Version 2.0. Guide To The Future:

Transcription

1 Version 2.0 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

2 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 Clinical Quality Measures for Oral Health EHR Selection EDR/EHR Selection Tool Step 1: Eligible Professional Assessment Step 2: Vendor Background Information Request for Information (RFI) Step 3: Review of Meaningful Use Core & Menu Set Objectives Step 4: Review of Meaningful Use Clinical Quality Measures (CQMs) Step : Vendor Response to Meaningful Use Certification and Reporting Measures Step 6: Vendor Response to NNOHA s Proposed CQMs for Oral Health Step 7: Vendor Response to EDR/EHR Practice-Specific Requirements Step 8: Vendor Response to Qualitative Requirements... 2 Step 9: Vendor Response to Vendor Solution Cost Step 10: Vendor Selection Criteria and Summary Ratings Discussion on Use of EDR/EHR Selection Tool, Vendor s Self Scoring and General Disclaimer Challenges Selecting and Implementing an EDR/EHR Solution EDR/EHR Implementation Strategies Conclusion: A Strategic Pathway to the Future Appendix A1: Meaningful Use Vendor Survey Responses Appendix A2: Rating Chart: Vendor Response to EDR/EHR Practice-Specific Requirements Appendix A3: Rating Chart: Vendor Response to Qualitative Requirements... 2 Appendix A4: Rating Chart: Vendor Response to Vendor Solution Cost... 3 Appendix A: Rating Chart: Vendor Selection Criteria and Summary Ratings... Appendix A6: Vendor Background Information and Evaluations... Product Name: QSI Dental Electronic Dental Record (EDR)... 7 Product Name: Dentrix Enterprise/Sage Intergy Product Name: Mediadent Product Name: Open Dental and eclinicalworks Appendix B: Sources of Information/Additional Resources Appendix C: Glossary Appendix D: References Appendix E: Credits National Network for Oral Health Access, August 2012 The 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. 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. 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. This publication was supported by Grant/Cooperative Agreement #U30CS0974 from the Health Resources and Services Administration (HRSA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA. 1

3 Meaningful Use For Oral Health Background One only has to listen to the news or pick up a journal to know that the United States health care delivery system is highly fragmented. Dentists, physicians, and other health care specialists utilize separate records with patient s health information residing in a broad mix of paper charts, ancient legacy systems, new web-based tools, and everything in between. This variation has resulted in a lack of coordination and effective data sharing among dental and other medical professionals, negatively affecting patient care. As a result, the federal government has invested billions of dollars to create a health information technology infrastructure. One important component of this support is the creation of financial incentives (stimulus funds) to encourage eligible professionals (EPs) and health care organizations to implement and use electronic health records (EHRs) effectively using a concept referred to as Meaningful Use. NQF 133: Title Children who have dental decay or cavities. 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: 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. 2 3

4 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 $63,70 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 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). 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 7% 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). 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 4

5 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. meeting the Meaningful Use requirements). The exclusion requirements for each objective are available at CMS s website link: 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 0% 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) Maintain up-to-date problem list of current and active diagnoses More than 0% of patients 2 years of age or older have height, weight, and blood pressure recorded as structured data More than 80% of patients have at least one entry 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 None Yes: Blood pressure No: Other vitals Yes 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. Maintain active medication list Maintain active medication allergy list Record smoking status for patients 13 years of age or older More than 80% of patients have at least one entry recorded as structured data More than 80% of patients have at least one entry recorded as structured data More than 0% of patients 13 years of age or older have smoking status recorded as structured data None None An EP who sees no patients 13 years or older Yes Yes Potential 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 Provide patients with clinical summaries for each office visit On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies) Clinical summaries provided to patients for more than 0% of all office visits within 3 business days More than 0% of requesting patients receive electronic copy within 3 business days An EP who has no office visits during the EHR reporting period 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 Potential 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 1 required Core Set objectives and 10 additional Menu Set objectives. CMS states that, To qualify for an incentive payment, 20 of these 2 objectives must be met. There are 1 required core objectives. The remaining 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 Generate and transmit permissible prescriptions electronically Computer provider order entry (CPOE) for medication orders More than 40% are transmitted electronically using certified EHR technology 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 An EP who writes fewer than 100 prescriptions during the EHR reporting period Potential Potential 6 7

6 Objective (cont.) Measure Exclusion Dentist Routine Implement drug-drug and drugallergy 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 Implement one clinical decision support rule and ability to track compliance with this rule Implement systems to protect privacy and security of patient data in the EHR Report clinical quality measures (CQMs) to CMS or states Perform at least one test of EHR s capacity to electronically exchange information One clinical decision support rule implemented Conduct or review a security risk analysis, implement security updates as necessary, and correct identified security deficiencies 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 None None None Yes Yes Yes Potential An EP must report on out of 10 Menu Set objectives; 1 of the must be a Public Health Objective (designated as *PH*) 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 Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Use EHR technology to identify patient-specific education resources and provide those to the patient as appropriate More than 40% of clinical laboratory test results whose results are in positive/ negative or numerical format are incorporated into EHRs as structured data Generate at least one listing of patients with a specific condition More than 10% of patients are provided patient-specific education resources An EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period None None Yes available via integration with an EHR (Intergy) Yes Yes Objective (cont.) Measure Exclusion Dentist Routine Perform medication reconciliation Potential between care settings Provide summary of care record for patients referred or transitioned to another provider or setting Send reminders to patients (per patient preference) for preventive and follow-up care Provide patients with timely electronic access to their health information (including laboratory results, problem list, medication lists, medication allergies) *PH* Submit electronic immunization data to immunization registries or immunization information systems *PH* Submit electronic syndromic surveillance data to public health agencies Medication reconciliation is performed for more than 0% of transitions of care Summary of care record is provided for more than 0% of patient transitions or referrals More than 20% of patients 6 years of age or older or years of age or younger are sent appropriate reminders More than 10% of patients are provided electronic access to information within 4 days of its being updated in the EHR Perform at least one test of data submission and follow-up submission (where registries can accept electronic submissions) Perform at least one test of data submission and follow-up submission (where public health agencies can accept electronic data) An EP who was not the recipient of any transitions of care during the EHR reporting period An EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period An EP who has no patients 6 years old or older or years old or younger with records maintained using certified EHR technology An EP that neither orders nor creates any of the information listed at 4 CFR (g) during the EHR reporting period An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically 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 Potential Potential No 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 EHRIncentivePrograms. 8 9

7 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: Clinical Quality Metrics Core Set 3 are required (select alternative core set measures if the core measure does not apply) Current CQMs: Core Set Measures (must select 3 measures) EPs Must Report on Three Core Set Measures Hypertension: Blood Pressure Measurement Tobacco Use Assessment & Counseling Adult Weight Screening and Follow-up Alternate Core Set Measures for EPs (substitute when any of the above 3 do not apply) Weight Assessment & Counseling for Children and Adolescents Influenza Vaccination for Patients > 0 years Childhood Immunization Status Dentist Routine Potential Potential No No No No Menu Set 3 out of other clinical quality measures alternative measures are required *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 6 Years and Older Screening Mammography Colorectal Cancer Screening Cervical Cancer Screening 0032 Chlamydia Screening in Women 0033 Controlling High Blood Pressure 0018 Asthma: Pharmacologic Therapy Asthma Assessment Use of Appropriate Medications for People with Asthma 0036 Childhood Immunization Status 0038 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Diabetes Mellitus: Urine Screening for Microalbumin Diabetes Mellitus: Hemoglobin A1c Poor Control Comprehensive Diabetes Care: HbA1c Control (<8.0%) 07 Diabetes Mellitus: Foot Exam Diabetic Retinopathy: Documentation of Retinopathy Diabetes Mellitus: High Blood Pressure Control Communication with the Physician Managing On-going Care Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient Oral Antiplatelet Therapy Prescribed for Patients with CAD Beta-Blocker Therapy for CAD Patients with Prior MI Beta-Blocker Therapy for Left Ventricular Dysfunction (LVSD) Drug Therapy for Lowering LDL-Cholesterol Use of Aspirin or Another Antithrombotic Warfarin Therapy for Patients with Atrial Fibrillation Blood Pressure Management Control Use of Aspirin or Another Antithrombotic ACE Inhibitor or ARB for Left Ventricular Dysfunction (LVSD) 0081 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer Colon Cancer: Chemotherapy for Stage II Colon Cancer Patients Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients Major Depression: (a) Effective Acute Phase Rx Treatment and (b) Continuation Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: 0004 (a) Initiation, (b) Engagement Prenatal Screening for Human Immunodeficiency Virus (HIV) 0012 Prenatal Anti-D Immune Globulin 0014 Appropriate Testing for Children with Pharyngitis Low Back Pain: Use of Imaging Studies

8 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). Proposed Top Three Alternate Core Set Measures for Dentists (substitute when any of the current CQMs do not apply) Annual Oral Health Visit Topical Fluoride or Fluoride Varnish Treatment Periodontal Disease Assessment DENTIST ROUTINE Yes Yes Yes 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.. Periodontal Disease Assessment Percentage of patients age 18 years and older who have been screened for the presence of periodontal disease. 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 who receive soft tissue screening, oral cancer exam and counseling. The number of patients age 18 years and older who have been screened for the presence of periodontal disease. The number of patients with a completed Phase 1 treatment within 12 months of initiation. 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. 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. 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. Proposed Other Alternate Core Set Measures for Dentists Dental Sealant Oral Cancer Risk Assessment & Counseling Completed Comprehensive Treatment Plan DENTIST ROUTINE Yes Yes Yes *For the definition of Phase 1 treatment, please refer to the Fundamentals Chapter of the Operations Manual for Health Center Oral Health Programs: Additional Menu Set Measures for Oral Health These CQMs for oral health would provide a significant step toward measurable, valuable, uniform clinical quality oral health measures across all Health Centers. 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. 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 133 and NQF 1419, were included in the Stage 2 proposed rule). 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) 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. Primary caries prevention intervention as part of well/ill child care as offered by primary care medical providers (INCLUDED in STAGE 2) Total eligible patients who received preventive dental services (EPSDT) Total eligible patients who received dental treatment services (EPSDT) 1419 N/A N/A 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. Percentage of new dental emergency patient visits (scheduled and unscheduled, walk-in) Percentage of pregnant patients that receive an oral exam or preventive dental treatment N/A N/A 12 13

9 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 133: 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 4 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 14 1

10 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: 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. 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- of the New York State MEDICAID Health Information Technology Plan: 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 1 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

11 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: 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. 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 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. START HERE Were at least 30% of dental services furnished to Medicaid patients in an outpatient setting? YES NO YES Do you practice predominantly in an FQHC or RHC with a 30% needy individual* patient volume threshold? NO Do you treat Medicare patients and bill Medicare Fee for Service for patient services? YES NO You are not eligible to receive an EDR/EHR incentive payment under the Medicare or Medicaid EHR incentive program. 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. Are you a Doctor of Oral Surgery or Dental Medicine? NO You are not eligible to receive an EDR/EHR incentive payment under the Medicare or Medicaid payment 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. 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 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) Vendor Response to Meaningful Use Certification and Reporting Measures YES Does your practice use an ONC certified EDR/EHR and report the core and menu set measures? YES 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. NO You are not eligible to receive an EDR/EHR incentive payment under the Medicare or Medicaid payment 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 Record EHR: Electronic Health Record FQHC: Federally Qualified Health Center RHC: Rural Health Center 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:

12 The NLR website will collect required information on the applicant, such as name, 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). Figure 2: Maximum EHR Incentive Payments (CMS, 2012) 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 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. 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 0, 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

13 Step : 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: (cont.) Dentrix EHR Solution (Sage Intergy) QSI EDR NextGen EHR Mediadent SuccessEHS Open Dental eclinical Works Dental sealant Oral cancer risk assessment & counseling Completed comprehensive treatment plan Children who received preventive dental care 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: 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. Children who have dental decay or cavities (INCLUDED IN STAGE 2) Primary caries prevention intervention as part of well/ ill child care as offered by primary care medical providers (INCLUDED IN STAGE 2) Total eligible patients who received dental treatment services (EPSDT) Percentage of new dental emergency patient visits (scheduled & unscheduled, walk-in) Percentage of pregnant patients that receive an oral exam or preventive dental treatment Periodontal disease assessment No Yes Yes Yes Considering NNOHA s proposed Clinical Quality Measures for oral health providers, would you be able to support the reporting of these sets of measures: Dentrix EHR Solution (Sage Intergy) QSI EDR NextGen EHR Mediadent SuccessEHS Open Dental eclinical Works Annual oral health visit Topical fluoride or fluoride varnish Treatment Periodontal disease assessment 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)

14 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. 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: 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: 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. 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 A

15 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 A. 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 26 27

16 Discussion On Use Of EDR/EHR Selection Tool, Vendor s Self Scoring And General Disclaimer 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. 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. 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. 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. 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. 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

