Electronic Dental Records (EDR): 'Open Source' and Commercial-Off-The Shelf (COTS) Solutions

Shepherdstown 23 August 2010Approximately 90 percent of all dentists in the U.S. now use computers in their practice. Dental informatics, a subfield of health informatics, is focused on the application of computers, telecommunications, and information science to improve all aspects of dental practice, including management, clinical care, education, and research. Use of electronic dental record (EDR) systems can boost a practice's bottom line, while directly benefiting patients. They can help reduce operating costs, streamline workflow, improve quality of care, and enhance patient safety. This article is designed to offer a high level overview on the development of computerized dental systems to date, highlighting examples of selected 'open source' and commercial-off-the-shelf (COTS) solutions. The article also offers a set of conclusions on the current state of dental information systems and a number of management recommendations.

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Dentistry

A dentist is a medical professional who has advanced knowledge of teeth, gums and mouth care and dental science. Two classifications for dentists include Doctor of Dental Surgery (DDS) and Doctor of Medical Dentistry (DMD). Dental hygienists and dental assistants within dental offices do many of the routine tasks such as dental cleanings, taking X-rays, simple maintenance and educating patients in sound oral hygiene practices.

Dentists care not only for teeth and gums, but also for the muscles and bones within or supporting the mouth. They may also perform surgeries within or around the mouth to promote dental health, improve appearance and prevent disease. The majority of dentists are private practitioners.

See http://education-portal.com/what_does_it_take_to_be_a_dentist.html

Software Solutions - Overview & Examples

The dental software industry has grown considerably over the past several decades. There are currently well over 40 commercial vendors that provide dental practice management, electronic dental record systems, and dental imaging systems for dental offices. Some of the leading commercial dental systems companies include Dentrix, Patterson Eaglesoft, Easy Dental, SoftDent, and PracticeWorks.

In a 2006, a JAMIA article entitled "Clinical Computing in General Dentistry", reported that 80 percent of all dental practices they surveyed were using a dental practice management systems. The article also reported that 70 percent of the dental offices surveyed used at least one other clinical software application, e.g. digitized dental imaging. The study also reported that approximately 25 percent of all general dentists were using a computer at chair side. More recent articles report the number has grown, with approximately 90 percent of all dental practices now using computerized dental systems. See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513654/

Three major categories of dental information have tended to dominate the field of dental informatics - practice management systems, electronic dental record (EDR) systems, and dental imaging systems. Practice management systems are primarily focused on patient demographics, appointment scheduling, billing, and management reports. Electronic Dental Record (EDR) systems are used to record diagnoses, dental history, progress notes, treatment plans, allergies and other clinical information. Dental imaging systems are used to capture, store and display digitized dental images and x-rays. Imaging systems are often interfaced with the practice management of EDR systems.

Practice Management & EDR Systems

Practice Management Systems are now installed in well over 80 percent of dental offices in the U.S. Electronic Dental Record (EDR) systems are currently installed in approximately 40 percent-60 percent of dental offices. What follows is a brief description of major commercial off-the-shelf (COTS) and 'open source' practice management and EDR systems.

Commercial-Off-The-Shelf (COTS)

Dentrix - With nearly 30,000 installations and 20 years of experience Dentrix is one of the leading companies providing comprehensive dental practice management solutions. See http://www.dentrix.com

Patterson Eaglesoft - This is a comprehensive practice management and dental information system that includes patient registration, scheduling, billing, treatment plans, progress notes, charting, and integrated digital imaging modules. See http://patterson.eaglesoft.net

Easy Dental - This full-featured practice management, insurance billing, and charting system is currently used by over 20,000 dental professionals. See http://www.easydental.com

Kodak SoftDent - This comprehensive product suite includes a practice management system with patient appointments, billing, coding, as well as other add-on modules that include charting, dental imaging, and a mobile dental app that works with your smartphone. See http://www.kodakdental.com/practice-management-systems/softdent.aspx

Open Source and/or Public Domain

OpenDental - While this is an open source dental practice management solution, there is a $99 monthly charge for full service and support. Modules include patient scheduling, billing, accounting, charting, treatment plans, and imaging. See http://www.opendental.com

