Get with the Program: Dental Sleep Medicine and Electronic Medical Records

by Richard B. Drake, DDS, D.ABDSM, and George S. “Gy” Yatros, DMD, D.ABDSM

“It has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in elucidation of the problem at hand, and each dependent upon the other for support.”

– William J. Mayo at 1910 commencement address to Rush Medical College

The implementation of electronic records in medicine and dentistry coupled with workflow redesign create a time-saving, efficiency-boosting leap forward for practices across the country.¹ Dentists lag slightly behind our physician colleagues when it comes to electronic records adoption. However, the trend is increasing, and one recently published article showed adoption to be 77% in a dental setting.² Electronic records adoption trends will continue to increase consummate to federal incentives, improved technical support, and further integration between medicine and dentistry. What impact does this have on dental sleep practices, what considerations should we give to these shifts, and what effects will it have on the future of our practices and our profession?

What’s in a Name? EMR, EHR, EDR, DSM, etc.

If you have practiced dentistry as long as we have, you likely remember filing cabinets overflowing with paper charts, peg systems for ledger entries, and countless envelopes containing radiographs that seemed to escape their proper homes and end up in the ‘mystery patient’ box. These cabinets contained sections for patient demographics, progress notes, ledger entries, health histories, personal notes, and insurance claims. We even used red and blue pencils to document our patients’ dental conditions. All the information we needed to treat our patients within our dental offices was contained within these files. They just weren’t easy to maintain. Nor were they standardized for others to efficiently access.

It’s difficult to comprehend how we operated over 30 years ago before we had electronic records. So, what is an electronic record?  Plainly stated, it is the same information contained within those reams of paper charts but organized into a digital format to improve workflow and patient care.

An electronic patient record is loosely defined as an information system designed to create, manage, and store data associated with a patient medical record. Since the 1980s, many terms have been used to refer to these records, including Computerized Patient Record, Computer Medical Record, and Automated Patient Record. Although these terms are frequently used interchangeably, the two most common terms for electronic records are defined by HealthIt.gov as:

Electronic Medical Records (EMRs): “Electronic medical records (EMRs) are digital versions of the paper charts in clinician offices, clinics, and hospitals. EMRs contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. EMRs are more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.”

Electronic Health Records (EHRs): “Electronic health records (EHRs) are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians involved in a patient’s care and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. EHRs also share information with other health care providers, such as laboratories and specialists. EHRs follow patients – to the specialist, the hospital, the nursing home, or even across the country.”³

EMRs are typically used in an office or group of offices to digitally maintain patient information for that specialty while also enabling that practice be more efficient through a synchronized, organized workflow. EHRs are designed to include a totality of the patient’s health information from various caregivers, labs, etc. and are designed to be shared among caregivers (and even the patient). Most electronic records utilized in dental offices today fit the definition of an EMR.

The American Dental Association

The American Dental Association (ADA) has stated their position on electronic health records. An Electronic Dental Record (EDR) is defined by the ADA as “a combination of processes and data structures, used by dentists, for purposes of documenting or conveying clinical facts, diagnoses, treatment plans, and services provided. For [ADA] purposes, EDR will be used interchangeably with EHR.”⁴

While there is no deadline or mandate to switch to EHRs for dental offices (unlike our medical colleagues), the ADA does emphasize that since 2015, dentists treating Medicare patients will be subject to payment adjustments if they cannot successfully demonstrate Meaningful Use.

What does Promoting Interoperability Programs (PIP), formerly referred to as ‘meaningful use’ mean for dentists and dental sleep medicine (DSM) practices? It primarily relates to reimbursement by federal programs such as Medicare or Medicaid via the Qualified Payment Program (QPP). If your practice is a Medicare or Medicaid provider, you may receive higher reimbursement for certain procedures if you qualify for Meaningful Use. But there is more to qualifying than just simply using a specific EMR. When considering whether to attain PIP certification, providers must weigh the non-trivial effort and cost against the potential increased income from higher reimbursement. In our experience coordinating with over 1,000 DSM practices, most find that the additional effort and expense involved with PIP compliance does not offset the additional income they might receive.

EDR vs. DSM EMR; The Choice is Yours

One significant barrier to EMR utilization has been the fact that many EMRs subscribed to a “one size fits all” approach that is detrimental to providers. In these scenarios, practices find the functionality limiting with tabs and features that are not applicable to the specialty or area of practice.⁵ Anecdotally, this has been reported by innumerable DSM clinicians, including the authors. EDRs were designed to store dental data and improve dental procedure workflow. Theoretically, you could devise a way to treat your patients and appropriately document treatment with an EDR or even a chiropractic EMR, but those methods generally do not provide efficient DSM workflow and DSM-specific patient documentation.