17 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. Identify and implement the EDR/EHR system and new workflow through staff training Monitor the EDR/EHR workflow and adjust as required to optimize efficiencies A typical comprehensive implementation program would include digital imaging, an EDR/EHR system, and integration and or migration of the existing practice management system. There are a number of implementation paths to consider from an all-at-once big bang approach by implementing digital imaging and EDR/EHR at all practice locations, to an incremental approach that starts with dental imaging first at a single practice location followed by the EDR/EHR integration and Go-Live. The big bang implementation has often led to implementation failure if it was not carefully planned and staff adequately trained on the new systems. Health Centers should discuss with the dental imaging and EDR/EHR vendors the incremental approach to system implementation. Generally within six to nine months, dental imaging and EDR/EHR systems can be implemented smoothly. NNOHA recommends a gradual, incremental approach to ensure success. Another strategy that some Health Centers have adopted is to go with the EHR portion first, and then bring on the digital imaging feature. Any approach should allow for adequate training of staff, especially if the Health Centers have long-term staff that may not be as technologically savvy and adept. EDR/EHR Implementation Strategies Strategic HIT Investment Before the introduction of Meaningful Use, the goal of EDR/EHR implementation was to digitize the traditional office practice workflow and make the traditional process of caring for a patient more efficient by replicating the paper workflow on the computer. The traditional approach will no longer suffice to meet the demands of the transformation of care delivery. The strategic roadmap to Meaningful Use of EHRs starts with redesigning practice workflows. The workflow steps a Health Center team could take include: Evaluate and document the current clinical, administrative and financial workflows Involve clinical and administrative staff in the workflow analysis and redesign Review workflow diagrams and supporting documentation of current workflows to ensure they encompass all of the practice s locations Identify areas of improvement and waste in the workflows Redesign workflows to improve clinical and office functionality and ensure the EDR/EHR system selection and training will ensure successful transition The following illustrates an incremental implementation approach. It outlines the vision of a digital dental practice and a migration path to get there, identifies the users and beneficiaries, the critical decisions that will be made, business and clinical benefits to be achieved, the process used to define the technologies and vendors, the migration path, and the risks and mitigation strategies associated with this transformation. Phase 1: Dental Imaging This phase will transition the organization from a film operation to a digital solution that will capture, store, and provide access to X-rays and pictures taken throughout the practice. This capability will improve operational performance, reduce costs, provide advanced imaging tools for oral health and early disease detection in an environmentally-friendly manner, and better serve patients in the community. A typical dental imaging solution would include integrated imaging components that provide quick, accurate, flexible ways to capture, store, manage, and access X-rays and pictures. Technologies include film-based scanners, direct and indirect intraoral/extraoral imaging systems and sensors, and image management software

18 Benefits and Return on Investment The initial capital outlay for a digital X-ray unit is higher than for a conventional film-based equivalent. However, once this initial investment has been depreciated, all subsequent X-ray exposures are practically free of charge and this pays dividends throughout the long economic life of the digital X-ray systems. There are several benefits with the addition of digital imaging: The proposed digital solutions will provide quality diagnostic images, lower radiation exposure to the patient, eliminate hazardous developer chemicals, and reduce staff and patient wait time for images. The digital patient images are saved automatically to the patient database and can be viewed chair side for patient education or at a remote location for a second consult. The Health Center can economize on labor costs and realize a reduction in expenditures on consumables. The digital solution will also unlock new sources of earnings potential. For instance, the darkroom can be devoted to other productive purposes. Benefits and Return on Investment An integrated dental imaging and EDR/EHR solution will provide additional benefits such as: Access to clinical data across medical and dental providers resulting in lower cost and fewer errors. More effective decision-making by clinicians and patients. Attainment of desired outcomes through prevention, early detection, and intervention. Less time associated with maintaining accurate, thorough, and legible documentation. Ability to easily view multiple diagnoses, and planned and completed dental treatments. In addition, the new Meaningful Use incentive program associated with Medicare and Medicaid will provide up to $63,70 for each dentist. This program will help Health Centers improve their operation, improve access to care for patients with needs, and improve financial performance by increasing reimbursement. Fixed costs Variable costs Digital Sensor and imaging software Personal computer system Barrier envelopes/sleeves Maintenance/repair costs Film Film & Film Processor Darkroom X-ray films and cassettes Chemicals Labor costs for film processing and cleaning Maintenance/repair costs Payback for EDR/EHR is typically two years without incentives for Meaningful Use. The combination of a digital imaging platform and the integrated EDR/EHR will enable Health Centers to improve care, reduce errors and risk, lower costs, and enhance the ability to serve populations for which they were not previously able to provide care. Due to the fact that this will establish a foundation to improve the financial and operational performance of a Health Center for years to come and there will be a rapid payback, there has never been a better time to find the right EDR/EHR solution. NNOHA can provide the tools and resources to guide Health Centers through this process. Note that there are maintenance and repair costs associated with both digital and film X-ray systems. Digital maintenance and repair costs may be higher; however, they may be covered under a warranty or extended maintenance agreement. Conclusion: A Strategic Pathway To The Future Phase 2: Office Automation Digital software solutions can transform the organization from a paper-based operation to an environment that leverages digital solutions to improve workflow, reduce costs, help the practice address payment reform, and increase revenues by qualifying for Meaningful Use incentives. The digital software solution is comprised of an EDR/EHR to help the clinicians capture patient information, enable e-prescribing, and be able to track and communicate with patients regarding treatment options/patient history, and the EPM to continue to provide capability for scheduling, reminders, and billing. The American Recovery and Reinvestment Act of 2009 (ARRA) includes a provision designed to improve the coordination of patient care, reduce costs and improve health outcomes. This provision is referred to as Meaningful Use, and the Centers for Medicare and Medicaid have implemented the Medicare and Medicaid EHR Incentive Programs that provide a financial incentive for the meaningful use of certified EHR technology to achieve health and efficiency goals. Through participation in the program and meaningfully using an EHR system, providers will achieve benefits beyond financial incentives, such as reduction in errors, availability of records and data, reminders and alerts, clinical decision support, and e-prescribing/refill automation (Centers for Medicare & Medicaid Services, 2011). This paper has been developed to assist oral health programs participate in Meaningful Use by providing a roadmap to assessing, selecting and implementing an EHR that includes electronic dental records in their clinics

19 Health Centers must create a strategic vision and develop a strategic plan for the identification and implementation of an efficient and effective EDR that is integrated into the overall HIT system. The selection and implementation of an EDR/EHR solution is critical to driving improvements in the quality of care through better coordination and improvements in patient safety. Thorough and careful planning is needed to participate in the meaningful use incentives. Before embarking on Meaning Use, Health Centers should consider the following strategic roadmap questions: What are the implications of participating in Meaningful Use? Are the dentists eligible for Meaningful Use incentives? What external organizations can assist in the early planning, implementation and achievement of Meaningful Use of EDR/EHR systems? What features and capabilities should be included beyond the NNOHA suggested requirements? What is the Center s capital and operating budget for an EDR/EHR solution? What EDR/EHR selection process and deployment model should be used? Policymakers and funders can encourage the development and acceptance of comprehensive oral health measures and an integrated approach to oral and general health. Health Centers continue to provide a testing ground for integrating care between the dental, medical, and mental health settings, through the successful use of EDR/EHR systems. Dental Directors have an opportunity to supplement capital costs with Meaningful Use incentive payments, create a long term strategic framework and solid foundation for the implementation of an EDR/EHR solution that will report Meaningful Use objectives among Health Center oral health programs and streamline the workflow. With the Health Center s requirements defined and these questions answered, the organization can start building a short list of EDR/EHR vendors and evaluate each system in-depth, positioning the organization for the era of Meaningful Use. Meaningful Use and health information technology are critical to delivery system reform supporting and driving sustained improvement in patient outcomes. The end goal is not only to have an efficient, quality practice, but also to improve the health of every community. These questions, along with information regarding eligibility for the incentive program, EDR/EHR and vendor selection criteria, and lists of vendors that have certified EDRs are addressed in this paper. Obtaining Meaningful Use incentives for EDR/EHR systems can provide the necessary funding, and can be a strategic step toward strengthening the connections between oral health and general health. Utilizing the NNOHA EDR/EHR selection tool will assist Health Centers in understanding this process. CMS recently announced the second stage of the three-stage process and two new CQMs for oral health. This is great news. NNOHA will provide additional updates to Meaningful Use Stages 2 and 3, and continue to support EDR/EHR adoption. The proposed rule announced by ONC identifies standards and criteria for the certification of EHR technology, so dentists can be sure that the systems they adopt are capable of performing the required functions to demonstrate either stage of Meaningful Use that would be in effect starting in NNOHA Is Committed To Guiding Stakeholders In The Strategic Roadmap Process: EDR/EHR vendors are important players in furthering Meaningful Use reporting for oral health through upgrading existing products or developing new products that meet the unique needs of Health Center oral health programs. While several vendors have made progress in adding new features to existing products, this sector of the HIT market remains largely untapped and currently uses products or workflow processes that are inadequate in meeting the needs of oral health providers. There are specific gaps for electronic dental chart systems, practice management systems, and digital radiography and other imaging products that if addressed, could help to spread HIT adoption in Health Center dental settings. There is also a need to better integrate these products in a cost-effective approach both within the Health Center oral health program and between the dental and medical side of Health Centers. The EDR opportunity for vendors is a large opportunity in the Health Center market. Over a billion dollars of ARRA funding is targeted to Health Centers and the Affordable Care Act provides another 11 billion in funding to the existing 1,080 Federally Qualified Health Centers over the next years. 34 3

20 Meaningful Use Requirements Appendix A1: Meaningful Use Vendor Survey Responses Meaningful Use Vendor Survey Responses The EDR/EHR vendor responses to Meaningful Use requirements: Dentrix Other EHR System: Vitera Intergy EHR Software (formerly Sage Intergy) QSI NextGen Mediadent SuccessEHS Open Dental eclinicalworks Maintain up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Dentrix Other EHR System: Vitera Intergy EHR Software (formerly Sage Intergy) QSI NextGen Mediadent SuccessEHS Open Dental eclinicalworks Is your EDR/EHR system certified by an ONC-Authorized Testing and Certification Body (ONC-ATCB) and reported to ONC? Comments: If no, does your company plan to obtain certification/other Comments: No No No Yes eclincalworks version 9.0 is certified If Dentrix Enterprise integrates with an ONC- ATCB certified EHRs, (e.g., One vendor is Sage Intergy V7.0 ID: , another vendor is MicroMD EMR v7., ID: CC then dentists can register for MU incentive. Yes Dentrix Enterprise is currently working towards modular certification. If QSI EDR is integrated with NextGen Ambulatory EHR, version.6 SP1 which is ONC- ATCB certified, ID: CC , then dentists can register for MU incentive. Yes QSI Dental is currently working towards modular certification. Core Set Objectives: Can you meet the Core Objectives for Meaningful Use for Stage 1 measure? If Mediadent is integrated with SuccessEHS which is ONC- ATCB certified, ID: CC then dentists can register for MU incentive. Yes QSI Dental is currently working towards modular certification. OpenDental EHR version 11.0 is ONC certified Currently both are ONC-ATCB certified. ecw Certification ID: CC Open Dental Certification ID: Dentists can register for MU incentive. Currently certified Smoking status for patients 13 years of age or older Provide patients with clinical summaries for each visit Provide patients with electronic copy of health info Generate and transmit permissible prescriptions electronically Computer provider order entry for medication orders Implement drug-drug interaction checks Capability to electronically key clinical info among providers and patientauthorized entities Implement one clinical decision support rule and ability to track compliance with this rule Protect privacy and security of patient data in the EHR Report clinical quality measures to CMS or states (see Oral Health Proposed Measures) Yes (Planned for 2012) Yes Yes Yes Yes (Planned for 2012) Yes Yes Yes Patient demographics (sex, race, ethnicity, date of birth, preferred language) Vital signs and chart changes (height, weight, BP, BMI, growth charts for children) Menu Set Objectives: Can you meet the Menu Set for Meaningful Use for Stage 1 measure? Drug formulary checks Yes (Planned for 2012) Yes Yes Yes Incorporate clinical laboratory test results into EHRs as structured data No, captured in EHR Yes Yes Yes 36 37

21 (cont.) Menu Set Objectives: Can you meet the Menu Set for Meaningful Use for Stage 1 measure? EDR/EHR Vendor Dentrix Enterprise & Sage Intergy QSI EDR & NextGen EHR Mediadent & SuccessEHS Open Dental & eclinicalworks Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach Use EHR technology to identify patient-specific Education resources and provide those to the patient Perform medication reconciliation between care settings Provide summary of care record for patients referred or transitioned to another provider or setting Send reminders to patients for preventive and f/u care Provide patients with electronic access to their health Information (lab results, problem list, meds Submit electronic immunization data to registries or immunization information systems Submit electronic syndromic surveillance data to public health agencies Yes (Planned for 2012) Yes Yes Yes Yes (Planned for 2012) Yes Yes Yes No Yes Yes (when used with SuccessEHS) No Yes Yes (when used with SuccessEHS) Yes Yes Key Requirements Clinical Care Management and Treatment Planning Requirements Standard high quality workflow for charting, information access, image access, and eprescribe 3 (eprescribe will be available in 2012) Treatment planning module Lab tracking of cases Recall tracking eprescribing and Rx printing Ability to manage and annotate radiographs Clinical charting and integrating images with intraoral cameras and radiographic imaging on one screen Periodontal charting with voice activation Providers can easily access production and collection reports for any specified time frame Insurance predeterminations entered with ease, also tracking of predeterminations Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) 3 (eprescribe will be,3 available in 2012) 3 Rating (1-, or Not Applicable) Appendix A2: Rating Chart: Vendor Response to EDR/EHR Practice-Specific Requirements Each of the four vendors responded to their company s ability to meet the practice-specific requirements and are listed below based on their integrated EHR solution. Following each requirement, the vendor provided a rating corresponding with the statement from the following that most accurately reflects the relevant offerings from the company: Rating: Currently is able to meet this requirement with a commercially available product that is in use within live customer environment 4 Currently is able to meet this requirement with commercially available product that is not yet in use within live customer environment 3 Soon will be able to meet this requirement with a product that is under development and expected to be commercially available within 3 months 2 Will be able to meet this requirement with a product that is under development and expected to be commercially available within 1 year 1 Is not able to meet this requirement; there are no plans to meet this requirement within 1 year Software accurately estimates patient s and insurance provider s portion of bill Ability to integrate outside financing programs, e.g. CareCredit Software can perform or incorporate programs that provide for the following (*vendor response based on lowest rating): electronic statements, online eligibility verification, electronic remittance advice (detailed explanation of benefits that automatically enters insurance payments to software ledger)

