Electronic vs. traditional recordkeeping

Aug. 1, 1996
Similar rules apply to both systems. For now it`s imperative to understand their strengths and limitations.

Similar rules apply to both systems. For now it`s imperative to understand their strengths and limitations.

Scott R. Green, DMD

Dentists are incorporating a variety of high-technology options into their offices. The ADA estimates that over 70 percent of the 150,000 dentists in America have computers. Many use intraoral cameras, digital radiography, occlusal analyzers and CD-ROM patient-education systems. Some offices are doing electronic charting, voice-recognition charting, electronic periodontal probing and are keeping electronic treatment notes. Some dentists are using the World Wide Web to communicate with other dentists all over the world, sending text and images. Confidentiality and security must be considered.

The American Dental Association is helping create the standards outlining the elements that make up the electronic patient health record. Until a defined standard exists, the dentist has to rely on available software. Each dentist chooses which hardware and software to include in his/her office. The instruments may be individual or networked. Integration of all the pieces is a difficult task. Some vendors create strategic alliances with other companies to ensure that the pieces will work together. Others require custom programming and bridges. The dentist may decide to only computerize front-office tasks, put computers in the operatories or network all the different elements together in a cohesive integrated, electronic patient health record.

Dr. Duane Schmidt is the managing general-practice dentist of a large group practice in Cedar Rapids, Iowa. His office is running Dentech software to manage the financial records of over 40,000 patients. His staff of 34 includes five dentists and six hygienists. The record contains treatment notes, "a standard block of words with inserts for personalization about many different procedures; for example, 24 different hygiene clinical notes." Dr. Schmidt is working on expanding his system to include charting and computer dental radiography in a network. "While it works fine, it doesn`t come up to my speed expectations, so work continues," he says.

Dr. Daniel Martinez is from Albuquerque, New Mexico. "Currently, I`m using the AcuCam and DentalMac as my image-management `team.` The computers are networked throughout the office, and the AcuCam unit is rolled into the operatories as needed and hooked up to the S-Video port of the Macs. DentalMac F/X has image-management software built in. Confidentiality is part of the system and these images are part of the patient record."

Dr. Glen Blanchard is from Carrollton, Texas. His network is running PracticeWorks, a Windows-based program. The associated program Chart-Works contains an electronic chart and images. These images may be full-facial photographs, intraoral views or digital radiographs. They are captured by the different instruments, converted to digital format and stored in the networked computers. "We do keep extraorals (portraits). We will start keeping intraorals soon," as soon as he has a computer in each operatory.

Dr. Bob Davis of Watsonville, California, uses Dentrix 5.0 on a network, including computers in the operatories. "I started with patient education, graduated to doing many treatment plans with an assistant right on the mouse, clicking in the treatment as I spoke, and did intraoral images or a videotape. Hygiene is doing perio-probe readings the same as treatment plans. One person greets the patient, seats, assists with the procedure, makes the next appointment at the chair, handles any financial details (also at the chair, which has increased our rate of payment) and the patient walks out smiling." Dr. Davis has an intraoral camera, but has, to date, elected to keep the video images separate from the chart and makes prints as needed. He uses Schick digital radiography on a separate computer with a one gigabyte hard drive to store the over 700 Mbs of radiographs he already has collected. "I want five years` worth of X-rays accessible at the click of a mouse. Then, I will consider archiving if I have to."

Dr. George Hetson of Kent, Connecticut, has networked his five office computers. His practice-management system, Easy Dental, is a basic DOS version. He says, "I use two of my computers for the Schick system. I have two dentists in our practice and two part-time hygienists. I have had the Schick system for 17 months. I currently have five gigabytes of uncompressed images. People need to know more about the hard-drive storage demands of systems like this so they can plan how to deal with this enormous data-generation problem." Every computer in the office has a large hard drive to store all the large image files.

