Mission Possible: Using HIT to Integrate Dental and Medical Care

December 16, 2015

Today’s post is by Colin Reusch, senior policy analyst, Children’s Dental Health Projectcolin headshot

For the most part, electronic health records (EHRs) for dental and medical care remain completely separate in both private and public insurance programs even when health insurers have assumed responsibility for dental benefits. In addition, Medicaid programs as well as their contractors often carve out dental services to a third party benefit or claims manager. Even in integrated hospital systems and community health centers with co-located medical and dental services, integrated health records systems are rarely present.

In addition to separate entities often being responsible for medical and dental benefits, the goal of integrated health information technology (HIT) for medical and dental care is hindered by the lack of common coding systems, software, and interoperability. For example, the coding nomenclature used in dental records is almost exclusively for billing whereas medical records use diagnostic codes.

It is, therefore, no small aim to have either a common EHR system for medical and dental providers or even interoperability of software across the two domains. While not wholly unattainable on the grand scale, it may be useful to consider a more incremental approach. State Medicaid programs, hospital systems, community health centers with co-located services and policymakers may be able to incorporate more simple electronic mechanisms to address the most pressing of concerns with regard to coordinated oral health care delivery.

HIT integration – technical by definition – requires a renewed focus on what is most important from a patient health perspective rather than a program or provider perspective.

The following are two illustrations of the “so what?” of dental-medical HIT integration:

Complex medical conditions
Because oral health is an essential component of overall health, it is not surprising that oral health conditions such as tooth decay impact the delivery of care for some health conditions. For example, addressing oral infections is a primary concern for physicians of patients with heart conditions. In addition, certain heart conditions may complicate the treatment of severe tooth decay.

Colleagues in Washington, D.C. shared with us an example of a child with a complex heart condition who was referred by a pediatric dentist to undergo treatment for cavities under general anesthesia. While the patient was placed on a waiting list for the operating room, there was no communication between dental providers and the patient’s’ cardiologist. The patient’s parent ultimately canceled the dental surgery, fearing that general anesthesia would adversely affect the patient as a result of the heart condition. As a result of delayed treatment, the patient’s tooth decay progressed significantly. Lack of provider coordination further delayed the treatment as the patient had not yet been cleared for dental surgery by the cardiologist.

A shared EHR would have made both medical and dental providers aware of conditions and pending treatments and could have facilitated the communication necessary to address the child’s condition in a timely manner. However, even a bit of low tech case management could have made a world of difference in coordinating care. An electronic marker for referral to dental treatment under general anesthesia could have triggered this.

Referral, care coordination and common service delivery
The primary care setting is one of the largest missed opportunities for addressing oral health early in life. Data indicate that the vast majority (nearly 80%) of Medicaid-enrolled children aged 1-2 years are receiving routine medical screenings such as well-child visits from primary care providers like pediatricians but only about 1 in 5 of those children receive any preventive services in the dental setting, suggesting that most are not seeing a dentist this early in life. Unfortunately even fewer are receiving oral health services from their primary care providers. However, with increasing emphasis on early dental visits and the institutionalization of oral health care in the pediatric setting, the issue of care dental coordination is critical.

The electronic coordination of common services such as oral health risk assessments and fluoride varnish by medical dental providers is essentially nonexistent in all but the most cohesive systems of care. For children deemed at moderate to high risk for cavities, both pediatric and dental offices should have access to information about diagnosis and treatment in order to provide appropriate and timely individualized care. In addition, the referral of high risk patients would be greatly facilitated by automated electronic communications between providers at the very least, and patients with complex medical issues may benefit from a team of providers keeping an eye on their health through a more collaborative approach.

Shared codes for common services and risk-level markers could be integrated into EHRs. Payers with shared responsibility for a patient’s medical and dental care may also be able to facilitate more robust electronic communication across providers when necessary.

3 Responses to Mission Possible: Using HIT to Integrate Dental and Medical Care

  1. Mary Moran Boudreau says:

    Thank you, Colin, for this blog which clarifies the current situation and steps forward to integration. It does seem daunting to “do it all” but each step is essential. Though our organization has taken very small baby steps into this arena, this may be our stepping stone for more action in this area.

    • Colin Reusch says:

      Doing it all at once is certainly an undertaking and given the historic separation of IT systems, nobody should be under the illusion that full integration can be achieved overnight or even over the course of a couple of years. But we have to start somewhere and I’m glad to hear that advocates at the state level see it as a priority.

  2. The EHR problem is huge, especially at the front end, in the actual provider offices. Systems are different across dental offices and between dental and medical offices. It will be difficult to integrate those disparate systems. At the back end, claims payment, the dental and medical systems may also be separate.

    On a more positive note, we, the Connecticut Dental Health Partnership, the dental plan for HUSKY Health, now have access to both the dental and medical claims data for our clients. This doesn’t help directly on the front end, but it does give us the ability to link medical and dental care after the fact. Our first project is to attribute our clients to their medical doctor. Then we can look at dental utilization by medical office and use that to target outreach to medical offices, initially for perinatal women and young children. There are challenges working with the data and we are resolving them. Most claim system don’t focus on where and who is providing the service, just who is getting paid. We are fortunate to have a single payer for both medical and dental claims.

    We also coordinate complex cases, although on a ‘manual’ basis, between dental and medical providers. The ability to look up medical claims is helpful, but and integrated HER would certainly be better.

    As to the care received by very young children in Connecticut, according to a recent analysis by CT Voices for Children, HUSKY A clients under the age of three have a preventive utilization rate of 40.4% and a treatment rate of 1.9%. The preventive rate was 24.1% in 2009 and the treatment rate was 2.6% in 2009, so the trend is good and in the right direction.

    The rates for oral assessments and fluoride varnish application are also improving. According to another report done recently by CT Voices, the number of children age five and under, who received one of those services by a medical provider, increased from 1.5% of that population to 7.8% from 2010 to 2014. That’s a good increase, but more can be done. In discussions with pediatric PCP offices and the folks doing the training for those codes, the barrier seems to be resistance by the medical office. We plan to meet soon to develop strategy to overcome that.

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