What Are the Features a Dentist’s EHR or EDR Must Have? Electronic Dental Record or EDR can meet the expectations and needs of a dental practice only if it possesses basic features and the data within the system is accurate. With the entry of speech recognition systems, medical transcriptionists have started wearing the cap of editors and performing a more important role. The process of electronic documentation is widely adopted in the United States, owing to its capability of speedy delivery of information and EHR incentives. However, dentists are a group still concerned about their present practice management and dental charting systems. They don’t necessarily bring together all the information these practitioners require to do their work, or make suggestions regarding the best practices for the treatment of their patients. Many dentists complain that it is really frustrating to try out different software in an attempt to find one that has everything they want. There are many practitioners who would rather stick with the practice of dictation and dental transcription. Let’s consider the features a dentist’s EHR or Electronic Dental Record (EDR) must have.
As the technology is fast growing, the capabilities of EDR will evolve over time. There are some basic features though that a dentist may always want to request and evaluate for themselves. Those features are as follows:
Digital Dashboard – A digital dashboard is where all the critical clinical information regarding a patient is aggregated on one screen in a summary form. The format of this screen would be customizable according to the needs of the dentist.
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Structured Data – Your system must have the ability to enter information into the progress notes in a structured manner instead of simply entering free text. This capability is sometimes referred to as ‘point and click’. A dentist can more easily categorize and identify critical information with structured data. It is also very easy to search and report on the information required if the data is kept in a structured way.
Isolation – The system should have the ability to isolate and send those portions of the dental chart that are relevant to the consulting specialists. Sometimes, the chart can be full of information which is not really relevant to the specialist’s requirements for treatment.
Image Integration – There should be integration of imaging within the patient chart. With this, dentists can avoid shuttling between one system and another to accommodate charting and reviewing images simultaneously.
Treatment Protocols and Planning Recommendations – Evidence-based treatment protocols and planning recommendations should be included in the system. This should be updated in real time as well.
Real-time Education Materials – Your EDR system should be able to show patient education materials to patients in real time according to the diagnoses. This will help dentists to engage in a conversation regarding the proposed treatment more effectively.
With these features, EDR will help dentists in efficient management of workflow, clinical documentation and treatments. However, until dentists think about all the steps within their workflow and patient care, and understand how these features can support these steps, they won’t get an EDR system that meets their expectations or needs. Importance of Quality EDR Data Not only must the dentist have a clear understanding about the workflow and capabilities of their EDR, but they should also ensure the quality and completeness of data within the system. The
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dental record must be authentic, accurate, legible and objective with individual records for each patient. Chart entries should include the initials or name of the individual who is making the note. Abbreviations should be standardized as per the practice. Risk management experts recommend a problem-oriented record since it produces a list that includes medical considerations, psychological/behavior constraints, and the oral health needs to be addressed after data collection. When problems are listed according to their importance in a standardized manner, it will help to avoid overlooking a particular area. Depending on the treatment, there must be specific details within the system. For example, the American Academy of Pediatric Dentistry (AAPD) provides some general recommendations on the documentation of orthodontic care. The signs and/or symptoms of TMJ disorders should be recorded when they occur before, during or after orthodontic treatment. During the treatment, the progress notes must include deficiencies in oral hygiene, patient complaints, loose bands and brackets, caries, root resorption and cancellations and failures. Role of Dental Transcription Electronic dental records are prone to several challenges that affect the integrity and accuracy of dental data. Transcription remains a good option to input correct information into the system. The challenges with EHR are:
EDR templates may have a limited number of selections which result in reducing the specificity of patient’s details. This will have a severe impact in case of complex cases.
Duplication (known as copy pasting, copy forwarding and cloning) can speed up the documentation process since dentists can quickly input the information into similar records without spending time to check the details. However, if your organization is not limiting this practice with proper guidelines, there is the possibility that practitioners may frequently copy-paste data to save their time and create data errors.
Many providers may use voice recognition software for inputting information into the EDR without validating the dictation for quick documentation. Even with the perfect speech recognition software, there may be errors due to difference in the voice of the
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dictator caused by particular reasons (for example, cold) or noise. Data entered without validation can result in grave errors. Medical transcription companies offer EHR/EMR transcription – practitioners can still dictate their notes, and then upload them to the transcription firm’s online platform. The company’s transcriptionists will transcribe the notes and then send them for quality review. After this, the files are uploaded to their online platform from where they can be immediately imported into the dentist’s EMR system. Dental practitioners can use the transcription company’s platform to edit, print, e-sign, and auto-fax the documents before importing them into the electronic medical record system.
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