OpenMolar - This is an open source dental practice management software suite that includes patient appointments, patient dental records, treatment planning, billing , etc. For more information, visit https://launchpad.net/openmolar

Cattails Software Suite is well suited for organizations that provide both dental and medical services and want an integrated patient record solution for their practices. The Cattails Dental module being developed by Marshfield Clinic in Wisconsin is based on the open-source dental software platform - Open Dental. For more detail, see http://www.dentalinformatics.com/projectdirectory/show_project.html?project_id=64

Dental Clinical Management System (DCMS) is a free and open-source system developed by Mobigator Technology Group for dental practices. DCMS is a streamlined and standardized electronic system specially designed for dental clinics. DCMS provides a user-friendly front end and comprehensive functionalities, covering standardized image-enabled patient records, configurable treatment and billing plans, and integrated inventory, account and report management. See http://dcms.mobigator.com/pages/index.asp?lang=en

VA VistA Dentistry Module(s) - The Dentistry module of the comprehensive VA VistA electronic health record (EHR) system incorporates a wide range of features necessary for the maintenance of patient dental records in a large medical center environment. Users can register a patient, enter dental treatment data, edit dental records, review, and print reports, schedule appointments for patients, perform patient record inquiries, and print or transmit data electronically to update the VA centralized database. The Dentistry module is integrated with the VistA patient registration and clinic scheduling modules. It is also integrated with the VistA Imaging system. VistA Imaging integrates medical images, including x-rays, pathology slides, videos, scanned documents, x-rays, photos, dental images, etc., into the EHR/EDR to be viewed by clinicians. VA VistA software modules are in the public domain and can be freely acquired, much like other open source products. See www.va.gov/VISTA_MONOGRAPH/.../2008_2009_VistAHealtheVet_Monograph_FC_0309.doc

vxDRM Plus is an enhanced to the VA VistA system developed by DSS, Inc. Electronic medical record (EMR) functions of VistA are exposed within the vxDRM Plus application resulting in a comprehensive patient health record that includes both medical and dental information. The system uses a Graphical User Interface to communicate with the VistA system, allowing single point data entry of patient dental information. Some key functions include:

  • Entry of dental conditions, plans and completed procedures.
  • Integrated Upper/Lower/Full Views with full color coded graphics.
  • Sequencing of Treatment Plan procedures.
  • Dental History Reports and views with date-change capability.
  • Quadrant or Tooth summaries.
  • Head/Neck Findings availability.
  • Periodontal charting.
  • Full Mouth Plaque Index with definitions.
  • Creation and maintenance of tooth-specific and general patient notes.
See http://www.dssinc.com/dss-drm.htm?id=VPN

Other Dental Systems

PHR Systems

Personal Health Record (PHR) systems are broader than a facility's electronic medical record (EMR). The PHR should contain any information relevant to an individual's health, including dental information, eye exams, etc. The Medicare.Gov web site on PHRs advocates that dental data ought to be included in PHRs, including dental insurance information. See http://www.medicare.gov/navigation/manage-your-health/personal-health-records/learn-more-phr.aspx

Google Health allows you to select and self-enter a limited number of dental conditions and procedures from a drop-down box, as well as dental insurance information, into one's personal health record. See www.google.com/health/

MS HealthVault allows you to self-enter any condition or procedure you want in free text, this could include dental information. There doesn't appear to be a place to enter dental insurance information at this time. Visit http://www.healthvault.com

While patient interaction with PHR systems is still very limited, the National Dental EDI Council (NDEDIC) has recognized their importance and begun to focus on ensuring the participation of dental insurance stakeholders in the development of PHR systems.

HIE Solutions

The ability to move dental information between EHR, EDR, and PHR systems via a health information exchange (HIE) network is needed and growing in importance.

The National Dental Electronic Data Interchange Council (NDEDIC) provides a community portal created to facilitate the exchange of information and unite stakeholders advancing the value and utilization of electronic connectivity in the dental community.