22 Key Requirements Clinical Care Management and Treatment Planning Requirements Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Key Requirements Clinical Care Management and Treatment Planning Requirements Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Rating (1-, or Not Applicable) Software must integrate clinical and financial information Clinical charting should easily facilitate entry of planned and completed treatment, as well as conditions Customizable treatment plans based on treatment priority order/clinical findings Ability to create alternative treatment plans based on clinical findings A comprehensive display of treatment completed and planned is displayed Treatment plans can be constructed in phases Onscreen treatment planning virtual charting is available Ability to print incomplete treatment plans by: provider, procedure or user defined criteria Ability to transmit treatment plans electronically to third party carriers for pre-determinations 2 Procedures performed and pending are tracked. A report of either can be produced A treatment plan broken down by visit with financial requirements, time spreads, & notes on a report for the patient is available Multiple treatment plans can be stored and generated for one patient The system provides the ability to identify and retain deleted and/or changed treatment plan items Printed treatment plans indicate date, time, and user printing the treatment plan Explanatory notes can be stored with individual treatment plan items Dentist can utilize a status to be applied to any treatment plan or its items Treatment plans can be constructed in phases including multiple treatment plans that can be stored and generated for one patient 3 Ability to automatically calculate insurance benefits and patient financial liability when entering procedures on a treatment plan Ability to monitor treatment plans by medical diagnosis such as diabetes Dental Lab tracking module is available that interfaces with the Appointment module indicating the patient s next scheduled appointment and allowing dental staff to enter by patient dual identifiers and location: the dental lab where the clinical case is being sent the date when the case was picked up the date when the case is requested back a description of the dental work being processed the signature or initials of the staff member sending out the case the actual date the dental lab work is returned the signature or initials of the staff member checking in the case

23 An integrated patient education system based on practice defined fields and reports from Health Center oral health disparities targeting specific systemic illness, oral conditions, or financial classes. Ability to create templates with treatment plans and chart notes that allow charting by exception to minimize typing Ability to display or generate next appointment, recall information The system has an integrated recare/recall system capable of generating multi-lingual patient reminders Built in ability to create treatment completion reports and user defined outcome measures such as: # of completed treatment plans # of children with sealed permanent molars # of infants and toddlers receiving fluoride varnish # of parents receiving anticipatory guidance # of diabetics receiving periodontal therapy 1 Productivity Measurement and Support Requirements Average patient case fee (average production and collection per patient over a date range by provider) is calculated Referral report showing referred, treatment planned, treatment performed, fees and collections is available The system quantifies the number of active patients using practice-defined criteria of active Historical reporting of transactions available by user-defined date parameters The system calculates unduplicated patients for UDS reporting Ability to assign an effective date to provider schedule templates and maintain several templates simultaneously for the same provider Ability to track the number of vacation, sick, personal, continuing education and holiday time taken by providers (and support staff) over the course of the year (when interfaced with medical) 1 (able to import provider schedules) 4 (using Intergy) 2 (except CE -1) 2 Productivity Measurement and Support Requirements System has a built-in way to track and report broken, failed, or canceled appointments according to user defined criteria System tracks lost production and unscheduled treatment from broken appointments System provides patient listing for confirmation of appointments (with comments on financial information if applicable) All statistics and reports available by location of treatment, provider, or combination thereof Ability to track via a virtual sign-in/sign-out time clock staff members punctuality. Ability to monitor access and efficiency using the following measures: track the average time in days to the third next available appointment for routine care track the average amount of time a patient waits to be seated for their appointment track the average amount of time of a patient visit from when the check in to when they check out monitor patient s satisfaction with their dental visit via an electronic patient satisfaction survey 4 (using Intergy or separate third party software)

24 Tooth and Periodontal Charting Ability to chart supernumerary teeth in primary and permanent dentitions. Ability to view radiographs on the same screen as the area being charted. Ability to see the date of the exam on the tooth charting and periodontal charting/ Periodontal Screening and Reporting (PSR) as part of the data collected. Ability to overlay the full mouth periodontal exam or PSR findings over the tooth charting for a better general synopsis. Ability to conduct a PSR independent of a full mouth periodontal examination. Ability to utilize voice recognition, voice activated software to record periodontal findings during a full mouth periodontal exam or PSR. Customizable practice-defined full mouth periodontal exam templates. Office Administration Requirements Automatically generates letters to patients or specialists (e.g. welcome letters with office policies) Voice activated dictation On screen alerts: recall alerts, medical alerts, financial alerts, etc. Check-in and check-out with ease without having to access multiple screens Tracking of missed and canceled appointments List of patients available to fill canceled appointments (Intergy or third party solutions like Microsoft Voice) (Perio Charting only) 1 Report detailing incomplete treatment plans so patients can be contacted Software seamlessly communicates that a patient has been checked in and is ready to be seated Changes in schedule seamlessly appears on operatory screen Seamless communication from treatment areas to front desk Field for Primary Dental Provider Name, Field for PCP name Field for patient status (Active, Discharged, Deceased, or Transferred) Budget plans for payments Can perform or incorporate programs that provide: electronic statements online eligibility verification electronic remittance advice (detailed explanation of benefits that automatically enters insurance payments to software ledger) By appointment type/global days indicator that does not allow appointment booking prior to 6 months (annual) Ability to view financial story (including payment history) as if it was in the central business office Ability to import and edit fee schedules COMPLETE report writer that can generate any report imaginable Alert for bad debt (multiple company options, internal vs. external) Non-covered service codes for Medicaid to be able to force to patient

25 Office Administration Requirements Can easily access production and collection reports for any specified time frame Ability to easily and completely integrate clinical and financial information Check-in and check-out with ease without having to access multiple screens Software seamlessly communicates that a patient has been checked in and is ready to be seated Changes in schedule seamlessly appear on operatory screen Seamless communication from treatment areas to front desk Billing Requirements Ability to support FQHC/ Medicaid requirements to bill by an encounter rate (individual procedures roll up to an encounter rate) Ability to calculate a sliding fee scale for service based on federal poverty guidelines Supports secure electronic billing to governmental payers Ability to print insurance forms for completed and planned services, including Medicaid and American Dental Association (ADA) standard dental claim forms Day sheet generation for balancing the deposits and viewing billings for the day Aging dates reflect Current (under 30 days), days, days, days, and over 120 days Separate and combined aging by provider, payer, contracts, grants, etc. Open item accounting for insurance billing and tracking Automatic generation of a fee upon entry of a procedure code Ability to see the outstanding balance from the Appointment Screen and Charting Form Claim form duplication for resubmission Insurance aging and auditing of submitted, paid, or nonsubmitted claims Insurance coverage breakdown per policy, employer, or company that list deductibles, maximums, % per category, etc. Reflection of primary insurance payment when secondary claim is sent Changes estimated insurance portion when entering charges Single-screen posting of batch insurance payments Supports electronic remittance posting Ability to transfer old balances to another responsible party Open-item accounting for insurance billing and tracking Open-item insurance estimation Secondary insurance processing generated by primary insurance response Ability to check insurance eligibility, insurer coverage for proposed treatment in real time Account balance broken down by: previous balance, today s treatment and fees, 3rd party coverage information Deductible and/or co-payment owed; remaining coverage; expected payment from 3rd party (Appt. screen) (with Intergy)

26 Statements Statements reflect estimated insurance benefit and patient balance; PPO, HMO coverage, processing and eligibility handling Dunning statements generated for billing Multiple cycles for billing statements (for example, aging date, alphanumeric by name, etc.) Financial arrangements on statements Statements printed on request for single patient Printing statements in userdefined order Adding a statement comment to a patient group Immediately displays walk-out statement (i.e., what is owed by patient and insurance) Claims Ability to produce an ADA and a UB04 form Encounter rate billing for FQHC/wrap sites and Ambulatory Patient Group (APG) sites UDS field capture capability (race, religion, income etc.) 837I Institutional Electronic Billing 837D Fee for Service Electronic Billing 83 ERA Electronic Remittance Posting 3, (available in some states) 3 Patient Lockbox ERA posting 3 2 Ability to hold multiple Tax IDs Charge Entry edit: record additional provider name (e.g. dental hygienist); supervisor billing/dental hygienist productivity Subscriber Billing Technical Requirements Ability to run the application on thin client technologies The system is available through an Application Service Provider (ASP) option. The system is HIPAA and Joint Commission compliant for security and privacy, with well-documented backup and restoration procedures Ability to access the system remotely via a virtual private network (VPN) from anywhere with internet access The system is standardsbased and hardware/software independent for digital radiography Access to the database for reporting purposes is made available through a commercially available reporting tool A tutorial is provided on how to export data from fields within the software to programs like Crystal Reports Reports and Microsoft Office applications are available Integration with PM/EHR Systems Ability to interface demographic information from EHR including one time population of database, using HL7 messaging standards (Health Choice Network) 1 Ability to send electronic statement files to vendor Pretreatment requests capability Charge Entry edit: ADA Require Tooth, ADA Require Surface, ADA Require Quad Ability to receive diagnoses, allergies, and medication lists interfaced from EHR Database is exportable/ importable or has interchangeability so that other applications can use the data 3 (via eprescribe planned for 2012) (with some EHRs) 48 49

27 Integrates Records Among Sites that are Geographically Disparate Ability to schedule one provider at multiple locations using the same provider number Online patient profile inquiry screen available at all sites All statistics and reports available by location of provider, treatment performed or combination thereof Offers keyboard hot keys to quickly switch between location sites for access to appointment schedules, patient records, etc. One database links geographically disparate sites Ability to operate the system in a mobile van with access to a central database Imaging Requirements Multiple users can access the same radiographs simultaneously Ability to roll over thumbnail views of scanned radiographs and documents in a series or table format with zoom preview option Integrated EDR document scanning module is compatible with duplex scanner software allowing scanning of two sides of documents at once Intraoral Cameras and Software: Modern and innovative design Provides sharp images USB docking stations Can be easily connected to existing networks Ability to easily present images to patient while in chair N/A Imaging Requirements Ability to easily present images to patient while in chair Fits into all working environments without disrupting usual work flow Integrated EDR document scanning module is compatible with duplex scanner software allowing scanning of two sides of documents at once X-Ray Units: Convenient location and Use: Wall, hand, stand, boom Ability to easily and effectively integrate with charting software Adequate total filtration is present Meets The Joint Commission Standards Meets TJC requirements for medication reconciliation between health records. Meets TJC standards for dual patient identifiers to prevent clinical errors Meets TJC standards for limiting medication abbreviations (i.e., dirty dozen ) and prevents users from entering these abbreviations. Nice to Have Additional Features Fee tickets (charge tickets for tomorrow) Work log billing follow-up tasks (Denials, A/R, etc.) (QSI is X-ray neutral) N/A 3 (via eprescribe) (with application programming interface to EHR) 3 (via eprescribe planned for 2012) (with API to EHR) 3 Sliding fee scale capability Reporting capability (charges, payments, adjustments, refunds, bad debt etc.) Place of service (Office, Hospital), facility name captured 0 1

28 1. 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. 2. Compelling Reasons to Select Solutions: Vendor s reasons for selecting their EDR/EHR and imaging solution. Appendix A3: Rating Chart: Vendor Response to Qualitative Requirements NNOHA s HIT Workgroup provided the ratings below based on survey responses, but each Health Center is encouraged to conduct their own assessment. Details of the vendor survey are summarized in the table below. Rating: Strongly Agree 4 Agree 3 Neither Agree nor Disagree 3. 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. 2 Disagree 1 Strongly Disagree NA Not Applicable Dentrix Other EHR System: Vitera Intergy EHR Software (formerly Sage Intergy) QSI NextGen Mediadent SuccessEHS Approval Ratings Reference Appendix A6: Vendor background information and evaluations (additional information to support the ratings) Open DentaL eclinicalworks Approval Ratings Reference Appendix A6: Vendor background information and evaluations (additional information to support the ratings). 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. 6. 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. 7. 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 Appendix A4: Rating Chart: Vendor Response to Vendor Solution Cost 4. 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. 4 Figure 3 below is only an example. The Health Center would review the vendor s response to software and hardware costs, professional costs, internal IT and other support costs, and third party costs and include the number corresponding with the statement from the following rating scale that most accurately reflects the relevant offerings: Rating: Strongly Agree 2 Disagree 4 Agree 1 Strongly Disagree 3 Neither Agree nor Disagree NA Not Applicable 2 3

