PennWell Dental Community
EHR Debate of the Century - Pruitt vs. All Comers
Kevin Henry, editor for Dental Economics, has invited healthcare IT experts other than me to a debate concerning electronic health records in dentistry.
http://community.pennwelldentalgroup.com/forum/topic/show?id=201342...
When I read that he was entertaining questions for a panel of experts, I hammered out twenty or so questions in less than five minutes and posted them below his comment. Every one of my questions is a subterranean stinker except for the last two. Those two are as sweet as honey. This could be fun.
I have to assume that the other unnamed and unarmed experts are healthcare IT stakeholders, not principals like me. Since I’m defending my patients’ turf instead of the price of a company’s stock, I cannot and will not lose. This could get exciting. Wake the kids. I’ll also do my best to spread the word about the train wreck in my own way.
I must take this opportunity to acknowledge the courage of PennWell and specifically Mr. Henry for stepping out in front of the vast silent, lost crowd to offer consumers transparency at last, and perhaps just in time. I will never forget your help in my efforts to salvage evidence-based miracles that my future grandchildren might still be able to enjoy, if we’re lucky.
“The events going on right now are the seeds of a unification of faith and honor of all thirteen colonies on our continent. The smallest fracture between us now will be like a tiny carving into a small oak sapling, which will grow large over time, and future generations will be able to read our failure in giant letters.” Thomas Paine, Chapter III, “Common Sense.” 1776
If we are to reap miracles from Open Source Evidence-Based Dentistry, we cannot afford to disappoint our patients the first time out with a loser EHR that ADA President Dr. John Findley says dentists will have to accept - regardless of the Hippocratic Oath. The interoperability that Findley does not understand but nevertheless promises the nation will never be realized if leadership continues with this reckless, parasite-infested course in healthcare IT adoption.
Open-Source EBD using trustworthy data will only get one chance at trust. Contrary to what Findley says, EHRs are not inevitable. It is abysmally foolish for a bureaucrat to suggest that the nation’s dentists, 85% of whom are sole-proprietor small business owners, will abandon their own Constitutional Rights for the common good. That is being far too generous with others’ rights, Dr. Findley.
Until both dentists and patients trust EDRs, interoperability simply will not happen anywhere. Consider this: EMR adoption by physicians is going so badly that HHS Secretary Michael Leavitt had to bribe 1200 physicians just to try EMRs. Do you know the difference between EMRs and EDRs? EMRs make tremendous sense.
How many dentists will the next Secretary have to bribe? Taxpayers should be warned that investing in EHRs in dentistry is a waste of healthcare dollars until Personal Identification Information (PII) is removed from them. What, I ask you, could be simpler than that? “And what about the interoperability with physicians’ records?” a deeply-rooted healthcare IT stakeholder might timidly ask. Forget the MDs. Forget Newt Gingrich. Forget ONCHIT. And especially, with extreme prejudice, forget the National Association of Dental Plans (NADP). Let’s set up our own system, with or without the ADA, collectively fine tune it to our own needs which only practicing dentists truly understand, and make the opportunists come to us for once, damn it. Just because physicians’ practices are so terribly infested with parasites that they cannot move into the future should not stop dentists from leading the way using precedent-setting innovation in a free market.
Even before Secretary Leavitt addressed the ADA House of Delegates in 2006, which Kevin Henry mentioned in the invitation to the coming debate, I wrote that maintaining EDRs with personal information is like storing bombs with fuses. It is still earthly stupid. So are we, the nation’s dentists, going to sit back in our lawn chairs and watch for the muddy explosion? Not me. I’m going to defuse the sucker. You just sit back and watch. Darrell K. Pruitt DDS
cc: spamgroup
http://community.pennwelldentalgroup.com/forum/topic/show?id=201342...
When I read that he was entertaining questions for a panel of experts, I hammered out twenty or so questions in less than five minutes and posted them below his comment. Every one of my questions is a subterranean stinker except for the last two. Those two are as sweet as honey. This could be fun.
I have to assume that the other unnamed and unarmed experts are healthcare IT stakeholders, not principals like me. Since I’m defending my patients’ turf instead of the price of a company’s stock, I cannot and will not lose. This could get exciting. Wake the kids. I’ll also do my best to spread the word about the train wreck in my own way.
I must take this opportunity to acknowledge the courage of PennWell and specifically Mr. Henry for stepping out in front of the vast silent, lost crowd to offer consumers transparency at last, and perhaps just in time. I will never forget your help in my efforts to salvage evidence-based miracles that my future grandchildren might still be able to enjoy, if we’re lucky.
