enterprise and Sage Intergy EHR. Please note Vitera is a separate corporation and has a HL7 interface to Dentrix Enterprise.

■ Mediadent/SuccessEHS – Mediadent EDR and Success EHS EHR. Please note that other EDR/EHR vendors may meet Health Centers’ requirements and would be included in this step.

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.

sTep 6: Vendor response To nnoha’s proposed cQMs For oral healTh

The NNOHA HIT Workgroup identified six Core Set Proposed Clinical Quality Measures (CQMs) for oral health 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 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 (sage intergy)

Qsi eDr – nextgen ehr

MeDiaDent – successehs

OPen Dental – eclinical wOrks

Considering NNOHA’s proposed Clinical Quality Measures for oral health providers, would you be able to support the reporting of these sets of measures:

Annual oral health visit Yes Yes Yes Yes

Topical fluoride or fluoride varnish Treatment

Yes Yes Yes Yes

Periodontal disease assessment

Yes Yes Yes Yes

(cOnt.) Dentrix – ehr sOlutiOn (sage intergy)

Qsi eDr – nextgen ehr

MeDiaDent – successehs

OPen Dental – eclinical wOrks

Dental sealant Yes Yes Yes Yes

Oral cancer risk assessment & counseling

Yes Yes Yes Yes

Completed comprehensive treatment plan

Yes Yes Yes Yes

Children who received preventive dental care

Yes Yes Yes Yes

Children who have dental decay or cavities (INCLUDED IN STAGE 2)

Yes Yes Yes Yes

Primary caries prevention intervention as part of well/ill child care as offered by primary care medical providers (INCLUDED IN STAGE 2)

Yes Yes Yes Yes

Total eligible patients who received dental treatment services (EPSDT)

Yes Yes Yes Yes

Percentage of new dental emergency patient visits (scheduled & unscheduled, walk-in)

No Yes Yes Yes

Percentage of pregnant patients that receive an oral exam or preventive dental treatment

Yes Yes Yes Yes

Periodontal disease assessment

Yes Yes Yes Yes

sTep 7: Vendor response To edr/ehr pracTice-speciFic reQuireMenTs

This step compares the vendor responses to EDR/EHR functional requirements. The NNOHA HIT Workgroup members expanded the EDR/EHR functional requirements to more closely reflect the needs of Health Center providers and administrators. This is an initial set of EDR/EHR functional requirements.

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 programs to use in their system evaluation and selection process but they are not intended to be complete or inclusive. Customizing and prioritizing the requirements to meet the organization’s needs are essential. Meaningful Use and other qualitative requirements have also been included and specify criteria that can be used to judge the operation of a system or vendor. Non-functional requirements are often called “qualities of a system” (e.g., quality goals, quality of service requirements).


The Health Center would identify the gaps of the current system(s) and identify the final set of key capabilities 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 software selection team will better position the organization to control the selection process, rather than let software vendors dictate the needs.

Each of the four vendors responded to their company’s ability to meet the requirements and the results are presented in Appendix A2.

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 integral part of any EDR is digital radiography. Common questions include what changes should be implemented and when they should take place. The answer is “it depends.” There may be financial constraints that govern when particular hardware can be purchased and which hardware is within the budget for the digital conversion. Several sources are available that discuss the benefits of each of the radiography technologies available in the market place (Comparison Study of Dental Sensors: http://dentalsensorstudy.com/). The roadmap to full realization of EDR should include this important consideration and sequence.

Other questions that often arise for Health Centers are on the choice of hardware: laptops, tablets, desktops, thin clients, etc. Again the correct choice is “it depends.” Questions to consider include, Is the clinic space new 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? How will patient education be presented, and are ergonomic configurations for the equipment and set up addressed to minimize repetitive injuries? These decisions are universal for any Center contemplating this next step. Failure

to address them can result in costly work-arounds or re-configurations later.