29 Figure 3: Sample Vendor Price Rating Chart Appendix A: Rating Chart: Vendor Selection Criteria and Summary Ratings Final Vendor Rating (Example Only) Deployment Costs Vendor Software Costs Vendor Hardware Costs Vendor Professional Services Costs Internal IT and Other Support Costs 3rd Party Costs Vendor 1 Vendor 2 Vendor 3 Vendor 4 Enter Rating (1-, NA) Enter Rating (1-, NA) Enter Rating (1-, NA) Enter Rating (1-, NA) A sample vendor rating chart is shown in Figure 4 below. 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. Figure 4: Sample Final Vendor Rating Chart Final Vendor Rating Vendor 1 Vendor 2 Vendor 3 Vendor 4 Enter Vendor: Criteria & Weights for EDR/EHR Selection Final Team Weights Total Deployment Costs Maintenance and Support Costs (yrs. 1-) Vendor Software Costs Vendor Hardware Costs Vendor Professional Services Costs Internal IT and Other Support Costs Functional Requirements Assessment from Step 7 0% Qualitative Requirements Assessment from Step 8 2% Total Cost Assessment from Step 9 2% Total 100% rd Party Costs Total Maintenance and Support Costs Appendix A6: Vendor Background Information and Evaluations Total Costs ( yrs.) The NNOHA HIT Workgroup engaged in a product evaluation of four leading electronic dental record systems that Vendor Software Costs Vendor Hardware Costs Vendor Professional Services Costs Internal IT and Other Support Costs 3rd Party Costs Total Costs ( yrs.) Overall Rating (1-, or NA) Overall Rating (1-, or NA) Overall Rating (1-, or NA) Overall Rating (1-, or NA) are committed to Meaningful Use and have EDR/EHR solutions for Health Centers. NNOHA thanks these EDR/EHR vendors for participating in the product demonstrations, responding to the Request for Information survey, and for providing the information that follows. The EDR/EHR Vendors: Vendors Electronic Dental Record (EDR) Electronic Health Record (EHR) Henry Schein Dental Dentrix Enterprise Sage Intergy or Other certified EHR vendor Mediadent and SuccessEHS Mediadent EDR SuccessEHS EHR Open Dental and eclinicalworks Open Dental EDR eclinicalworks EHR Total Cost Assessment QSI Dental and NextGen QSI EDR NextGen EHR 4

30 These EDR/EHR vendors were given sample dental system requirements and asked to demonstrate their product to the HIT Workgroup with these requirements in mind. Demonstrations were conducted in September through November of 2011 via the Internet and at the annual NNOHA conference. Readers should keep in mind that the demonstrations were brief, approximately 1 hour, and thus could not address all the issues, questions, and requirements comprehensively. Although the HIT Workgroup has provided a narrative summary and evaluation of the key Health Center requirements, it should not be interpreted as a certification process. Dental Directors and Health Center staff are encouraged to use this information as a basis for their own system selection and procurement process. The final decision on EDR/EHR venders lays with the Health Center and their due diligence processes. The Workgroup s overall impression of these products is that they share many similar key product features, each has its strengths and weaknesses, and there is no one size fits all solution. There is, however, a major difference between software designed for private practice and that geared for the Health Center market. Several private practice systems do not have product roadmap plans that meet EHR integration requirements; however, they have excellent practice management systems and EDRs that integrate with digital imaging products. The EDR vendors were chosen based on their existing or potential market share in the Health Center setting, capability of meeting Meaningful Use reporting requirements, and suitability for the Health Center market. These vendors have integrated with other EHR ONC certified products, they have added new product features, added Meaningful Use reports, and are developing future interoperable solutions that are Integrating the Healthcare Enterprise (IHE) standards compliant. IHE promotes the coordinated use of such established standards as DICOM, HL7 (both standards for transmission of electronic information) and web services to address specific clinical needs in support of improving patient care. Product Name: QSI Dental Electronic Dental Record (EDR) Company: Quality Systems, Inc. (QSI, Inc.) Contact: Natalie Chamberlain, Regional Sales Executive - QSI Dental Address: Von Karman Avenue Suite 600, Irvine, CA Office: , Ext. 292 Cell: Fax: [email protected] Website: Vendor s Statement Of Capabilities Quality Systems, Incorporated (CQI). and it s NextGen Healthcare subsidiary develop and provide a broad range of computer-based business applications for United States hospital, physician and dental markets. These include practice management, electronic health records, revenue cycle management and e-business applications. The focus is on growing organically with a strong emphasis on reinvestment in new product and service development initiatives. With over 3 years of experience implementing dental practice solutions, QSI represents the most comprehensive information technology product suite available for dental practice organizations in the marketplace today. During the last three decades, QSI has built a reputation of anticipating changes in health care and delivering solutions that address those changes. QSI, throughout its entire history has remained focused on the needs of large, ambulatory group practice enterprises. Within the marketplace, QSI is the only vendor who, for more than 30 years, has consistently implemented and supported dental practice organizations that manage 100 or more clinical practice locations per single practice entity. Large enterprises require cost-effective, standardized, stable, reliable, secure solutions, which are compliant with state and federal regulations. QSI Dental has 80 employees and several third party relationships. QSI has a history of delivering solutions that meet these requirements, and is a company that understands the need to deliver its products and services in a timely, flexible, and responsive manner to ensure the success of its customers clinical and business operations. QSI believes that our diverse and long-term client base demonstrate QSI s ability to implement and support dental solutions for diverse practice requirements. Currently, QSI has implemented and supports clients of all practice size and types, from one location to more than 400 live practice sites managed by a single company - more than any other dental practice management company in the U.S. marketplace. 6 7

31 Client Base (# of organizations) There are approximately 6,000 practice sites utilizing QSI and NextGen products of which approximately 2,000 utilize the QSI dental solution suite. Number of Safety Net/Health Center Clients There are approximately 180 safety net/health Center clients utilizing the NextGen EPM/EMR suite of which approximately 10% utilize the QSI electronic dental record. The NextGen product suite, including the QSI electronic dental record was recently purchased by the Illinois Primary Health Care Association for implementation at 30 of its member organizations. Largest Client (number of connected sites) Currently the largest (single) client supported by QSI has 40+ active locations utilizing the QSI dental practice management solution. The largest (single) client utilizing both the electronic dental record and practice management solution has 16+ active locations and adds at least one new office location per month. Software-as-a-Service (SaaS) Technology QSI also offers a SaaS solution. NextDDS takes advantage of Web 2.0 technology to provide the anytime, anywhere connectivity to vital patient data, information and records. NNOHA HIT Workgroup Evaluation Highlights The QSI EDR and integrated NextGen EHR product offering has several new features and is considered a solid EDR/ EHR solution for Health Centers by the NNOHA Workgroup. QSI demonstrated an efficient integration of the EDR and the company s NextGen EHR product. QSI s many strengths include: user friendliness, HIPAA compliance for secure information exchange, billing, patient care, treatment planning, EDR training, service and support, and Meaningful Use reporting. The system has userdefinable fields throughout the application that are fully reportable. There is comprehensive training and support, federal and state regulation monitoring, and an understanding of FQHCs Migrant Healthcare, Homeless Healthcare, and government payors. Patient records and reports are easily accessed by location of treatment and provider. The Uniform Data System (UDS) reporting can be performed and there is a comprehensive understanding of billing for FQHCs, Medicaid, and sliding fee scales. QSI Dental EDR is integrated with NextGen Ambulatory EHR and version.6 SP1 is ONC-ATCB certified for Meaningful Use across the continuum of care. The benefits include: HL7 protocols for information exchange Consolidated UDS and financial reporting Ambulatory EHR for allergies, medical history and scanned information Combined patient prescription history, medications management and drug Patient prescriptions can be created using centralized EHR Single practice management solution for entire clinic with centralized patient appointment scheduling, accounts receivable and billing management Vendor neutral in terms of integrating digital radiography QSI Dental has added several new product features as follows: Synchronized Login from NextGen Application Launcher Direct access from (EDR) application module to EPM & EHR EDR Toolbar options launch provider directly to: EHR Rx, Allergies, Dental Home Page, ICS Prescriptions from EHR post back into the dental record Shared EHR/EDR allergy list Encounter detail lookup Ability to assign diagnoses codes to dental procedures The Workgroup did identify areas in product features that could be enhanced including insurance predeterminations, transmitting treatment plans, alternative treatment plans, thin client configuration for Voice Activated periodontal charting, dental lab tracking, ASP option, clinical quality measure reporting for oral health and clinical and financial dashboards. Health Centers considering a thin client system integrating EDR with digital imaging products (X-ray and visible imaging) should review licensing options and system performance. NNOHA s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: 3 Completely satisfied 2 Partially satisfied 1 Not at all satisfied Ratings of Functional and Qualitative Requirements Rating Clinical Care Management and Treatment Planning Requirements 2 Productivity Measurement and Support Requirements 3 Tooth and Periodontal Charting 3 Office Administrative Requirements 3 Billing 3 Statements 3 Technical Requirements 2 Integration with Practice Management (PM) / EHR Systems 3 Integrates Records Among Sites that are Geographically Disparate 3 Imaging Requirements 3 Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 Nice to Have Additional Features 3 Implementation and Support Services 3 Compelling Reasons to Select Solutions 3 Meaningful Use (MU) Plans 3 Integration Capabilities 3 Conversion Capabilities 3 Ways to Purchase Solutions 2 Demonstration of Vendor EDR/EHR Capabilities 3 8 9

32 Vendor Response To RFI Survey The RFI survey results for EDR/EHR system requirements are summarized below. Implementation and Support Services Implementation: Vendor s response to the approach to define/implement systems to meet all requirements: QSI s implementation services provide health centers a comprehensive technical staff and implementation framework guides that will meet the health center expectations. Support: Vendor s resources assigned to customer support. Tools/approaches utilized to help diagnose and resolve customer issues, with remote diagnosis and on-site: QSI s support services are available during normal business hours and are responsive to the needs of the health center. 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: QSI Dental can be purchased directly or an approved VAR. If the CHC is currently using or plans on purchasing NextGen EPM/EHR for their Medical/Dental solution along with QSI EDR an automatic 2% Combined License discount would be offered. There is no charge to interface QSI EDR to NextGen EPM (Practice Management). Additional interfaces and costs would need to be quoted separately. Pricing Scenario: Vendor s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. This is for software costs only no hardware, no IT, no imaging: QSI EDR example: Compelling Reasons to Select Solutions Vendor s reasons for selecting their EDR/EHR and imaging solution: QSI s singular development approach, solid financial position and advanced nature of dental clinical functionality. QSI s 3 plus years of experience in Dental software development. Meaningful Use (MU) Vendor s response to plans to attain MU certification and provide tools, knowledge, and services available to assist in attaining MU incentives: QSI EDR not yet certified, but as soon as certification is open for the Electronic Dental Record, QSI Dental will be applying for certification. QSI EDR is integrated with NextGen EHR.6 which is ONC certified. Integration Capabilities Vendor s response to capabilities to integrate EDR/EHR with radiographic imaging and intraoral camera technologies, manage the images, access the images from within charting software, and optimize workflow: QSI Dental is x-ray neutral and can bridge to most major brands of Digital x-ray hardware and software in the market additional discussions are required to ensure the integrated bridge. QSI Image which is QSI s imaging solution is also neutral to most Digital x-ray Hardware brands in the market with the exception of Dexis. Additional discussions are required to ensure integration. Conversion Capabilities Vendor s response to their approach and experience to plan, implement, and test conversion process, including conversion of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality: QSI provides complete data conversion as part of the implementation process. Information from present files is transferred to the QSI System using electronic and manual approaches. A QSI Data Conversion Specialist will review each alternative with you to select the most timely and cost-effective approach for the organization. During the conversion process, electronic file images, copies or printed reports of all data are provided to QSI. Data are converted prior to training to facilitate system orientation through the use of familiar information