“The events going on right now are the seeds of a unification of faith and honor of all thirteen colonies on our continent. The smallest fracture between us now will be like a tiny carving into a small oak sapling, which will grow large over time, and future generations will be able to read our failure in giant letters.” Thomas Paine, Chapter III, “Common Sense.” 1776
If we are to reap miracles from Open Source Evidence-Based Dentistry, we cannot afford to disappoint our patients the first time out with a loser EHR that ADA President Dr. John Findley says dentists will have to accept - regardless of the Hippocratic Oath. The interoperability that Findley does not understand but nevertheless promises the nation will never be realized if leadership continues with this reckless, parasite-infested course in healthcare IT adoption.
Open-Source EBD using trustworthy data will only get one chance at trust. Contrary to what Findley says, EHRs are not inevitable. It is abysmally foolish for a bureaucrat to suggest that the nation’s dentists, 85% of whom are sole-proprietor small business owners, will abandon their own Constitutional Rights for the common good. That is being far too generous with others’ rights, Dr. Findley.
Until both dentists and patients trust EDRs, interoperability simply will not happen anywhere. Consider this: EMR adoption by physicians is going so badly that HHS Secretary Michael Leavitt had to bribe 1200 physicians just to try EMRs. Do you know the difference between EMRs and EDRs? EMRs make tremendous sense.
How many dentists will the next Secretary have to bribe? Taxpayers should be warned that investing in EHRs in dentistry is a waste of healthcare dollars until Personal Identification Information (PII) is removed from them. What, I ask you, could be simpler than that? “And what about the interoperability with physicians’ records?” a deeply-rooted healthcare IT stakeholder might timidly ask. Forget the MDs. Forget Newt Gingrich. Forget ONCHIT. And especially, with extreme prejudice, forget the National Association of Dental Plans (NADP). Let’s set up our own system, with or without the ADA, collectively fine tune it to our own needs which only practicing dentists truly understand, and make the opportunists come to us for once, damn it. Just because physicians’ practices are so terribly infested with parasites that they cannot move into the future should not stop dentists from leading the way using precedent-setting innovation in a free market.
Even before Secretary Leavitt addressed the ADA House of Delegates in 2006, which Kevin Henry mentioned in the invitation to the coming debate, I wrote that maintaining EDRs with personal information is like storing bombs with fuses. It is still earthly stupid. So are we, the nation’s dentists, going to sit back in our lawn chairs and watch for the muddy explosion? Not me. I’m going to defuse the sucker. You just sit back and watch. Darrell K. Pruitt DDS
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Replies to This Discussion
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Permalink Reply by Jill Kring Carter on -
At 10:45am on October 26th, 2008, Darrell Pruitt said…
Jill, I am enjoying our conversations.
“While I agree with you on some things and not others…” Please share with me what you don’t agree with, and I will tell you why you are wrong.
Over the last couple of years, I cannot tell you how many times I have heard a qualified agreement like yours, almost word-for-word. Yet invariably, nobody will go the next step and tell me what they don’t agree with. Is it any wonder why I became a bully?
The last time this happened was in March of this year when Dr. James Bramson told me the very same thing. He said that he liked some of my points, but that he also did not agree with everything I said.
In my last email to him, I pleaded with him: “Tell me where I am wrong, Jim. Don’t make me guess.”
I never heard from Dr. Bramson again. He was fired as executive director of the ADA less than a month later and as yet no explanation has been given. After about a month, they shut down his email. As far as I can tell, he is out of touch.
Until I heard he was fired, I thought I was making rapid progress with my goals. Oh, the memories, Jill.
Here’s some breaking news for you. Healthcarefinancials picked up the news about the EHR debate of the century.
http://healthcarefinancials.wordpress.com/2008/10/26/the-great-ehr-...
About that army… I bring a quiet but attentive crowd. Darrell
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Permalink Reply by Jill Kring Carter on
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Darrell, I too am enjoying this. It's about time, eh?
So, in answer to your question. It's very simple, really. I agree that EDR, alone, is completely and utterly, unnecessary.
That said, with the knowledge of the importance of the oral/systemic link; how dental work can impose risk on some depending on their health status, and how dentists are finally enjoying more recognition for what they are - another of the many, vital specialties of health care - the dental record, as importantly as that of the PCP, GYN or Oncologists record, must...all....be.....connected. So, this, I suppose, is one thing on which we disagree.