Each of these dentists has embarked on the path of integrating new high technology into his practice. Each has unique needs and priorities. In every case, the number of patients and the amount of data in each electronic record produces data-storage concerns. Image files may be very large. All the data must be protected. Hard drives crash. Network data disappears. Computer owners know the importance of backing up data and using passwords. Many back up on a set schedule, others do it on intuition and others never get around to it. When your data disappears, you are lost.

Storing data can take a significant amount of time, fre-quently a few hours. Many offices schedule the process during slow times, or times out of the office. The data transfer rate of the backup system used and the amount of data to be backed-up determine the actual time involved. Files may be set up to separate the actual programs from the data. Processing only the data will make the operation faster. The data may be compressed for either space or speed. There also is the option of a total backup (copying all the files) or a modified file backup (ignoring the files that have not been changed). The dentist needs to check with the software provider to review the product recommendations and protect accuracy, especially of images. The program will be inaccessible during the backup. The backup utility software also should have a compare option to confirm that the backup copy is accurate. This may double the processing time.

Dr. Duane Schmidt`s office has many charts. They contain text, but no images. His patient-management system is "is passworded so we can keep people in or out of anything. Our system closes each evening and all data is locked in place so it cannot be changed. You cannot, therefore, alter a record, only add to it. Thus, our records are unadulterated." His office does a tape "backup every night, automatic." The new "backup is taken each night to a different staff home." There are five tapes, one for each day, each in a different place. They back up "all patient data, no programs."

Dr. Daniel Martinez uses a 270 Mb Syquest cartridge drive. "A Syquest backup is essentially a removable hard drive. Backups are done daily, including the image data. I also duplicate the server`s data to another machine on the network on a daily basis, automatically (scheduled) at about 7:30 p.m. Once a case is completed, the images are downloaded off the server to Syquest cartridges, which are cataloged, to keep hard-disk space available. I use a different set of cartridges for each day, thus I have a previous week`s worth of data at any one time. Also, a yearly archive is made and taken off-line and stored indefinitely. The number of backup options these days actually is rather phenomenal as one also can use CD-ROM and optical systems which provide for gigabytes of storage."

Dr. Glen Blanchard has "a batch file that the staff utilize at the end of each day. At the touch of a key, the appropriate directories get copied from the server to a workstation, and then the server gets backed up onto tape. My office manager pushes the correct key and then leaves for the day. So, one workstation and the server are left on all the time (monitors are turned off) in order to perform these functions. Each morning, she takes the tape from the previous night and puts it in her purse (she removes the tape that was in her purse and puts it back into circulation). We have approximately eight tapes that run through this cycle. The two PCs each have a U.P.S." They back up "about 230 megabytes to tape daily. We also have two tapes that we use to back up our images. Images are not part of our daily backup as this directory will get quite large. Since images are not absolutely critical, we back up these over lunch twice per week (not daily). We currently are backing up about 20 meg of images twice per week, in addition to the 230 meg mentioned above, which is done daily. I currently am running two 540 meg hard drives on my server. These are set up to mirror one another. This is another backup."

Dr. Bob Davis uses a tape backup. He says he "lets it run overnight. It takes about an hour, so sometimes we do it over lunch." He has a separate "set of tapes for every day of the week. We retire the lowest number at the end of each month. Those are stored at my house. I usually have one in my briefcase. We are running Novaback software for Win-dows. Schick uses it, too. It has a built-in checking utility, which tells you at the end that the backup was completed. We do a complete backup at present. Dentrix uses a Zip utility onto floppies. It now takes three floppies after two years, since it is compressed." During the backup, "we can do other functions, such as word processing, but need to be out of Dentrix on all stations."

Dr. George Hetson does "a scheduled modified backup everyday. I do a full backup once a month. All are done with auto compare. I keep three sets of archived, full backups and I do the full at the end of the month."