33 Product Name: Dentrix Enterprise/Sage Intergy Company: Henry Schein, Inc. Dentrix Contact: Pam Reece, Director, Enterprise and Specialty Solutions Address: 727 East Utah Valley Drive, American Fork, Utah Office: Cell: Website: Dentrix Enterprise was first installed in September of In addition to being a full enterprise solution, Dentrix Enterprise offers an extensive array of HL7 interfaces with over 30 HL7 compliant medical practice management and electronic health record systems. Whether a client is in need of a complete practice management system with a fully integrated electronic dental record or simply an electronic dental record interfaced with their medical practice management/ehr system, Dentrix Enterprise has the right solution. Client Base (# of organizations) Dentrix Dental Systems holds the number one market share position with a growing user base of over 3,000 Dentrix Enterprise installed sites, and more than 38,000 DENTRIX installed dental practices. According to both Clinical Research Associates (CRA) dental software surveys, Dentrix Dental Systems continues to maintain the highest level customer satisfaction in the industry while growing the user base exponentially. Contact: Randy Foley Office: Cell: FAX: [email protected] Vendor s Statement Of Capabilities Headquartered in American Fork, Utah, Henry Schein Practice Solutions, Inc. was established in 1986 with the mission of developing an easy-to-use Microsoft Windows Dental Practice Management Software that met the practice and clinical management needs of the dental profession. More than two years were spent observing all of the clinical and business functions performed in dental offices with the goal of developing automated, multi-tasking and comprehensive dental practice management software that also offered ease of use. This extensive research and software development resulted in the first DENTRIX System introduction in Dentrix Dental Systems was first to offer the dental profession the convenience and ease-of-use of the Microsoft Windows Operating System, more than five years ahead of all other companies. Dentrix Dental Systems has been listening to tens of thousands of user suggestions over our 20 year history of successful DENTRIX installations. Hundreds of advanced features have been added to create superb office workflow. Longevity and experience programming in the Windows environment explains Dentrix Dental Systems cutting edge response to the evolving digital technologies, proven functionality and a high-quality product. Dentrix Dental Systems, Inc./Henry Schein Practice Solutions, Inc. is a wholly owned subsidiary of Henry Schein, Inc., an international corporation based in Melville, New York. As a healthcare supplier since 1932, Henry Schein is traded publicly on the NASDQ and is regarded as a corporation based on traditional values by both its customers and investors. In 2004, Henry Schein made the Fortune 00. In 2006, Henry Schein was named most admired in its industry by Fortune s 2006 list of Most Admired Companies and has ranked number one in its industry in social responsibility for five consecutive years. NNOHA HIT Workgroup Evaluation Highlights The Dentrix Enterprise and integrated EHR product offering (e.g., Sage Software Intergy) has several new features and is considered a potential EDR/EHR solution for Health Centers by the NNOHA Workgroup. Dentrix demonstrated a solid EDR solution and identified several ONC-ATCB certified and HL7 compliant medical practice management and electronic health record systems. Health Choice Network (HCN) supported the demonstration of their technology partners, Sage Software (Intergy), Henry Schein (Dentrix/Dexis), and Microsoft (Amalga). During the past year, HCN continued to implement Meaningful Use-certified electronic health records (EHR) and oral health records Health Centers nationwide. HCN guides its members to meaningful use of EHR as defined by the Office of the National Coordinator for Health Information Technology. This includes meeting all of the measures of the Stage 1 Meaningful Use Requirements. With the use of the integrated bridge, Amalga, Dentrix is able to integrate tightly with any EHR products. Amalga can be used to connect together many unrelated medical systems using a wide variety of data types in order to provide an immediate, updated composite portrait of the patient s healthcare history. All of Amalga s components are integrated using middleware software that allows the creation of standard approaches and tools to interface with the many software and hardware systems. Amalga is designed to collect not only clinical data, but also financial and operational data for hospital administrators. Dentrix Enterprise has many strengths including: Rapid access to patient demographics, insurance policies, financial transactions and clinical data Use current EMR to register and update patient records Import and export patient demographics with Admissions, Discharges, Transfers (ADT) Export procedure, charge and payment with Financial Management Transfers (DFT) Import and export appointments with Scheduling Transfers (SIU) Import provider and staff setup information with Master File Electronic exchange of healthcare-related data 62 63

34 Dental practice management software such as Dentrix Enterprise and Dentrix can receive modular certification. This, however, does not completely solve the problem and Health Centers must invest in other systems that together meet all 1 core objectives and measures. Dentrix Enterprise is currently working towards modular certification. Dentrix, however, could be integrated with a certified EMR product such as Sage Intergy and meet the MU requirements, just like all other EDR products at the present time. Henry Schein Practice Solutions is working with several groups, including the ADA, CMS, Health Resources and Services Administration (HRSA), National Network for Oral Health Access (NNOHA) and the American Association of Oral and Maxillofacial Surgeons (AAOMS), to highlight the need for a certification standard. Dentrix Enterprise has added several new product features as follows: Search Payment in Ledger Multiple Referrals GURU Integration Hid/Mask SSN Enhancement to Perio Score etrans.1 (Allow Edit of claim) Rate Code Feature Treatment Plan Fee Update Enhance Clinical Notes Feature Note Spell Check DDX Integration Enhance Treatment Planner (Presenter) Feature Enhance Document Center Feature Meaningful Use Auto-Log Off Emergency Access Vital Signs/BMI Feature Oral Health Reports Close/Block Operatory (Schedule Event) Log Patient Information when Viewed 010 Mandate The Workgroup did identify areas in product features that could be enhanced, including eprescribing and Rx printing, printed treated plans, dental lab tracking, voice activated dictation, electronic remittance advice/posting, low cost HL7 interface to other EMR/EHRs, clinical quality measure reporting for oral health, and clinical and financial dashboards. NNOHA s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: 3 Completely satisfied 2 Partially satisfied 1 Not at all satisfied Ratings of Functional and Qualitative Requirements Rating Clinical Care Management and Treatment Planning Requirements 2 Productivity Measurement and Support Requirements 3 Tooth and Periodontal Charting 3 Office Administrative Requirements 2 Billing 3 Statements 2 Technical Requirements 3 Integration with Practice Management (PM)/EHR Systems 3 Integrates Records Among Sites that are Geographically Disparate 3 Imaging Requirements 3 Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 Nice to Have Additional Features 3 Implementation and Support Services 3 Compelling Reasons to Select Solutions 3 Meaningful Use (MU) Plans 2/*3 Intergy Integration Capabilities 3 Conversion Capabilities 3 Ways to Purchase Solutions 3 Demonstration of Vendor EDR/EHR Capabilities 3 Vendor Response To RFI Survey The RFI survey results for EDR/EHR system requirements are summarized below. Implementation and Support Services Implementation: Vendor s response to the approach to define/implement systems to meet all requirements: For all new implementations, an account manager is assigned and accountable for the remote install, data conversion, HL7 installation and configuration, remote and onsite training and Go Live. Tiered implementation packages are available based upon need including onsite implementation and installation services. Includes an account manager, a certified software trainer, and (if applicable) an HL7 and/or data conversion technician. All Enterprise level technicians and account managers are fully trained on Enterprise. Enterprise trainers are fully certified on the Enterprise system. Time requirements for projects vary but tend to include 20 hours of account management time and 40 hours of on-site training time. 7am pm Mountain. 64 6

35 Support: Vendor s resources assigned to customer support. Tools/approaches utilized to help diagnose and resolve customer issues, with remote diagnosis and on-site: HSPS provides a dedicated technical support team to provide remote support assistance for Dentrix Enterprise. Dentrix Enterprise support team offers: Phone support assistance support assistance Click to chat Online live and recorded training sessions Published online searchable knowledge base Standard protocol for resolving customer issues Initial troubleshooting with support technician If unresolved, escalation to development team Digital Radiography Support is handled directly by digital x-ray manufacturer. Compelling Reasons to Select Solutions Vendor s reasons for selecting their EDR/EHR and imaging solution: True Medicaid FQHC billing components including: Automatic sliding fees Wrap around for encounter rates billing Multiple alternative Medicaid fee schedules Only true HL7 compliant EDR (ability to interface with ANY HL7 compliant software) extends the ability of any integrated delivery network the capability of adding an electronic dental record to a fully certified EHR: Self-contained UDS reporting Number one electronic dental chart and dental practice management system used nationwide Leading electronic dental record in the CHC market Fully integrated digital x-ray component (Dexis) Fully integrated with the largest electronic dental claims clearinghouse Open architecture SQL Periodontal index and outcomes reporting Backing of the Henry Schein Inc. Meaningful Use (MU) Vendor s response to plans to attain MU certification and provide tools, knowledge, and services available to assist in attaining MU incentives: While there are no dental specific criteria specified for Meaningful Use certification, Dentrix Enterprise is currently seeking modular certification via CCHIT. Dentrix have been in regular talks with ONC, CMS, ADA, and other associations to push the need for a dental specific certification. Dentrix Enterprise interfaces with over 30 different medical systems, providing the NNOHA members a wide variety of choices to select the right EHR that fits their needs. With access to a fully certified EHR interfaced to Dentrix Enterprise, a dental provider that meets the Medicaid thresholds meets Meaningful Use. The capability to utilize a dental specific module developed for oral health providers with any HL7 compliant medical EHR is a strength of Dentrix Enterprise. Dentrix software is based on over 20 years of research and constant work with dental customer partners to develop the best electronic dental record and practice management solution in the CHC and public health markets. 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: Dentrix Enterprise maintains a true, two way integration with Dexis for digital radiography. This integration allows clinicians to see x-rays from within the patient s chart and allows billing staff to attach x-rays directly to claims for electronic billing. The Dexis imaging system is optimized to run alongside Dentrix Enterprise in a thin-client wide area network with centralized data storage. Conversion Capabilities Vendor s response to their approach and experience to plan, implement, and test conversion process, including conversion of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality: All third party software systems can be converted into Dentrix Enterprise capturing most data fields such as patients, providers, appointments, prior clinical treatment, procedures, and notes, etc. The initial converted database is delivered in a test environment for data and mapping validation. All third party systems go through extensive testing with a test conversion followed by a validation conversion for Go Live. Process conversion and mapping is addressed onsite by a certified Dentrix Trainer. Account Managers and Implementation Engineers work with each customer to assist in mapping current to new processes. A Dentrix Enterprise account manager, data conversion technician, and Dentrix Trainer will access functionality differences and advise on appropriate data mapping solutions. Dentrix Enterprise also has webinar training available for additional training on 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: Dentrix Enterprise is sold directly by HSPS (Henry Schein Practice Solutions) and offers multiple bundles and pricing tiers based on size and interface requirements. For example, a clinic that wishes to integrate dental and bill out of their medical software can purchase an EDR only bundle which essentially provides the HL7 interface at half price. Dentrix Enterprise does not currently provide a hosted model. However, Health Choice Network out of Florida does provide hosting services for health centers utilizing Dentrix Enterprise. Bundled dental supply contract are available when applicable. Average retail fee from Dentrix Enterprise for HL7 interfacing is $1,000 for bi-directional. Medical vendor fees will vary

36 Pricing Methodology and Annual Maintenance Fees: Vendor s response to pricing: Satellite Sites Each dental office that installs or runs the Dentrix Enterprise software at that location is required to obtain a separate Site License. Pricing models include a minimal five concurrent users per site or a ten concurrent user per site. Pricing models for either the five or ten concurrent user models also include an Electronic Dental Record only model or a full Electronic Dental Record with practice management model. The former will be interfaced to an HL7 compliant medical program whereas all billing is passed to the medical program and the latter model can be used where Dentrix Enterprise is used for billing as well as an EDR. For the Electronic Dental Record-only the Dentrix Enterprise application site license for 10 concurrent users per site includes the following products: HL7 Bidirectional Interface, Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO BILLING): The EDR only model includes a bi-directional interface. Please note that a fee may be charged for the HL7 interface from your medical software for their side of the HL7 Interface. Digital X-rays, Intra-oral Imaging and Voice Charting are optional with all configurations. The investment figures above are per site for up to 10 workstations, additional workstations are $00 each plus $60 per year for annual support & enhancements. For the Electronic Dental Record only the Dentrix Enterprise application site license for concurrent users per site includes the following products: HL7 Bidirectional Interface, Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO BILLING): The investment figures above are per site for up to workstations, additional workstations are $1,9 each plus $190 per year for annual support & enhancements. For the Practice Management and Electronic Dental Record Model the Dentrix Enterprise application site license for 10 concurrent users per site includes the following products: Ledger (Billing), Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO HL7 Interface): 68 69

37 Please note that some medical software packages require that an HL7 interface be licensed for their software as well. It is the responsibility of the medical software to send the appropriate HL7 messages and to process the ones that are sent from Dentrix. For the Practice Management Model a typical implementation that will enable you to have a one way interface of basic demographic data from your HL7 compatible medical software to Dentrix Enterprise is $4,99 plus an annual license of $1,200. A typical bidirectional interface with basic demographic information coming from the medical software and completed dental charges being sent to the medical software is $9,99 plus an annual license fee of $1,200. Additional fees may apply for additional systems and data fields such as, Appointments, Patient Visit Numbers and Clinical Notes. The investment figures above are per site for up to 10 workstations; additional workstations are $00 each plus $60 per year for annual support & enhancements. For the Practice Management and Electronic Dental Record Model the Dentrix Enterprise application site license for concurrent users per site includes the following products: Ledger (Billing), Office Manager, Family File, Electronic Scheduling, Patient Restorative and Perio Charting and Document Center, (NO HL7 Interface): Installation Installations need to be scheduled during a pre-installation conference call that will be held to assure a smooth transition to Dentrix Enterprise. Installation of the software performed over a telephone connection by our technicians including the creation of the data tables on your SQL Server, and testing the connectivity between the database, OS and application is included. On-site installation assistance from our Technical department for 40 hours on-site is available for $8,000 plus travel related expenses. Additional time is billed at the rate of $20 per hour plus travel. Weekend telephone installation is available at an additional cost of $6,000. Training $800 per eight-hour day, plus travel expenses from a Dentrix Certified Trainer. As an option, we provide a Train the Trainer Program at our corporate facility in Utah or at your site. The course is a full week and will only include students from your organization. The Train the Trainer Program is $3,600 for the first person and $600 for each additional person in the same class. Travel expenses are not included in the tuition. Data Conversion There are three parts of a data conversion: Extraction of data from old system Manipulating the data to conform to a standard file format Building the database The investment figures above are per site for up to workstations, additional workstations are $1,9 each plus $190 per year for annual support & enhancements. HL7 Interface The investment for the HL7 interface is included with the EDR only model and optional with the Practice Management Model. A typical bi-directional interface consists of basic demographic information coming from the medical software and completed dental charges being sent to the medical software. Other options include appointment data with visit numbers coming from the medical system and clinical notes being sent to the medical system. The fee is $1,20 per database. The following items are not included in the above investments: Hardware, preparation of the computer site & on-site labor and/or installation Third party software such as Microsoft 2003 Server, Microsoft Terminal Server, Citrix, Microsoft SQL 2000/200 & Microsoft Word Custom software modifications Applicable state & local sales taxes Travel expenses for training/on site install HL7 fees from medical system 70 71