I believe EHR solves the issue of connectivity of the patients "complete" (including dental) record, and I believe a complete dental record is vital, especially in a time when the technology allows for it. Yes, it's in its infancy stages and is far from perfect, and yes, providers must partake in this for the eventual common good (I think we disagree on that as well). I also use this analogy, though not medical - ATM technology at one time couldn't talk to another bank, and we all cussed at that. Now, most of us can't imagine life without ATM's - life without the bank in Iowa (or Germany for that matter) talking to my bank in PA and giving me my cash when I need it. Want a medical analogy? Remember when all we had was X-ray? Now we have U/S, CT, PET, BAT, MRI - and thank god, cost or not. There was a lot of adjustment/adapting as imaging technology evolved, and much cost, but also much better diagnosis (due to better information), and thus, better care.
As for the importance of total connectivity via eventual interoperability (which will of course take time with evolution of the technology), there is no better example than the patient who came in to have an extraction, and when asked if anything had changed in her health status, replied with "No", not once, but twice, both the the EFDA and the DMD, but as she exited the operatory and went to the desk to make her follow-up appt., she made note to a receptionist who asked how she’s been feeling, how “the CHEMO has just been EXHAUSTING” …………………
Patients do not understand the importance of all providers being made aware of all health issues. Hell, even many dentists don't yet get it yet, and that is just scary. EHR will, and I do say, eventually, solve so many problems as it relates to quality of care through that simple thing called "Complete, accurate and current information."
That said, I fully agree with you on the issues and concerns you have of payors using data to grade quality. Reality is though, they've been doing it all along with your current identifiers.....the NPI is designed to be void of certain identifiers, and thus, eventually, as it all gets perfected, will do just that, OR, it will go away entirely, if you win your battle to remove the NPI, rather than perfect it to be what it was designed to be in the first place - a streamlined, and eventually, universal method.
Finally, you need not try to convince me I am ‘wrong’ on any of this. There is no right or wrong on this. There is only the camp that wins the most votes in the end. That said, I encourage you to fight it with everything you have, because it is you and your developing army, who will help insure that quality and security issues continue to be addressed all along the way, ultimately resulting in a truly effective electronic records system that delivers on the goal – interoperability delivering access to complete, accurate and current information, resulting in better care for everyone.
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Permalink Reply by Darrell Pruitt on -
“That said, with the knowledge of the importance of the oral/systemic link; how dental work can impose risk on some depending on their health status, and how dentists are finally enjoying more recognition for what they are - another of the many, vital specialties of health care - the dental record, as importantly as that of the PCP, GYN or Oncologists record, must...all....be.....connected. So, this, I suppose, is one thing on which we disagree.”
Jill, I told you that I would tell you why you are wrong. Here it is: We don’t disagree.
Of course dentistry needs interoperability with MDs, but we simply cannot get there from here. Dentists could be almost 90% plugged into the Internet with safe, de-identified data long before the physicians can even begin to stop the hemorrhage of not only PII, but also medical IDs.
We must think laterally.
Why in the world do we want to adopt the paralyzing HIPAA problems that the physicians are experiencing?
“We may need to solve problems not by removing the cause but by designing the way forward even if the cause remains in place.” Edward de Bono - pioneer of Lateral thinking (Wikiquote).
Nobody is interested in dental records, yet HIPAA will not go away. Why create a black market for dental records by attaching medical reports that dentists may not request, even if they are trained to interpret them? Find another way to share dangerous information, and share it only as it is necessary and only with those who need the information to perform their duties. There are such things as flash drives, you know.
There is no reason for a dental assistant to know a patient’s birth date, much less their social security number. First and last names work well in society - middle initial as needed. Outside California, first and last names are not included in HIPAA-protected information. California spawns a truckload of new ideas. Some are bad.
Just because there is a mandate does not mean that rational thought should cease.
I’ll take up more of your points soon. Darrell K. Pruitt DDS
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Permalink Reply by Jill Kring Carter on
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Hitting on just a couple points here, because I won't engage in 'right and wrong' arguments over 'personal opinion.' This is all a matter of opinion - every last piece of the arguments set forth here.
So, I reiterate from an earlier post that the better medical systems, which have evolved, allow for assigning user rights to the nth degree. And, you are right, the CDA/EFDA needn't know certain things, and needn't see them. But the early systems hadn't thought of this then, but with evolution and attention paid to the issues, assigned rights by the administrator have become more and more (to the point of exceedingly) custom. There is no reason why this evolution can't be pushed for on the dental side as well.
In the meantime, we agree that HIPAA has become a joke in medicine and needn't be put upon dentistry as well, thus, everyone who agrees needs to simultaneously argue for its eradication, or at worst, complete overhaul.
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Permalink Reply by Darrell Pruitt on
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For you, these are only opinions. For me it is right vs. wrong. And you are wrong, in my opinion.
