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How Medical–Dental EHR Integration Can Improve Diabetes Care

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct
1 Credit CME
Abstract

Since the mid-1990s, poor oral health has been neglected as a public health threat, despite its recognition as epidemic in scale by the US Department of Health and Human Services Office of the Surgeon General. Americans' poor oral health influences their overall health and, from a population standpoint, incurs dire economic and human costs. This article describes how health information transfer within the Marshfield Clinic Health System's integrated medical and dental practice can improve diabetes care. This article also considers ethics and equity implications of improving MDP electronic health record interoperability in this large, rural Wisconsin organization.

Records and Equity

Quiz Ref IDChronic diseases are best managed by coordinating care, such that interventions are discussed within teams of cross-disciplinary clinicians and efficiently incorporated into service delivery, facilitating patients' understanding of their options, care, and recovery plans. However, separate medical-dental service delivery streams and reimbursement systems and limited interprofessional training continue to undermine effective chronic disease management strategies.13Quiz Ref IDOral health's importance to general health is not routinely discussed in primary care settings, which results in missed research and patient education opportunities, prevention implementation, and dental referrals.4 Moreover, siloed medical and dental practice inequitably affects patients with chronic conditions, since separate storage and inadequate sharing of patients' health records can compromise quality of care, especially during routine medical or dental appointments or emergency department visits.

This article describes the need for improved electronic health record (EHR) interoperability and how health information transfer within the Marshfield Clinic Health System's (MCHS) integrated medical and dental practice can improve diabetes care.

Diabetes and Health Information Exchange

In 2000, the US Surgeon General recognized oral disease as a “silent epidemic”5 that increases morbidity and the economic burden of disease.68 Chronic oral diseases (eg, dental caries and periodontal disease) are linked to patients' development of chronic diseases, such as diabetes.9,10 Total deaths in the United States due to diabetes is expected to increase by 38% between 2015 and 2030,11 and several dental diseases are common complications of diabetes.12 Periodontal disease interventions could lower annual costs for patients with Type 2 diabetes, stroke, heart disease, and pregnancy and reduce inpatient admissions.13Quiz Ref IDDespite these benefits, geriatric, pediatric, low-income, uninsured, underinsured, and chronically ill patients are particularly likely to have their oral health needs underestimated or missed altogether by clinicians.14 One reason for these patients' unmet oral health needs is that operable health information exchange (HIE) between medical and dental clinicians about such patients is nonexistent or inferior.15 The rest of this article is devoted to explaining why HIE is a patient-centered care practice that can improve patients' outcomes and reduce healthcare utilization for patients with diabetes.1618

The Institute for Electrical and Electronics Engineering defines interoperability as “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.”19 To help promote interoperability and holistic patient care, the Institute of Medicine developed a list of health information technology (HIT) recommendations to support effective, efficient flow of patients' health information across care settings.20Quiz Ref IDEHR integration promotes health equity by improving HIT interoperability and enabling secure HIE.21Quiz Ref IDPhysical and virtual integration of organizations' EHR infrastructure can generally be implemented in 1 of 3 ways:

  1. Ad hoc implementation: fully integrated medical-dental EHR architecture conforms to national standards.

  2. Broad implementation: EHR architecture supports interoperability within proprietary clinical information systems (eg, EPIC's Wisdom module22).

  3. Universal implementation: EHR architecture supports interoperability across different clinical information systems (eg, regional HIE platforms).

Some organizations, such as the MCHS, Kaiser Permanente, HealthPartners, and federally qualified health centers (FQHCs), have adopted and implemented virtual and physical EHR integration where dental and medical practices are geographically close in order to promote care continuity for patients, including those with diabetes.4

Establishing Interoperability

The MCHS was founded in 1916 as Marshfield Clinic and is one of the largest comprehensive integrated health systems in the United States.23,24 A multispecialty group and health professions learning environment, MCHS serves communities in health professional shortage areas25 and patients living in central, western, and northern regions of Wisconsin and in Michigan's Upper Peninsula.26 In the early 2000s, oral health services access for rural Medicare- and Medicaid-eligible patients was substantially limited. Family Health Center (FHC), an FQHC that has served low-income, underinsured, and uninsured patients since 1974, partnered with MCHS in 2002 to establish a dental safety net. Tendental care sites now serve more than 50000 unique patients annually,24 regardless of income or insurance status, with a goal of mitigating health inequity (see 1).

