Proponents of electronic health records (EHRs) have long touted the merits of digital versus paper records -- and yet, adoption among dentists and physicians remains low. A recent study in the Journal of the American Dental Association (December 2008, Vol.139:12, pp. 1632-1642) suggested that usability, especially for first-time users in solo or small group practices, is the culprit.
Some medical professionals, however, say the real issue is patient privacy, while others argue that the systems on the market don't always offer a clear return on investment (ROI).
"The many benefits that are possible from data mining interoperable EHRs will never be attained if patients or doctors don't trust the security," Darrell Pruitt, D.D.S., of Fort Worth, TX, and a prolific online commentator about EHRs told DrBicuspid.com in an e-mail. "If the stakeholders roll out a product that disrespects patients' rights to privacy, Americans will never trust EHRs, and all the magic that could benefit our grandchildren will never be realized."
— U.S. Department of Health and Human
Services Secretary Mike Leavitt
Deborah Peel, M.D. -- past president of the Texas Society of Psychiatric Physicians who has been in private practice in Austin for more than 30 years -- has become a vocal opponent to EHRs for just this reason. Her advocacy group, Patient Privacy Rights, claims that employers could use medical records to decide whether someone gets a job, and bankers could think twice about giving cancer survivors loans or mortgages.
"With electronic health records, the risk to patient privacy is real," the organization stated in a recent press release. "Existing laws do not go far enough. Today, 4 million providers and their employees decide when, where, and who gets your sensitive health data, not you, and electronic systems are not secure. Meanwhile, Americans' personal health information is worth billions. It is the perfect storm for massive privacy violations that will ultimately lead to discrimination by employers, insurers, banks, and more."
Just last October, in fact, more than 300,000 dental records at the University of Florida College of Dentistry were "hacked" by what university officials say was "an unauthorized intruder." Information stored on the school's server included names, addresses, birth dates, Social Security numbers, and, in some cases, dental procedure information for patients dating back to 1990.
"Our university, as with any university or college, is constantly under attack by people trying to find and exploit potential weaknesses in our IT security defense mechanisms," Charles E. Frazier, the university's interim chief information officer, said in a press release when the security breach was first discovered. "It is a sophisticated and never-ending 'cat and mouse' battle in which sometimes the mouse wins."
The issue is so important that the U.S. government has now stepped in. After U.S. President-elect Barack Obama announced last month that healthcare IT -- including spurring EHR adoption -- will be part of his multibillion-dollar U.S. economic stimulus package, Department of Health and Human Services (HHS) Secretary Mike Leavitt unveiled eight "privacy principles" for electronic patient data, ranging from ensuring that consumers are provided with "simple and timely means" to obtain and correct personal health information to putting limits on the collection, use, and disclosure of that information.
"Finding the balance between increased access to information and privacy is very important," Leavitt stated in a press release on December 15. "If we don't have it, we won't succeed."
Return on investment
While patient privacy is clearly a major hurdle in the transition to a "paperless" office, some practitioners are also daunted by the cost. A typical practice management system -- of which clinical records are one component -- can cost $30,000 to $40,000 to implement, according to some estimates. (Martin Jablow, D.M.D., believes you can spend half that and still set up a fully functional computerized office. Read more.)
"The issue is that only 25% of dental offices have computers in their operatories, and you cannot manage a practice [digitally] unless you have computers in all of your operatories," said Tom Cockerell, D.D.S., a practicing dentist in Fort Worth, TX, and founder of an Internet-based patient record system company called Dental Symphony. "And they have to be up-to-date and have good monitors and operating systems and switches and routers. Your office has to be set up well to do electronic effectively."
Another reason for low EHR adoption among dentists is that half the systems as they exist now are not very helpful and do not take advantage of higher-order computing systems, Dr. Cockerell added.
"The key is that computer applications are not very good as they exist now," he said. "They are really good at appointments and scheduling and bringing in digital radiography, but that's it. Otherwise they are clunky and slow and expensive. That is the reason most dentists have not shifted over. Why would I spend $30,000 outfitting an office when the product is hard to navigate and it is difficult to see how you are helping patients?"
Dr. Jablow agrees.
"The problem with legacy software is that it has to support everything before it instead of the way we need things done today," he said.
Some software developers are attempting to close the gap with products that take advantage of newer technologies and platforms and are more affordable. MacPractice, for example, offers Mac-based applications for dental practice management and patient charting that visually mirror paper charts, utilizing many of the icons and data flow already familiar to Mac users at a cost of $1,500 for the dental package. Meanwhile, Dental Symphony offers a modular, Internet-based dental patient record system with virtual (online) patient interviews, automated clinical reports and treatment planning, a medical and drug library, and Google-type tab and search features -- all for a subscription fee of $50 to $100 a month and no need to install a local area network (LAN) server.
Such approaches may help facilitate the development of a combined medical/dental record that both physicians and dentists could more easily adopt and share information through. That's the goal of Valerie Powell, Ph.D., a computer professor at Robert Morris University in Pittsburgh, PA, who co-authored a 40-page report on interoperable EHRs that was recently submitted to Tom Daschle, the nominee for HHS secretary under Obama.
"Our nation needs excellent chronic care, and I have a vision of dentistry contributing in much more significant ways to the overall health of our society," she said.
Still, some dentists still feel EHRs in general pose too much risk.
"Love of technology should not blind doctors of the potential harm that may result from a universal, portable health record that follows the patient, as well as a slew of other, unknown prying eyes," Dr. Pruitt stated recently on the DrBicuspid.com Forums. "After all, the welfare of our patients should be our primary driving motivation."
Dr. Cockerell takes a more optimistic view of the potential impact of EHRs.
"I certainly understand and respect that there has to be a way to preserve everyone's privacy here, but I see it as a task and a challenge rather than a barrier," he said. "Those who believe EHRs don't make patient care better are very wrong. They improve access and speed and provide comparative data. We need this technology not just for reasons of productivity but for evidence-based research."
Powell believes the issues run much deeper.
"I am calling for a new, improved model of healthcare so that EHRs will have an improved model," she stated recently on the DrBicuspid.com Forums. "It is actually an objection to and rejection of electronic health records as they are currently being developed, implemented, and sold to medical and dental providers. I object to a flawed healthcare system in which a patient receives care in two inadequately articulated 'care streams' -- one medical and one dental. Creating two streams of electronic records will only replicate the currently flawed model of healthcare."