When one cannot distinguish right from wrong, one is likely to contradict oneself. Let me give you an example.
“There is no reason why this evolution can't be pushed for on the dental side as well.”
“HIPAA has become a joke in medicine and needn't be put upon dentistry as well.”
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Permalink Reply by Jill Kring Carter on
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I'm talking about the evolution of electronic records - the technology itself - not the HIPAA issue specifically - in that post. HIPAA is a joke, and certainly must be addressed - either thrown out and started over, or radically modified.
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Permalink Reply by Darrell Pruitt on
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Sorry. I misunderstood.
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Permalink Reply by Darrell Pruitt on
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We agree once again. HIPAA is a blunder, but future EDRs can certainly use the advances in software technology that have already been developed and proven in the medical field - we just don’t need very much of it, and we don’t need HIPAA.
Dentistry is a simple business. For decades, very busy practices ran efficiently using only pegboard, ledger cards and lots of carbon paper. The bottleneck in dentistry is not the front desk, it is the speed of the dentist. If it was not for intentional complications caused by insurance companies, dental office employees could be laid off - saving even more money on healthcare.
It is no wonder that physicians’ practices need computers. On top of all the complicated hoops it takes just to get paid these days, in the 1970s, family practitioners could make a living seeing 15 to 20 patients a day. Now they see 40 to 45 to make less money. That is three times the traffic. That is a lot of paperwork, even if it is done on a computer.
Some MDs carry alarms to alert them when it is time to move to their next patient. I have a little redhead kid later today that I don’t know how long it will take to keep him still long enough to inject local anesthetic.
Dentistry is not like whole-body medical care. Interpreting test results is a miniscule part of my practice. In my line of work, most of the time I’m busy with my hands - concentrating on engineering-type of problems.
It takes longer now to extract a tooth than it did 30 years ago simply because of the ever-increasing paperwork - which nobody reads before signing. How long would it take if patients actually read what they sign?
Because of the terrible changes that were made to HIPAA in the 2003 amendment that was rushed through Congress, computers are now complicating dentistry. Complications like HIPAA and the FTC’s “Red Flag Rules” require more staff, more paperwork and yes, more computer power. Insurance companies hire clever actuarial experts to design strategic complications which never benefit dental patients. Soon, if we don’t wake up, those same insurance companies will be determining dentists’ value and posting it on the Internet using dentists’ NPI numbers and FOIA-disclosable data. Did you notice that HIPAA was modular? Many dentists still don’t realize that the NPI number is HIPAA, and very few know how permanent the identifier is.
Insurance companies and countless other stakeholders cause complications for leverage, sometimes threatening to delay payments to dentists. HIPAA gives them a handle.
That’s my opinion.
Darrell K. Pruitt DDS
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Permalink Reply by Jill Kring Carter on
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A M E N - on every count.
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Permalink Reply by Jill Kring Carter on
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I must amend what I just said with regard to access to the info by those in the practice. I DO think the EFDA, like the RN or LPN, has every right to see health information of a patient, just as the MD, DO, DC , PT, DMD or DDS does. They are involved, directly, in patient care and treatment, and as such, face the same risk of malpractice and such for their actions or errors - like the woman who didn't tell her dentist OR the hygienist that she was undergoing chemo therapy at the time of her extraction.....
Only too often I've witnessed a nurse, assistant or hygienist point out something potentially serious that the doctor had missed with regard to patient information.....those patients can only be thankful they knew the information, and thus, pointed it out.
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Permalink Reply by Darrell Pruitt on
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This is wild. Our messages must be spread out all over this forum, crossing paths. I have to review the previous topic to figure out where I am in the conversation. It is like playing multiple chess games simultaneously.
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If your amendment for enabling assistants to have access to dental patients’ entire medical history is your argument against segmenting EDRs, it is lame. What can possibly be the advantage in having everything in one huge complicated basket?
Give dentists control of who sees what, and don’t leave PII on the computer at night. After all, it’s the dentist’s butt when things go wrong.
Once again, don’t assume computers will solve the problem of incomplete records. They won’t.
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Permalink Reply by John J. Ryan, DMD on -
Just more analogies of what dentists see coming and for which we are rightly concerned about EHRs. Our primary concern is for protecting our notes and doing what we need to do to protect those notes for our patients. It is nearly the last thing that we truly have control over in the best interest of our patients. Records are held to the utmost privacy within our practice’s structure. My active and archived files are in fire-proof shelving where accesses to them are alarmed by code. Inside the files contain private information justified in ink with no white-out allowed. Corrections are a clear solid line with noted correction and initialed. Walk down our path for a moment and imagine this intrusion onto your profession with somewhat a partial list of hypothetical statements. This is what the primary advocates of EHRs are basically selling to us dentists, which we see as pretty gruesome:
1) "We'll take over your dental record requirements from here..."