Some dentists are creative in storing the backup tapes of disks. Many take them home or send them home with a staff member. Dr. Bob Davis says, "The ones in the office are in a fireproof safe." Dentists concerned with preserving evidence for potential litigation have been known to send backup tapes to themselves, or an attorney, in a sealed, dated envelope.

Clinical management software needs to address this concern of documentation and security. Dr. Donald Collins, manager, ADA Council on Dental Practice, states that "electronically kept records" and those "requiring a correction to a completed entry, should 1) permanently retain the original entry; 2) automatically generate and link a dated audit trail to the authorized person making the change(s); 3) include the change(s); and 4) automatically prompt for a reason(s) for the change." He also is concerned that there need to be "system safeguards for security, which is safety from loss or damage to data; and integrity, which is prevention of random data loss during collecting, storage, retrieval or during transmission; and access, which is authorized availability, convenience, reliability and ease of data use."

Joel Kozikowski, senior programmer at Integrated Dental Technologies (IDT)/Practice Works, says, "Both PW Office Management and Charting use an entry date/service date concept to provide an audit trail and to prevent record alterations and/or forgery. Each transaction, be it financial or clinical, is stamped with the date the user said the transaction occurred (the service date), and the date the entry was actually made (the entry date). Any back-dating of transactions, then, are exposed by the recent entry date. If a record is `removed,` it is marked as `corrected` and is not physically removed from the file. If a record is `changed,` the old record is `removed` using the above method, and the corrected entry is put in the file with a service date of the original entry, but an entry date of today. Currently, anyone in the office can make these corrections. Version 4.0 (currently in development) will have a complete password security and auditing system that will allow the doctor to review or prevent alterations."

Drs. Blanchard and Martinez are active on the Internet. They both get involved in discussions relating to specific patients. The Internet groups frequently are used as study groups and a source for second opinions. Dr. Blanchard says, "I discuss things that happen in the office from time to time, but I do not use the names of patients in my discussions."

The legal issues of security and confidentiality of electronic records are being tested in the courts. According to Michele Thorne, Assistant General Counsel to the ADA, Division of Legal Affairs, "The concerns are similar with paper and electronic records.

"The electronic technology is newer and less tested. You need at least the same protections with electronic records that you have with handwritten records." She feels that, "It may still be safest to have a nonelectronic form of patient record for a number of reasons: (1) In some states, there may be `quill pen` laws that require ink entries in patient records. The doctor should check out the laws in his/her state. (2) Another concern relates to confidentiality and security. The doctor has an ethical and legal duty to keep patient-health-care information confidential. A doctor who wants to keep electronic patient records can check with the software company to determine the extent of the confidentiality and security protections in the software. For example, are passwords required to access the records? (3) Authentication of records is important from a malpractice standpoint. What if the records are used as evidence in court? How can each record be `authenticated?` Did the doctor himself complete the record? On what date were entries made? (4) If you use an informed-consent form, how would that be done electronically? How would you be sure the signature is authentic? Is there, for example, an encryption technique that can be used? (5) Will the electronic record meet the state record-retention requirements?" Ms. Thorne recommends, "If you want to keep electronic records, it is a good idea to discuss the matter first with your dental board, your attorney and your malpractice insurer."

The electronic patient record has input from many health-care providers. Currently, hospitals and multidentist offices are concerned with a mechanism to authenticate the individual creating each entry. Dr. Collins says that software design "priority should be given to a unique identifier or digital signature." Many states now allow this if a hard-copy signature is on file.

The rules that apply to both electronic and traditional records are similar. Electronic recordkeeping has some unique concerns. For now, it is imperative that dentists understand the strengths and limitations of existing systems, work with their software companies to provide adequate documentation and confidentiality, check their state laws and use common sense to protect themselves, their patients and their records.

A general dentist in Frenchtown, MT., he writes and lectures on computer applications and the Internet. President of Scott Green-On-Line, he provides consulting, development and beta-test services for companies on the World Wide Web. He may be reached at 406-626-4337 or [email protected].

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