The Dental Caucus, an informal industry group, brings together electronic data interchange (EDI) network stakeholder organizations to encourage the efficient utilization of EDI and to seek out enhancements and solutions that are designed to improve the interconnectivity process. It is especially interested in providing dental and dental benefits industry input into the ASC X12 standards-making process. See http://www.x12.org/x12org/industry/index.cfm

Utah Health Information Network (UHIN) - UHIN is an example of a state health information network that supports the dental community and is focused on helping to reduce costs for dental practices. Dental claims, payments, reports, and x-rays can be transferred electronically through UHIN. Electronic transactions are formatted in a national ANSI or X12file format. This ensures that anyone that is receiving or sending transactions can expect that the data will be in the same place in the file. For more information, visit http://uhin.org/pages/products-services/dental.php

Dental Imaging Systems

The DentalCompare web site lists some of the many alternative dental imaging products currently available. Visit http://www.dentalcompare.com/jump/42/Digital-Imaging.html. Examples include:

Kodak Dental Imaging Systems - Kodak offers a wide range of digital cameras, intra- and extraoral imaging systems, cone beam 3-D systems, imaging software, and accessories. See http://www.kodakdental.com/us_region/index.aspx#

Dexis - The Dexis Platinum digital X-ray sensors and imaging software integrates with most major practice management systems. See http://www.dexis.com

Imaging Sciences i-CAT is a leader in cone beam 3-D dental imaging for dental applications only. It provides high-definition, digital imaging at reduced cost with less radiation to the patient. See http://www.imagingsciences.com/pro_iCAT.htm

Mobile Dental Apps

We are seeing a major sea change at work - the emergence of mobile Health Apps, including Dental Apps, as part of the innovative fifth generation of multi-media computer interfaces for consumers and health care providers. Expect this space to continue to grow at a very rapid clip.

The following link provides a list of free or low cost Dental Apps for iPhones and/or smartphones that can be used by either dentists or consumers. See http://bibbynews.wordpress.com/2010/03/05/updated-list-of-iphone-apps-for-dentistry/

Some of the mobile dental apps listed include:

  • 3D Teeth
  • Dental Assistant
  • CheckDent
  • Mouth & Teeth
  • Dental Expert
  • Dental Encyclopedia

Conclusions & Recommendations

The following are a number of general observations, conclusions and recommendations by the author with regards to Dental Informatics:

The Dental profession has stepped out ahead of their physician counterparts with regards to the use of computer systems. Over 80 percent of dental offices currently use practice management systems and over 70 percent are using other software modules such as dental imaging or electronic dental records (EDR). Physicians and medical informaticists may want to look to the field of dental informatics for 'best practices' and 'lessons learned' in implementing information systems.

A focus on consumers and personal health record (PHR) are the next frontier to be conquered. All PHR systems need to capture a range of standardized dental information, from particular dental conditions and procedures to insurance and claims data, in addition to other medical and health related information. As patients become more focused on preventive health care, they will want to start carefully tracking the type of procedures performed, their frequency, and costs.

There has been considerable progress on data standards and mechanisms needed on electronic data interchange (EDI) of dental claims information. As the National Health Information Network (NHIN) continues to evolve, additional efforts need to be made to enhance the standards and capabilities of EHR, EDR, and PHR systems so they can exchange a wider range of detailed medical and dental data elements, including digitized dental images.

A new phenomenon is the emergence of free or lower cost 'open source' dental software solutions. This mirrors what is happening in the computer software industry as a whole. This should prove helpful to small practices that have been reluctant to make the somewhat costly investment in dental information systems, in the U.S. and around the world.

There needs to be increased collaboration between medical and dental informaticists on a wide range of solutions such as - PHR systems; HIE networks; mobile Health Apps; architecture & standards; privacy & security; and the creation of public health databases that contain both medical and dental information for use by public health organizations and researchers.

Dental Informatics - Selected References & Web Sites

Authors:

Peter Groen is an author, lecturer, independent consultant, former hospital CIO, and one of the founders of the Shepherd University Research Corporation (SURC). Email: groenpj@cs.com

Valerie Powell, Ph.D, is a professor at Robert Morris University specializing in health informatics. Email: powell@rmu.edu


Peter Groen, Valerie Powell

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