38 Product Name: Mediadent Company: SuccessEHS Contact: Matt Holtzer, Chief Operating Officer/Director of CHC Sales Office: Ext. 330 Cell: Fax: Website: Vendor s Statement Of Capabilities MediaDent Dental software is a wholly owned division of SuccessEHS and has been providing top-quality products for over a decade. Our solutions continually help practices become more efficient, productive, and inevitably increase their bottom line. We ve incorporated new groundbreaking technology into our system. As a result, MediaDent can share dental patient data with HL7 compatible medical systems such as Sage Intergy, SuccessEHS, Healthport, eclinicalworks, GE Centricity, MSI, Epic, MediTab, and NextGen. MediaDent can consolidate the data in multi-location organizations so that all patient data and images are available at every clinic or configure an ASP/SaaS solution so that all the data is on a single server. With our latest API (Application Program Interface) development, the dentist can simply click on the Rx or Medical History icons in the MediaDent EDR which will open the active patient s record in Intergy and SuccessEHS. MMD is currently working with other EMRs and has the ability to develop a similar interface with almost any solution. In some EMRs, the dentist could also create an order computerized physician order entry (CPOE) for something like a biopsy and the dental treatment/progress notes can automatically replicate into the patient s summary as they are created. A CPOE is a process of electronic entry of dental practitioner instructions for the treatment of patients under his or her care. MediaDent is offered on both a server-based solution for those who maintain their own network with an IT department, as well as an ASP/hosted solution (SaaS) where MediaDent or the client s IT department could host and maintain the server, and all that is needed is a 1. Mbps or better broadband connection at each location. MediaDent works with any combination of thin client/terminal and/or fat client/pcs. MediaDent is the ONLY dental EDR and imaging provider that can also offer a hosted solution with digital imaging and utilize digital sensors, digital pans, intraoral cameras and phosphor plate scanners without the requirement to setup a store and forward configuration with multiple servers. MediaDent is a Single Source Dental Solution and can provide all of the EDR AND Imaging software as well as all of the imaging devices (sensors, pans, cameras, scanners) and computer equipment necessary, if requested, and MediaDent will provide support for all of the software AND hardware. Only ONE support call is required for problem resolution. MediaDent is the only Health Center solution who owns, develops and supports all of the software required. No other Dental Health Center system can offer a Single Source Solution and they have to coordinate the purchase, implementation and support with at least two other companies to provide a similar solution. MediaDent Enterprise solution offers more extensive features than other solutions including provider, location, organizational and enterprise segregation. So depending upon whether a single database for each location is desired, one for each organization or even one for the entire membership, MediaDent can separate the patient s demographics, accounts and charts in many ways. Client Base SuccessEHS has over 6,000 providers with 20,000 users in 47 states utilizing our EDR, PM/EMR and billing products SuccessEHS serves over 10% of the Health Center market MediaDent EDR has over 3,00 users MediaDent has over 10 organizations using our enterprise/multi-location EDR product Number of Safety Net/Health Center Clients SuccessEHS has over 190 Health Center organizations with over 900 sites using our EDR and/or PM/EMR Software Products serve over 2,100 Providers in the Health Center Market Largest Client EHS Turnkey customer with 18 users ASP/Hosted user with 30 users MediaDent 17 Locations with about 400 users 10 Clients with 0+ Workstations in one location 1 Customer with 22 providers SuccessEHS operates its own multi-million dollar data center that currently serves over 10,000 licensed users across the United States 72 73

39 NNOHA HIT Workgroup Evaluation Highlights The Mediadent and integrated SuccessEHS product offering is considered a potential EDR/EMR solution for Health Centers by the NNOHA Workgroup. Mediadent demonstrated an excellent EDR solution and when integrated with SuccessEHS, an ONC certified EHR, dentists can register for Meaningful Use incentives. SuccessEHS 6.0 is a CCHIT Certified 2011 Ambulatory EHR, and additionally certified for Child Health, with a -star usability rating; this product received certification as a Complete EHR on September 30, The clinical quality measures certified include: NQF 0421, NQF 0013, NQF 0028, NQF 0041, NQF 0024, NQF 0038, NQF 0043, NQF 0031, and NQF Dental customers can benefit from the SuccessEHS hosting infrastructure, which includes Software as a Service (SaaS), Turnkey and Hosted Turnkey setups. SuccessEHS is one of the few vendors to offer independent dental practitioners a fully cloud-based EDR, including imaging, via its SaaS hosting option. MediaDent has many strengths including: A Single Source Dental Solution that can provide all of the EDR and Imaging software as well as all of the imaging devices (sensors, pans, cameras, scanners) and computer equipment. Solid technological infrastructure and strong support staff SaaS hosting option; offers both hosted and server-based system WITH IMAGING capabilities Robust reporting capabilities in the core EDR product, and also Data Miner custom report writer A high level of integration and Open Architecture The Workgroup did identify areas in product features that could be enhanced including integrated patient education, electronic remittance advice/posting, monitoring patient satisfaction with dental visit, voice activated dictation, customizable periodontal exam templates, clinical quality measure reporting for oral health, and clinical and financial dashboards. NNOHA s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: 3 Completely satisfied 2 Partially satisfied 1 Not at all satisfied Ratings of Functional and Qualitative Requirements Rating Clinical Care Management and Treatment Planning Requirements 2 Productivity Measurement and Support Requirements 3 Tooth and Periodontal Charting 2 Office Administrative Requirements 2 Billing 3 Statements 2 Technical Requirements 3 Integration with Practice Management (PM)/EHR Systems 3 Integrates Records Among Sites that are Geographically Disparate 3 Imaging Requirements 3 Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 Nice to Have Additional Features 3 Implementation and Support Services 3 Compelling Reasons to Select Solutions 3 Meaningful Use (MU) Plans 2 Integration Capabilities 3 Conversion Capabilities 3 Ways to Purchase Solutions 3 Demonstration of Vendor EDR/EHR Capabilities 3 Vendor Response To RFI Survey The RFI survey results for EDR/EHR system requirements are summarized below. Implementation and Support Services Implementation: Vendor s response to the approach to define / implement systems to meet all requirements: MediaDent assigns a Project Manager to work with the dental group to provide engineering support and implementation support for the EDR and Imaging solution. The Project Manager will evaluate the configuration that is in place at each location and provide recommendations as to any additional equipment or software that is required that is not provided by MediaDent so that the clinic achieves a successful implementation. MediaDent has standard specifications that will be sent to the IT group working with the dental clinic and will typically include 10-1 hours of project management time for most installations. Once the design is agreed upon, the Project Manager will coordinate with the IT staff to assist in the installation of the MediaDent software on the server(s) after verifying remote access of some sort for project assistance. MediaDent will schedule a technician to come to the customer site(s) for additional assistance, as necessary, and will also provide on-site assistance for installation support and testing of the imaging devices, as necessary. Once all of the installation services are completed, MediaDent will coordinate with the clinic s EMR provider to implement the HL7 interface. If the member uses SuccessEHS or Sage Intergy, MediaDent will also configure for the API interface. After all of these steps have been completed, MediaDent will schedule the training and typically include 10-1 hours for most installations plus one day per site if the clinic(s) are planning to use sensors or pans. Training: MediaDent will assign an Implementation Specialist to the project. There are a number of different ways training services are provided and MediaDent will develop the best method for each clinic. Typically, MediaDent will work with each Dental Director before any on-site training to create their specific 74 7

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

41 MediaDent provides excellent support and utilizes many advanced features to quickly answer customer issues and update systems. MediaDent incorporates NetSupport to access your system within seconds to save you and us valuable time. MediaDent can receive support requests by phone, website or , and all calls are triaged and logged into our customer system. Updates can be automatically download to the server very quickly, usually in a matter of just a few minutes and workstations simply log off and log back on the get the updates. Meaningful Use (MU) Vendor s response to plans to attain MU certification and provide tools, knowledge, and services available to assist in attaining MU incentives: Currently, there are no certifications available for an EDR as an independent module. As soon as a testing procedure for EDR is defined by one of the certifying agencies such as CCHIT or Drummond, MediaDent will complete the certification process. In the meantime, MediaDent, in conjunction with whichever medical solution the organization uses, would be part of the certification of that medical software. As long as the dental providers use the medical software for any functions, such as prescriptions, they should be eligible for MU incentives. In addition, MediaDent is the dental division of SuccessEHS who does have a certified product as outlined below and can be offered to any FQHC who needs to change to a qualifying solution. SuccessEHS is 2011/2012 compliant and was certified as a Complete EHR on September 30, 2010, by the Certification Commission for Health Information Technology (CCHIT ), an ONC ATCB, in accordance with the applicable Eligible Provider certification criteria adopted by the Secretary of Health and Human Services. The 2011/2012 criteria support the Stage 1 Meaningful Use measures required to qualify eligible providers and hospitals for funding under the American Recovery and Reinvestment Act (ARRA). 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: MediaDent has developed a complete imaging software solution that is fully integrated with the EDR/Chart software. MediaDent owns the software and provides all of the installation, implementation and support that is necessary for the product. All images are taken and viewed within our MediaDent software and all images are viewable within the chart as well as full screen mode which allows the provider to optimize their productivity. A workflow will be defined by our implementation specialists to best match your clinic procedures. The imaging solution works with several sensors and intraoral cameras, most phosphor plate scanners and almost all digital pans. In addition, the images are able to be exported or ed in an encrypted format directly from MediaDent. The ability to automatically attach and transmit an image to submit to insurance for either pre-authorization or payment is also built into the MediaDent software with our NEA module. 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 systems functionality to new functionality: MediaDent has successfully converted data from most dental practice management systems including Dentrix, EagleSoft, PracticeWorks, SoftDent and many more. Each situation is different and our Project Manager will assist the IT staff in the evaluation. In most cases, MediaDent is able to transfer the demographics, appointment book and treatment history, but usually cannot get the pending treatment plans, notes and images. If a dental clinic is converting from standalone dental software that has not been interfaced with their medical solution, it is usually best to not convert the data and instead, link to the medical software which will populate the patient and appointment records so that all of the patients IDs match. The old system will be used as reference. Sometimes MediaDent will just convert the appointment book, but each case is evaluated independently. 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: MediaDent EDR and Imaging can be purchased direct and the company has several partnerships and dealers who refer business to the company. There are four primary modules that are available Practice Management, EDR/Charting, Digital Imaging and HL7/API Interfaces. In addition to software, MediaDent sells digital x-rays sensors, phosphor plate scanners, digital pans, intraoral cameras, signature pads, document scanners and almost any Dell brand equipment for your network. MediaDent provides the complete solution and offers the installation and implementation services for the system as well as the necessary training and support to allow the user to succeed. All of these products can be implemented in either a traditional server/ PC configuration or setup as an ASP/Hosted system with terminals instead of PCs and no servers. The ASP solution can be hosted by MediaDent or the client if they have a capable IT Department. MediaDent has established HL7 interfaces with many of the medical software solutions including SuccessEHS, Sage Intergy, eclinicalworks, NextGen, MSI, GE Centricity, McKesson Practice Partners and Healthport. HL7 allows patient demographics (ADT) and appointment information (SIU) to flow from the medical software to MediaDent and billing/encounter information (DFT) to flow from MediaDent back to the medical software. Both MediaDent and the medical software usually have a fee for the HL7. In addition, MediaDent has an API interface with SuccessEHS and Sage which allows the dentist to use the medical software prescription, medication, allergy and medical history modules. MediaDent is also in development with several other vendors at this time. Typically, there is a slight additional charge for this interface as well. MediaDent is the only company that offers all the components that you will need to implement a complete dental solution. All software, services and hosting is owned, developed and maintained by MediaDent. In addition, MediaDent can provide all of the imaging components required by most dental practices. MediaDent offer a complete solution instead of a grouping of products from various companies. All other solutions combine one company s EDR with another company s imaging along with a third company s x-ray devices. MediaDent is also the only company that hosts their solution directly. Pricing Methodology and Annual Maintenance Fees: Software: (Depends on number of users and sites) MediaDent EDR Licenses MediaDent Imaging Licenses HL7 Interface (ADT, SIU and DFT) API Interface (prescriptions, medical history) Data Miner Custom Report Writer Scanner Software RCC Channel Communication Software ASP Hosting: (Depends on number of users and sites) Hosting Fee for Data Center Hardware: Digital Sensor Size #1 Digital Sensor Size #2 USB Interface Unit Digital Pan with Stand Soredex Optime Phosphor Plate System $1,000 to $1,00 per license $300 to $ 900 per license $6,000 per organization $2,00 per organization (if applicable) $99 per authoring license $39 per member $19 per imaging client workstation $30 to $60 per month per license $,99 each $6,99 each $1,29 each $29,99 each $9,99 each 78 79