2) "..the last tool you truly have control over for making assessments and decisions;"
3) "...we'll put our proprietary controls and limitations on it that best suits our stakeholders' interests. We may throw in some bells and whistles that you have to pay for because we think it looks better this way..."
4) "...we may take on additional third-party interests as our relationship progresses, and have the right to interject additional nuances that we control that you will have to pay for and comply with by law..."
5) "...we'll be enclosing a disclosure for you to sign releasing us from YOUR errors regardless of any technical errors or glitches on our part. This further releases us from any errors of yours or your staff's parts. In summary, releasing us and holding you fully accountable to the law for errors, regardless of innocent human typographical or input errors, where you may be made a spectacle of by example..."
6) "...we have partnered with the ADA and the HHS to be certain to make certain you are in compliance with EHR compliances, and will send the EHR compliance police to fine you and possibly shut you down for any non-compliance and/or if any disgruntled and protected party chooses to file a complaint..."
7) "...we'll send the FTC your way if you band together with other dentists to oppose the mandate….”
8) “…if for any reason, your office is shut down or closed, you will be required to continue to pay our monthly maintenance fees for maintenance of your patients’ records by law and where non-payment is noted, we'll notify the proper authorities for non-compliance while we reserve the right to take you to court for on-going payments..."
9) "...we need you to sign and/or acknowledge this disclosure, for our protections, that you immediately take the time and expense to properly notify all involved parties, and possibly buy air time for an immediate public announcement in the event you didn't keep to snuff what we forced down your throats. This applies regardless of your technical expertise, if any technical information is hacked into or stolen..."
10) "...we need you to sign and/or acknowledge to hold us harmless as you may be shut down and considered guilty until proven innocent if any complaint is filed by a disgruntled party, noting they are protected by the whistle-blower act and have every right to file a bogus complaint, where the legal expense is not our responsibility and where we are released fully form any such claim..."
11) "...in New Hampshire, your requirement is to keep dental records are for life, so you will be expected to cover the ongoing upgrade costs for continual conversion and migrations. You will also need to purchase equipment necessary to provide persistent access in the forms and formats we tell you to have for; paper, microfilm, x-rays, inter-oral photographs, photographs and prescriptions, and whatever else we decide you must make electronic..."
12) "...it is your responsibility, not ours, to use our software while promising to safeguard access, protect patients' privacy, even if and when you change your staff, or an associate or yourself leaves to join another practice, whether or not practices merge, or whether or not you file for bankruptcy..."
13) "...you will hold us harmless, with protection under the new EHR interoperability laws for insurers' protection (obtained through lobbyists) that while our stakeholders may strike up relationships with your insurance providers, in the best interests of their stockholders and low loss ratio concerns, that we may use your records for as much as, but not limited to, red-flagging/cherry-picking to be used "against" your patient as the insurer is more concerned with using his VIP perks on a holiday for maintaining low loss-ratios than the health of your patients..."
14) "...as it is our decision to push the EHR concept to the ADA, HHS, legislators and your patients, any action(s) on your part that opposes our goodwill will be deemed as your creating of harms onto us. In general terms of any of your negativity, even when explaining the potential risks and costs of the system that may increase your fees, where we plan to not adequately address, for our own sakes, you will be sued for slander..."
Is it a surprise that dentists and physicians with insight to the certainty of travesty that will occur with EHRs, see that such a phenomenon is beyond gruesome. Aside from being the most intrusive underwriting invasion tool in United States history, EHRs do nothing to fix or clean a tooth. And while it also does nothing to remove dental pain, EHRs would result the most expensive blunder and most difficult process to maintain and protect the privacy rights of patients. Beyond hours of wages to be paid for its use that most practices would suffer, the costs of its technical purchase, training and on-going upgrades and maintenance needed to protect the rights of patients and dentists alike could cause the 20-somethings to choose another profession; cause the 60-somethings and up to go into retirement, cause every professional in the middle to adjust their pricing accordingly against their will and desire. Sorry if I sound a little better; either have been down these roads before, or know of those who have.
Jack Ryan
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General dentist in Fort Worth, Texas. I surround myself with the most wonderful staff and the kindest patients in the nation. It is our mutual confidence and respect that grants me the freedom to stand nose-to-nose with anyone in the marketplace. I’m blessed. And I like to write.
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