Increasingly, Health Center oral health programs are operating outside the four walls of the traditional Health Center. Tele-medicine is becoming an important modality

of care. Dentists can consult with another specialist and determine an appropriate care plan rather than requiring the patient to move through multiple locations and appointments. Mobile equipment is allowing for care delivery in schools, senior centers, or other temporary spaces. With this trend of care provision, it is important to discuss the ease of operations and connectivity of electronic records 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 information be available at the point of care delivery? What are the infrastructure

requirements for such systems to operate seamlessly and reliably? What are the storage backup features? All these questions need to be carefully considered,

discussed and answered with the entire dental team before implementation.

sTep 8: Vendor response To QualiTaTiVe reQuireMenTs

This step requires the Health Center to review and rate the vendor response to other qualitative requirements listed in the table below. The Health Center would determine the vendor’s capability including EDR/EHR implementation, 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 other sources of information.

Approval ratings would be determined by the Health Center for each category that follows:

■ Implementation and Support Services: — Implementation: Vendor’s response to the approach to define/implement systems to meet

all requirements.

— Support: Vendor’s resources assigned to customer support. Tools/approaches utilized to help diagnose and resolve customer issues, with remote diagnosis and on-site.

■ Compelling Reasons to Select Solutions: — Vendor’s reasons for selecting their EDR/EHR and imaging solution.

■ Meaningful Use (MU) Plans: — Vendor’s response to plans to attain MU certification and provide tools, knowledge, and services

available to assist in attaining MU incentives.

■ 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.

■ 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, mapping

current system’s functionality to new functionality.

■ 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 compelling reasons why such purchasing approaches are valuable.

■ Demonstration of Vendor – EDR/EHR Capabilities: — Vendor’s response to demonstration script and presentation of company financial stability,

deployment time/effort/risks, customer references, EDR/EHR product features and functions

including interoperability, health information exchange and clinical decision support.

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 FutureGuide to the Future 26 27

sTep 9: Vendor response To Vendor soluTion cosT

The NNOHA HIT Workgroup requested pricing information from each vendor and that data is included in Appendix A4. The Workgroup did not provide ratings for this process step since

there are several different pricing models (e.g. monthly subscriptions, up-front license, special discounting and financing options), and recommends that the Health Center

carefully review each selection process while considering a vendor. The Workgroup does not recommend that price be the primary decision criteria; however it can be an important tie breaker. Additionally, having three or four vendors compete for business may create a more competitive pricing dynamic.

The RFI process should include a detailed price quote from vendors including deployment costs, maintenance and support costs and total cost of ownership costs,

inclusive of all costs associated with the system. This includes software licenses, interface development, special customization, support, training, and other fees. The vendor should

specify any networking or third-party hardware equipment needed to run the system. Recognize that there are many pricing options and it is important to compare responses on

an equivalent basis.

The sample vendor price-rating chart is located in Appendix A4 and suggested for Health Centers to use in evaluating vendor proposals.

sTep 10: Vendor selecTion criTeria and suMMary raTinGs

The online selection tool process continues with the calculation of the final ratings from steps 7, 8 and 9 based on vendor selection criteria and final team weights. A sample vendor rating chart is shown in Appendix A5. The highest rated vendor results indicate the preferred vendor solution for consideration that meets the given 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 workflow problems. Benefits include Meaningful Use incentive payments, improved patient care, streamlined workflow, and increased productivity.

Narrowing the list of EDR/EHR vendors is an important step. The Health Center should explain to the final list of vendors what is expected from them during the selection process and give them a timeline. Once the final 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 legal advice is strongly recommended. Several EDR/EHR vendor contracts contain basic information such as licensing, pricing, included services and support. Unlike a standard contract, an EHR vendor contract typically includes complex legal language related to Health Insurance Portability and Accountability Act (HIPAA) Business Associate agreements, indemnification, and other non-EHR related terms.

Most contracts presented by EDR/EHR vendors are written to protect the vendor and not the Health Center. The Center should request language changes to make the intent of the contract more “equal;” however, some vendors may not be flexible about language changes. There are several areas that the organization should review closely such as “auto-renew” clauses and a potential “out clause” if the vendor does not meet contract terms and conditions.

Prior to making a final decision, ensure the team has thoroughly scored and ranked the vendor solutions that have been evaluated. Request the leading vendor candidate to provide at least two customer references that are very similar to the practice specialty and user needs/requirements. Typical questions to ask the references include, the challenges they faced during implementation, the responsiveness to service and support issues, end-user satisfaction, and access to user groups. Note, service and support issues should be explored fully especially when there are several vendor systems and components. The Health Center should be clear about what vendor organization is responsible for responding in a timely manner to system problems.