42 Document Scanner Signature Pad Unigrip Sensor Holders Kit Services: Implementation Installation Training Digital Pan Installation and Freight Support: EDR Imaging HL7 (with API if used) Network Hardware: Customized Proposal Upon Request $49 each $30 each $120 each $10 per hour $70 per day plus travel expenses $800 per day plus travel expenses $1,99 per pan plus travel expenses $1 per month per license $10 per month per license $100 per month per member Vendor s Statement Of Capabilities Open Dental is a comprehensive software package that offers very robust solutions for many different kinds of clinics. Open Dental has an efficient workflow, a powerful database, and many well-designed tools for data management. As the only open source dental software in the world, it provides users with the assurance that the software belongs firmly to the users and to the entire dental community. Open Dental is also the only PC dental software that has been certified as an EHR. Open Dental can directly create 837 dental, medical, and institutional claims, and has HL7 interfaces for use with medical software, in particular, eclinicalworks. Open Dental s outstanding customer support and unmatched responsiveness to user needs have resulted in a rapidly growing, enthusiastic user base. Client Base (# of organizations): Open Dental is in use at approximately 4,000 locations. Number of Safety Net/Health Center Clients: This information is not tracked, but is estimated at 100 locations. Largest Client (number of connected sites and number of users in one organization): 12 sites with approximately 100 users. ASP Hosting: Pricing Scenario Vendor s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. This is for software costs only no hardware, no IT, no imaging: Assumes 8 total workstations, an HL7 interface to medical software, 3 days of training and standard 10 hours of implementation services. Software Purchase: $21,900 plus $180 per month support ASP: $2,800 plus $1,400 per month for software, support and hosting Product Name: Open Dental and eclinicalworks Company: Open Dental Contact: Jordan Sparks, DMD, President Address: 1462 Commercial St. SE, Salem, OR Office: Fax: [email protected] Website: It can be hosted off-site in a variety of different ways. Open Dental does not yet offer that service directly. Company: eclinicalworks Dental Contact: Kelli Smith, Business Development Address: 2 Technology Drive, Westborough, MA 0181 Office: Ext [email protected] Website: Vendor s Statement Of Capabilities Directly interfacing eclinicalworks with Open Dental practices improve patient safety and streamline workflows by removing manual, double entry of patient data, and increase care team collaboration by sharing information across systems. eclinicalworks has developed a tight interface with Open Dental for charting and treatment in an ambulatory setting. The dental interface will provide dental functionality for those ambulatory medical clinics that offer dental services, leveraging the strengths of the eclinicalworks application in the following areas: 80 81

43 Centralized scheduling of appointments Centralized billing of all clinic activity Sharing of relevant clinical information at the point-of-care Medication management, reconciliation, and allergy/interaction checking at the time medications are prescribed e-prescribing via Surescripts (if the practice chooses to install a Surescripts) Client Base (# of organizations) and number of safety net/health Center clients: eclinicalworks: actively implementing 400 Health Centers across the country Open Dental: Approximately 60 are live with Open Dental Largest Client (number of connected sites and number of users in one organization): sites with approximately 2 users ASP Hosting: Yes, currently limited to new clients Pricing Methodology: Subscription based pricing model: Client engages directly with Open Dental for support and training No up-front cost to use the open dental integrated model in eclinicalworks. Standard provider licensing pricing applies Annual Maintenance Fees: $7 per provider per month to Open Dental NNOHA HIT Workgroup Evaluation Highlights The Open Dental and eclinicalworks (ecw) solution is a tightly integrated product. Both products are considered a solid EDR/EHR foundation solution for Health Centers by the NNOHA Workgroup. eclinicalworks has more than 1,600 employees dedicated to this one product, the 1,600:1 ratio is the highest employee-to-product ratio in the industry. This, coupled with ecw s 24x7 support structure makes ecw well positioned to move forward with NNOHA s initiative. Open Dental and ecw demonstrated an efficient integration of the two products. Open Dental is also the only PC dental software that has been certified as an EHR and provides users with the assurance that the software belongs firmly to the users and to the entire dental community. By interfacing eclinicalworks with Open Dental, practices improve patient safety and streamline workflows by removing manual, double entry of patient data, and increase care team collaboration by sharing information across systems. Open Dental and eclinicalworks has several strengths including: user-friendliness, HIPAA compliance for secure information exchange, billing, patient care, treatment planning, training, service and support, and meaningful use reporting. The system has user-definable fields throughout the application that are fully reportable. There is comprehensive training and support, federal and state regulation monitoring, and an understanding of Health Centers Migrant Healthcare, Homeless Healthcare, and government payers. Patient records and reports are easily accessed by location of treatment and provider. UDS reporting can be performed and there is a comprehensive understanding of billing for Health Centers, Medicaid, and sliding fee scales. Open Dental and eclinicalworks are both ONC-ATCB certified for Meaningful Use across the continuum of care. Open Dental has several new features and benefits including: Easy to access and share data Tutorials on-line cover the minimal setup functions Support complete patient records (HIPAA compliant) Comprehensive billing system with e-claim support Dashboard includes several practice parameters in graphical format Batch insurance payments The Workgroup did identify areas in Open Dental and eclinicalworks product features that could be enhanced including dental imaging integration (both radiographic and visible imaging), eligibility verification, periodontal charting, electronic remittance advice/posting, clinical quality measure reporting for oral health, and clinical and financial dashboards. NNOHA s Workgroup ratings as shown in the table below are based on product demonstrations, responses to the RFI, surveys and supporting research. The NNOHA Workgroup rating scale follows: 3 Completely satisfied 2 Partially satisfied 1 Not at all satisfied Ratings of Functional and Qualitative Requirements Rating Clinical Care Management and Treatment Planning Requirements 3 Productivity Measurement and Support Requirements 3 Tooth and Periodontal Charting 3 Office Administrative Requirements 2 Billing 2 Statements 3 Technical Requirements 3 Integration with Practice Management (PM)/EHR Systems 3 Integrates Records Among Sites that are Geographically Disparate 3 Imaging Requirements 2 Meets The Joint Commission (TJC) (formerly JCAHO) Standards 3 Nice to Have Additional Features 3 Implementation and Support Services 3 Compelling Reasons to Select Solutions 3 Meaningful Use (MU) Plans 3 Integration Capabilities 3 Conversion Capabilities 3 Ways to Purchase Solutions 3 Demonstration of Vendor EDR/EHR Capabilities

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

45 Conversion Capabilities Vendor s response to their approach and experience to plan, implement, and test conversion process, including conversion of the data, mapping current processes to new processes, and mapping current systems functionality to new functionality: Open Dental: Open Dental has built complex scripting tools that automate conversions from many other database formats. Each conversion script presents unique challenges that the company continues to refine with each new customer conversion. eclinicalworks: Data migration is typically done in two steps, namely the initial migration and the final migration. The initial migration is a preliminary, test migration which is conducted to ensure the highest quality data transfer. It also allows the practice to test the data before it is migrated for the final time. The initial migration is done just after the eclinicalworks software installation which is typically one two weeks before the practice starts using eclinicalworks software. During the initial migration, the data mapping is established between the current PM or EMR system of the practice and eclinicalworks. The purpose of final migration is to deliver the most recent data in eclinicalworks and to ensure that the practice does not lose any data entered into the old system during the data transition. 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: Open Dental: There is no up-front cost for Open Dental. There is a monthly fee which covers telephone support and frequent updates. After the short initial contract, the customer can continue to use the software even if they discontinue support. There is no charge for any of the many included bridges to other programs, and generally no charge for HL7 interfaces. eclinicalworks: Open Dental has a direct agreement with ecw clients who are looking for an integrated dental solution with eclinicalworks. ecw has partnered with Open Dental to offer the integrated dental solution with eclinicalworks EMR at a minimum subscription cost which the client pays directly to Open Dental on a monthly basis. ecw does not charge any interfaces charges related to Open Dental integration. Also Open Dental directs all the clients on the required hardware to install Open Dental software. Pricing Methodology and Annual Maintenance Fees: Open Dental: Subscription based pricing model: Client engages directly with Open Dental for support and training. No up-front cost to use the open dental integrated model in ecw. Standard provider licensing pricing applies. $149/month/site plus $10/month for every dentist beyond 3. Drops to $99/month after the first year. EHR module is an additional $60/dentist/month. If using the medical software for MU, then this is not needed. ecw: $7 per provider per month to Open Dental. Pricing Scenario: Vendor s response to pricing for a six operatory, single site, 3 provider operation with no mobile unit. This is for software costs only no hardware, no IT, no imaging: Open Dental: 1 $149 per month (per site charge). 3 per provider (per provider EHR charge). Appendix B: Sources of Information/Additional Resources The following resources provide additional information regarding Meaningful Use and EDR/EHR selection and implementation. NNOHA Website: HHS Oral Health Initiative 2010: The Office of the National Coordinator for Health Information Technology (ONC) Electronic Health Records and Meaningful Use: CMS EHR Meaningful Use Overview: CMS Attestation Guide: ONC Certified HIT Product List maintained: NQF s Measure Evaluation Criteria / NQF endorsement process: HHS Office of the National Coordinator for Health Information Technology HIT Policy Committee Meaningful Use Workgroup: ADA Website: ADA SCDI meetings, ADA SCDI membership to view proposed ANSI/ADA specifications and technical reports that are available for review and comment: HITECH Answers Website: University of Pittsburgh Department of Dental Informatics: Tides CCI Publication: Healthcare Technology Resource Guide (Sample Contract): New York State Medicaid Health Information Technology Plan: HRSA s Oral Health IT Toolbox:

46 Appendix C: Glossary Application Service Provider A business that manages and distributes software-based services and solutions to customers over a network from a central data center. Clinical Decision Support Computer programs designed to assist physicians and other health professionals with decision-making tasks, linking health observations (signs and symptoms) with health knowledge (best practices and current research) to influence choices made by clinicians to improve care. CPOE (Computerized Provider Order Entry) A computer application that allows a physician s orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems. Orders for pharmacy, laboratory, radiology, and treatment protocols are communicated over a computer network to the medical staff or to the departments/entities responsible for fulfilling the order. DICOM (Digital Imaging and Communications in Medicine) A widely used standard for representing and communicating radiology images and reports. DSS (Decision Support System) Computer tools or applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples include drug interaction alerts at the time medication is prescribed and reminders for specific guideline-based interventions during the care of patients with chronic disease. Information is presented in a patient-centric view of individual care and also in a population or aggregate view to support population management and quality improvement. EDR (Electronic Dental Record) EDR software provides clinical charting for dentists and eliminates paper charts. Some common features of EDR software include exam results, patient images, treatment plan charts, and periodontal charts. Exams, treatment plans, procedures and images are viewed in the patient record on a display. EHR (Electronic Health Record) A real time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision making. An EHR is a medical record or any other information relating to the past, present or future physical and mental health, or condition of a patient which resides in computers which capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing health care and health-related services. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting. EHR records include patient demographics, progress notes, SOAP (Subjective, Objective, Assessment, and Plan) notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. erx (Electronic Prescribing) A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physicians access to patient specific information to screen for drug interactions and allergies. HIE (Health Information Exchange) Provides the capability to electronically move clinical information between disparate health care information systems to facilitate access to, and retrieval of, clinical data, thereby helping to provide safer, timely, efficient, effective, equitable patient-centered care. HIE is also known as a regional health information organization (RHIO). The notion of HIE is the precursor to RHIO and is used interchangeably when discussing RHIOs. HIT (Health Information Technology) The application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making. HL7 (Health Level 7) An ANSI standard for healthcare-specific data exchange between computer applications. HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other materials. Interoperability The ability of various HIT products to exchange information safely and securely, and to preserve the meaning of the data that is being shared. Office of the National Coordinator for Health IT (ONCHIT) Provides counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of an interoperable health information technology infrastructure. SaaS (Software-as-a-Service) SaaS is closely related to the ASP (Application Service Provider) and on demand computing software delivery models. Applications are hosted by a service provider and made available to customers over a network, typically the Internet. Sources: California HealthCare Foundation Glossary: Selected Health Information Technology Terms: US National Library of Medicine National Institute of Health HIT Glossary: Appendix D: References Centers for Medicare & Medicaid Services. (2011). CMS EHR Meaningful Use Overview. Retrieved on August 20, 2011 from Centers for Disease Control and Prevention. (2011). Electronic Health Record Systems and Intent to Apply for Meaningful Use Incentives Among Office-based Physician Practices: United States, Retrieved on August 20, 2011 from Centers for Medicare & Medicaid Services. (2012).Medicare EHR Incentive Program, Physician Quality Reporting System and e-prescribing Comparison. Retrieved on April 26, 2012 from Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//EHRIncentivePayments-ICN pdf Centers for Medicare & Medicaid Services. (2012). Stage 2 Meaningful Use NPRM Moves Toward Patient- Centered Care Through Wider Use of EHRs. Retrieved on April 26, 2012 from stage-2-meaningful-use-nprm-moves-toward-patient-centered-care-through-wider-use-of-ehrs/ Comparison Study of Dental Sensors. Retrieved on August 23, 2011 from Federal Register. (2010). Retrieved on October 1, 2011 from