A DSM EMR can provide practices with systems, documentation templates, and workflow tabs relevant to compliance and efficiency particular to the field of dental sleep medicine. Examples of these software products include DentalWriter (Nierman Practice Management), imagn sleep software (Devdent), and DS3 (Dental Sleep Solutions, LLC). The following are some applications and functionality that DSM EMRs may provide: 

• Screening applications – The first step for dental offices getting involved in DSM is to have an effective system to help identify “at risk” patients. More than 22 million Americans suffer from OSA and an estimated 80% remain undiagnosed.⁶ This makes an effective screening tool a critical function.
• Patient portal for sleep and health history – Interactive patient portals streamline patient intake and minimize time in the office; this is especially important as practices strive to mitigate COVID exposure risk. Confirm that any portal you use is compliant with all Health Insurance Portability and Accountability Act (HIPAA) guidelines as expressed by Health and Human Services.⁷
• SOAP note creation – SOAP notes, an acronym for “Subjective, Objective, Assessment, Plan” have been commonplace in medicine for nearly 50 years, but this documentation framework is relatively unknown in dentistry.⁸ Many insurance payors require notes in the SOAP format and your physician counterparts are accustomed to this standard. As the old saying goes, “when in Rome…” A DSM EMR with standardized and customizable SOAP note templates will aid you in multidisciplinary communication and medical claims filing.
• Communication facilitation with other providers – As DSM providers, it is our obligation to communicate with our patients’ other healthcare providers. With a typical dental sleep patient our offices generate nearly a dozen communiques with their other pro This should include template letters and other forms of customizable correspondence so that you can efficiently and effectively articulate patient status to their primary care physicians and attending specialists.
• Ability to file medical claims – Many EDRs cannot submit medical claims while others do but the authors could not identify one vendor that promoted this functionality as a core feature. Many insurance payors will only accept electronically filed medical insurance claims, and some such as Aetna and Cigna promise expedited processing compared to manually filed claims.^9,10 Most DSM practices rely on medical billing as a large part of their success; an efficient medical billing system is essential.
• Communication with third party service providers – One of the most daunting challenges to implementing DSM is that we, as dentists, cannot do this alone. Of course, we must coordinate with physicians. We also frequently communicate with ancillary service providers such as sleep testing companies, medical billers, dental labs, telemedicine platforms, and others. Some DSM EMRs integrate with these other third-party firms which can save you and your team time and money by eliminating the need for unnecessarily redundant software systems or less convenient communication methods.
• Cloud-based vs On-premise – While we have an admitted bias toward cloud-based software, it is the result of our own experiences coupled with the trending evolution of Software as a Service (SaaS). On-premise software solutions typically require greater capital expenditures, put the onus for security on the owner, and they can be challenging to scale across multiple locations. SaaS usually involves a relatively low subscription fee, security and updates are managed by the third-party provider, and the service can be readily networked across numerous locations.¹¹
• Ease of use and user support – As with any software purchase, ease of use and continual support are crucial to adoption and effectual utilization. Difficulty navigating digital records and steep learning curves have been cited as reasons for discontinuing use of electronic records by general dentists.¹² Robust onboarding support and continued coaching for dentists and teams have been shown to be critical to a DSM practice’s success.

Bad News & Good News – Insurance Audits & Practice Transitions

As mentioned previously, electronic claims submission via a DSM EMR can expedite payments. With the upside of insurance payments is the unlikely but possible downside of a medical insurance audit. Complying with medico-legal and payor guidelines is critical. It is our position that medical records and dental charts should never be mixed. In the event of an audit from either a dental or medical insurance group, it is recommended that the insurance auditor has only the information he or she needs and that it is organized in a familiar and standardized method. Imagine a medical auditor looking through pages of your dental software, confused by radiographs, treatment plans, periodontal charting, and communication from periodontists. A well-organized DSM EMR should ensure any audit processes are conducted smoothly and painlessly for all involved.

Another novel reason to separate your dental and DSM records is to increase the future value of these businesses. Once your DSM practice is up and running it will be a distinct business within your business and will have its own value. A growing number of general dentists are opting to leave “bread and butter” dentistry and transition to exclusively practice DSM. Maintaining a separate EMR and EDR will ensure that when the time comes to sell your practice, you can get a valuation for your dental practice while retaining ownership of your DSM practice. That business will essentially live within your DSM EMR. The value of both separately is frequently much greater than combined.  We have worked with many offices who give testament that this separation totally changed their practice and economic future for the better. Bill Scheier, DDS, D.ABDSM recently sold his Cape Cod, MA dental practice while retaining his DSM practice. Dr. Scheier stated, “I am thankful that many years ago I took some good advice and began utilizing software exclusively designed for managing a dental sleep practice. At the time I was just looking for a better way to treat my DSM patients with no vision of the future sale of my dental practice. I realize now that the decision to separate my DSM practice allowed for the smooth transition to my dedicated dental sleep practice.”

Get Started Now!

The single biggest mistake we see is offices delaying implementation of a DSM EMR. These well-intentioned dentists proclaim, “after I start delivering devices regularly then I’ll invest in a DSM EMR”. This is the monody of a fledgling DSM practice. Without the innovative efficiency of a DSM EMR, most dental offices will face mounting frustration, molehills will become mountains, and they will fail to launch or gain meaningful traction.

When contemplating the purchase of a DSM EMR there are numerous factors to consider. This article is not intended to be an exhaustive treatise defining the rationale for the use of a DSM EMR. Nor is it designed to provide a comprehensive list of criteria to inform your buying decision. Instead, we are confident this article will make you a more savvy and informed consumer so you can make the leap into the future. With an efficient DSM workflow you can ensure compliance with relevant guidelines, unmoor yourself from archaic documentation processes, and be free to focus on delivery of the care your patients deserve.