FINAl CHECk lIST:Additionally, as a good reminder, the following checklist

should be considered and updated during the selection

process for an EDR/EHR.

■ Define EDR/EHR system and Meaningful Use (MU) requirements

■ Clinical and care management and treatment planning requirements

■ Front-office requirements (on premises)

■ Back-office requirements (billing and finance)

■ Image capture equipment

■ Integration among above

■ Identify key stakeholders & decision makers

■ Develop business model and Return on Investment (ROI)

■ Estimate funding needs and other key resources

■ Identify alternative vendors

■ Research basic and advanced software capabilities

■ Vendor selection

■ Request for Information (RFI)

■ Define criteria for selection

■ Demonstrations/Presentations

■ Check references/Site visit

■ Evaluate and select the best alternative

■ Negotiate the best deal possible

■ Request a detailed price quote

■ Provide necessary data for a price quote

■ Ensure quotes are complete: software, service, training, etc.

■ Compare all quotes on an equivalent basis

■ Request the vendors’ software license agreement (SLA)

■ Financing

■ Philanthropy sources

■ Meaningful Use incentives

■ Capital and operational funds


discussion on use oF edr/ehr selecTion Tool, Vendor’s selF scorinG and General disclaiMer

The ultimate decision on EDR/EHR vendor selection lies within the Health Center and their due diligence processes. While most Health Centers function within predetermined criteria, there are unique factors that may lead a Health Center to choose one vendor over another. NNOHA has identified several products that meet the unique criteria of Health Center oral health programs; all vendors presented here are already in full use at Health Centers across the country. The question that remains to be answered, is which product will be the best match for a particular Health Center.

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 and few vendors have achieved ONC certification from an ONC-Authorized Testing and Certification Body (ATCB); however some vendors have plans to meet Meaningful Use requirements in the near future (NORC, 2011).

With the integration of medical and dental programs, Meaningful Use requirements, and patient-centered medical home initiatives, the selection of the electronic health record system is shared between the various departments. Additionally, clinical departments as well as their support systems such as the finance, information technology, and practice management departments should all participate in the selection of the product that 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 features become available, portions of or scoring in this report will become outdated.

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 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.

Demonstrations will certainly lead to discussions on how a particular technology can be incorporated into the work flow and physical configuration in a particular operatory. Reviewing demos is perhaps the most critical step in the software selection process. Health Centers should provide each vendor with a few “demo scripts” to detail specific workflows (e.g. patient registration, charting, and billing) that they want to see in the demo. For each vendor, the review team could use a “demo scorecard” to record the evaluation. Some questions might include: What are the 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?

Another example of a demo script could be the reporting or billing structure. All systems can bill for their services, but the pathway, checks and balances, and numbers of clicks needed to get a claim out the door vary. All systems have the ability to report on the data they collect, but for many the raw data is imported into reporting software 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 billing data. Many times these database structures do not lend themselves to reporting efficiency. Data warehousing and tools designed specifically for reporting needs improve these capabilities. Again, the Health Center should be asking the vendor to demonstrate key features, improvements in workflows and all Heath Center key decision makers should be involved.

challenGes selecTinG and iMpleMenTinG an edr/ehr soluTion

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.


■ ePrescription (computer-generated prescriptions created by the health care provider and sent directly to the pharmacy) is an excellent tool for all providers but it may not be an incentive for practices in

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 manufacturers are striving to easily interface with ANY EHR system. Digital X-Ray integration with

EDR products may still be an issue to consider.

Ideally, the oral health program should be able to select its own EDR product that serves the needs of the dental providers and, the decision of an EDR product should not depend on the selection of an EMR on the medical side. Dental Directors will have to use persuasive skills to ensure that the clinical, financial and administrative requirements of the oral health program are included with medical requirements of the Health Center.

These are only a few key challenges facing a Health Center. This white paper provides a strategic framework for selecting an EDR/EHR system and moving forward to achieving Meaningful Use of EDR/EHR systems.

edr/ehr iMpleMe

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