47 Gaylin, D., Moiduddin, A., Mohamoud, S., Lundeen, K., & Kelly, J. (June 2011). Public attitudes about health information technology and its relationship to health care quality, costs, and privacy. HSR: Health Services Research.46 (3) Harris, Y. & Leigh, J. (2011). Meaningful Use for Dentists: What it Means for Me? Retrieved on October 26, 2011 from Health Resources and Services Administration (2011). What is Meaningful Use? Retrieved on October 1, 2011 from Tankersley, R., Wong, D., Snow, M., Birdwell, R., & McFarland, J. (March 2010). RE: Notice of Proposed Rulemaking: Medicare and Medicaid programs; electronic health record incentive program. Retrieved July 11, 2011 from mmehrincentiveprog.pdf&cdpath=/dqa_ltr_coalition_mmehrincentiveprog.pdf Thompson, T. & Brailer, D. (2004). The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care. Department of Health and Human Services. Retrieved On August 23, 2011, from Healthy People Retrieved on August 20, 2011 from Heinrich, J. (2004). HHS s Efforts to Promote Health Information Technology and Legal Barriers to Its Adoption. United States Government Accountability Office. Retrieved on August 23, 2011 from Heubusch, K. (2010). Clinical quality measures for providers. Journal of AHIMA. 6a. Retrieved August 20, 2011 from Hoffman, S & Podgurski, A. (2011). Meaningful Use and Certification of Health Information Technology: What about Safety? Retrieved on August 2, 2011 from Institute of Medicine. (2001). Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, D.C., National Academy Press. Jones, K.C. (2009). Obama Wants E-Health Records In Five Years. President-elect says medical information on all Americans should be digitized by Retrieved on August 2, 2011 from Melvin, V. (2008). HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy. United States Government Accountability Office. Retrieved on August 21, 2011 from National Network of Oral Health Access. (2011). NNOHA HIT and Meaningful Use (MU) Framework for Eligible Professionals (Dentists), Adoption Incentives & EHR Implementation. Retrieved on August 26, 2011 from National Quality Forum. (2011). Measure evaluation criteria and guidance summary tables. Retrieved on August 20, 2011, from National Quality Forum. (2011). Retrieved on August 20, 2011 from NORC. (2011). Quality Oral Health Care in Medicaid Through Health IT. Retrieved on September, 30, 2011 from Robert Wood Johnson Foundation (2006). Health Information Technology in the United States: The Information Base for Progress. Retrieved on August 27, 2011 from Rudman, W., Hart-Hester, S., Jones, W., Caputo, N., Madison, M. (2010). Integrating medical and dental records: a new frontier in health information management. Journal of AHIMA 81, (10) Appendix E: Credits NNOHA Health IT (HIT) And Meaningful Use (MU) Workgroups Members of NNOHA s HIT Workgroup have volunteered their time researching and supporting this project. A special heartfelt thank you to the Meaningful Use Workgroup members for proposing and evaluating the Clinical Quality Measures for Oral Health. Huong N. Le, DDS, FACD NNOHA HIT Workgroup Chairperson Dental Director, Asian Health Services Steven Russell, MEEM, MSHA, CPHIT NNOHA HIT Consultant Director of Dental Services, Strategic Interests Colleen Lampron, MPH Former Executive Director, National Network for Oral Health Access Amanda Stangis, MPH Director of Programs, California Primary Care Association Andie Martinez Patterson, MPP Assistant Director of Policy, California Primary Care Association Sonia Sheck Clinical Projects Coordinator, Colorado Community Health Network Maggie Drozdowski Maule, DMD, MBA Dental Director, Community Health Center, Inc. Lyn Blankenship EHR Project Coordinator, Community Health Centers Clifford Hames, DDS VP, Chief Dental Officer/Chief Infection Control Officer, Hudson River HealthCare Karen Dent, CDA, EFDA Oral Health Network Director, Missouri Primary Care Association Shannon Quirk, MSW Oral Health Affairs Manager, Massachusetts League of Community Health Centers Ryan Krull Project Coordinator, Missouri Primary Care Association Noelle Parker Manager, Missouri Primary Care Association Barbara Woods Project Coordinator, Missouri Primary Care Association Mary Ellen Yankosky, RDH, BS Vice Chair, New York State Oral Health Coalition Terry Russell, RDH, MSHA New York State Oral Health Coalition Dental Operations Administrator, Suncoast Community Health Centers 90 91

48 NNOHA Health Information Technology (HIT) Workgroup NNOHA Health Information Technology (HIT) Workgroup members enumerated several specific objectives in their vision for greater technology adoption in the Health Center oral health setting: Foster integration of medical and dental information Increase the efficiency and accuracy of required reporting to HRSA Focus on all aspects of the patient s health, including oral, systemic, mental and behavioral health Enhance dentist recruitment and retention Gather and use data to support population health improvements Evaluate the effectiveness of clinical interventions Enable quality of care improvement measurement Improve the quality of care for patients Increase patient safety. Steven T. Russell, MEEM, MSHA, CPHIT: Steven Russell is a Meaningful Use and HIT consultant for NNOHA and other health care organizations. He received his undergraduate engineering degree from Syracuse University and graduate degrees from Rochester Institute of Technology and Roberts Wesleyan College. His certifications include Professional in Healthcare IT, Program Management, Lean Six Sigma and Competitive Intelligence. Steven held the position of World Wide Manager Business Research and Development Healthcare Information Systems at Carestream Health. At Eastman Kodak Health Group he held positions of Innovation & Integrated Solutions Manager, Manager of Technology Innovation, and Director of Strategic Planning for Dental Systems and received several patent awards. Steven has served on the ADA Standards Committee on Dental Informatics (SCDI) and other standards developing organizations. He has prepared grants in conjunction with the Unity Health System, Rochester RHIO and Regional Extension Centers in New York State. He has also chaired panel reviews for the U.S. Department of HHS, Office of the National Coordinator Beacon Community Program that provides funding for the advancement of HIT, workflow redesign and care coordination and CMS Innovation grants that fosters health care transformation by finding new ways to pay for and deliver care that improve care and health while lowering costs. Steven is an adjunct professor in the MS Health Information Administration program at Roberts Wesleyan College, and also serves as the Access to Care Chair and Steering Board Member for the New York State Oral Health Coalition. Special Recognition: The NNOHA HIT leadership extends a special recognition to the Roberts Wesleyan College, Master of Science Health Administration program staff and students for assisting in the research efforts for this project and increasing awareness of improving oral health for Health Centers across the nation. Whether focused on clinical or public health, these goals are to improve patient outcomes, and it is widely recognized that these efforts are not scalable without the effective use of technology. PRIMARY AUTHORS: Thank you to the following individuals for their input and review of this white paper: Hyewon Lee, DMD Lieutenant, U.S. Public Health Service Dental Consultant, Office of Strategic Priorities (OSP), HRSA NNOHA Project Officer Emily Jones, MPP Public Health Analyst Office of Quality and Data, Quality Branch Bureau of Primary Health Care, HRSA Lisa A. Wald, MPH Public Health Analyst Office of Training and Technical Assistance Coordination Bureau of Primary Health Care, HRSA Huong N. Le, DDS, FACD (MA expected in 2012): Dr. Huong Le joined the Health Center world in 1989 after a few years in private practice. Since 2003, Dr. Le has served as Dental Director at Asian Health Services in Oakland, California. Dr. Le is a member of the American Dental Association (ADA), California Dental Association (CDA) and Alameda County Dental Society where she is Immediate-Past President. She is a former member of CDA Policy Development Council, CDA and ADA delegation. Dr. Le is currently President-Elect of the National Network for Oral Health Access (NNOHA) and Immediate Past President of the Western Clinicians Network (WCN). Dr. Le has appointments as an Associate Clinical Professor at University of California San Francisco (UCSF) School of Dentistry and Assistant Clinical Professor at A. T. Still School of Dental and Oral Health. She is California Assistant Director of Lutheran Medical Center Advanced Education in General Dentistry (AEGD) residency programs. On behalf of NNOHA, Dr. Le has collaborated with the ADA, ASTDD, and other organizations on various projects related to EHR. In November, 2008, NNOHA s HIT Workgroup published its first white paper titled : Using HIT to Improve Oral Health Access and Outcomes. Dr. Le received an Outstanding Clinician Award from NNOHA in 2007, Outstanding Contributor Award from the California Pipeline Program in June, 2009, and Outstanding Service Award in Community Partnership from UCSF School of Dentistry in July, Her oral health program at Asian Health Services, in collaboration with UCSF School of Dentistry, has recently been awarded a multi-year research grant by National Institute of Health (NIH). In March, 2009, she was appointed by California Governor Arnold Schwarzenegger to serve on the state Dental Board of California. She is serving her second term on the board where she was recently elected to be Vice-President. Dr. Le also serves on California Managed Risk Medical Insurance Board (MRMIB) Dental Advisory Leadership Group, in California. She was also a member of the National Association of Community Health Centers Dental and Behavioral Advisory Workforce Report Group in Dr. Le is a graduate of Baylor University, University of Texas Dental Branch in Houston, and General Practice in Hospital Dentistry Residency at Loma Linda VA Hospital. Dr. Le is a Fellow of American College of Dentists. Dr. Le is working on her MA in Dental Education and is expected to receive her degree in December Margaret Drozdowski Maule, DMD, MBA: Dr. Margaret Drozdowski Maule received her undergraduate degree from St. Joseph s College and her graduate degree from the University of Connecticut School of Dental Medicine in She completed her residency training in Advanced Education in General Dentistry also at the University of Connecticut. She earned an MBA degree from Cornell University in May, Dr. Drozdowski Maule spent three years in private practice before joining Community Health Center, Inc. in Connecticut in September Since 200, she has served as the Dental Director for the agency. Currently, Community Health Center, Inc has seven locations throughout the state of Connecticut operating 46 dental chairs, and over 10 mobile dental delivery sites. Dr. Drozdowski Maule continues a general dentistry practice at the New Britain site. She has a faculty appointment at the University of Connecticut School of Dentistry and participates in clinical supervision of AEGD residents and 4th year dental students. In 2008, she was named as one of 40 under 40 outstanding graduates of the University of Connecticut. Dr. Drozdowski Maule also serves on the NNOHA Board of Directors. NNOHA Staff: Annette Zacharias Executive Director [email protected] Mitsuko Ikeda Project Director [email protected] The National Network for Oral Health Access (NNOHA) The National Network for Oral Health Access (NNOHA), a 01(c)3 non-profit organization, was founded in 1991 by a group of Health Center Dental Directors. They recognized that peer-to-peer networking, services, and collaboration could improve operations of Health Center oral health programs that serve underserved populations. NNOHA has a diverse membership of safety-net oral health providers: Dental Directors, dental hygienists, and their support teams, who understand that inadequate access to oral health services can adversely affect a person s speech, appearance, health, and quality of life. To better serve these low-income individuals, NNOHA coordinates efforts to benefit community, migrant, and homeless Health Center oral health programs across the United States. NNOHA communicates with its members and supporters via: An online forum where colleagues can post questions, share advice and network A quarterly newsletter in both electronic and hard copy formats The website, which includes contact info, links, and reference materials, including the Dental Operations Manual and a dental forms library The annual National Primary Oral Health Conference, where members can obtain Continuing Education credits, network, and learn the latest oral health best practices. For more information visit Maria Smith, MPA Project Coordinator [email protected] Irene Hilton, DDS, MPH Dental Consultant [email protected] Jennifer Hein Operations Manager [email protected] Barbara E. Bailey, RDH, PhD Interim Executive Director 92 93

49 The National Network for Oral Health Access (NNOHA) The National Network for Oral Health Access (NNOHA), a 01(c)3 non-profit organization, was founded in 1991 by a group of Health Center Dental Directors. They recognized that peer-to-peer networking, services, and collaboration could improve operations of Health Center oral health programs that serve underserved populations. NNOHA has a diverse membership of safety-net oral health providers: Dental Directors, dental hygienists, and their support teams, who understand that inadequate access to oral health services can adversely affect a person s speech, appearance, health, and quality of life. To better serve these low-income individuals, NNOHA coordinates efforts to benefit community, migrant, and homeless Health Center oral health programs across the United States. NNOHA communicates with its members and supporters via: An online forum where colleagues can post questions, share advice and network A quarterly newsletter in both electronic and hard copy formats The website, which includes contact info, links, and reference materials, including the Dental Operations Manual and a dental forms library The annual National Primary Oral Health Conference, where members can obtain Continuing Education credits, network, and learn the latest oral health best practices. For more information visit PMB: 329, 3700 Quebec Street, Unit 100 Denver, CO Phone: Fax: [email protected] Web: Follow us on Facebook ( and Twitter (