Table. Insurance Status of Patients at Marshfield Clinic Health System's 10 Dental Centersa

Year
Insurance type201720182019
Commercial11 980 (20.04%)12 559 (21.44%)12 781 (22.60%)
Medicaid37 716 (63.09%)36 571 (62.11%)34 769 (61.49%)
Self-pay4 869 (8.14%)4 728 (8.03%)4 634 (8.19%)
Sliding fee scale5213 (8.72%)5 018 (8.52%)4 354 (7.70%)
Total59 77858 87656 538

Although MCHS services are supported by a customized medical-dental integrated EHR (iEHR),23,24 barriers to medical-dental care integration for patients with diabetes remained and were further studied. Based on 2018–2019 aggregate EHR data, 8% of MCHS medical and dental patients (6363 of 71 811) were diagnosed with diabetes. Approximately, 7% of patients diagnosed with diabetes (32 131 of 472 591) only visited MCHS medical, but not dental, centers. With these data in mind, investigators first sought to understand perceived practice gaps and barriers to medical-dental integration.27,28 Surveys2,3,29 and focus groups were conducted with MCHS/FHC medical and dental clinicians to assess their knowledge of, attitudes toward, and practice of integrated care.2,3,29,30 Participants' responses informed development of educational tools for clinicians and patients, informed which metrics would be used to assess these tools' efficacy, and led to incorporating a clinical decision support alert tool (CDSAT) into practice to help diagnose patients with diabetes.

Figure. Screenshot of the Clinical Decision Support Alert Tool Used at Marshfield Clinic Health System
©Marshfield Clinic Health System (MCHS), Inc. All rights reserved. Reprinted with permission of MCHS.

Eligibility criteria in the CDSAT of a patient's iEHR alert primary care clinicians to conduct visual oral examinations of patients with diabetes. Four years after the CDSAT was implemented in 2014 at 2 pilot MCHS medical sites, evaluation of the CDSAT revealed that it triggered a total of 7723 patients' EHRs to issue an alert. In response to alerts, primary care clinicians visually orally examined 4943 patients with diabetes (64%); among those patients, 170 were referred to dentists and 626 were advised to visit a dentist. Additionally, another study developed risk assessment tools using informatics techniques. As informatics tools help predict diabetes risk among patients in dental settings,31 the study team screened patients for risk of diabetes using machine-learning techniques that extracted medical-dental variables from the iEHR. Using this predictive tool in MCHS dental centers enabled patients at risk for developing diabetes to be identified by dentists, who then referred them to physicians.

Next Steps

Centers for Medicaidand Medicareservices data indicate that MCHS was the most successful participant in a 2011 Physician Group Practice demonstration project, as it earned 57% of the $107.6 million in gross savings realized over a 5-year period, most of which was distributed among the 10 participating MCHS institutions based on performance.32 Outcomes of the demonstration project validated that integrating medical and dental care, supported by use of informatics and quality tracking, delivered high-quality care at reduced cost.32 Subsequent research and quality improvement projects have also demonstrated improvements in healthcare outcomes, patient safety, and patient satisfaction.2628,33 While medical-dental HIE is the focus of this case study, integrated care, according to the World Health Organization, is about patients' experiences—specifically, about “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.”34 Integrated service delivery facilitated by HIE also nourishes professional ethics and health equity.3537

MCHS/FHC established medical-dental interoperability, via EHR integration, to identify diabetic and prediabetic patients in predominantly rural areas of Wisconsin and Michigan and to facilitate such patients' access to prevention and management interventions. Integrated care holds promise for alleviating health inequities, specifically for rural populations. President Joseph Biden has been pressured to appoint a rural health “czar,”38 and medical-dental integration successes of the MCHS/FHC model could be replicated in other US regions and for other chronic disease states.

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2022;24(1):E99-105.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Neel Shimpi, BDS, MM, PhD is an associate research scientist at the Marshfield Clinic Research Institute's Center for Oral and Systemic Health in Wisconsin. A trained dental surgeon with expertise in healthcare management and biomedical and health informatics, she has been advancing medical-dental integration for over 8 years. Her interests include medical-dental integration, dental informatics, and investigating oral and systemic health integration; Elizabeth Buchanan, PhD is the director of the Office of Research Support Services and a senior research scientist at the Marshfield Clinic Research Institute in Wisconsin. She is a frequent speaker and consultant for institutional review boards and research ethics boards and is professionally active in the organization Public Responsibility in medicine and research. Her scholarship focuses on research ethics (especially the internet), compliance, and regulations; Amit Acharya, BDS, MS, PhD is the chief research officer and system vice president of research at Advocate Aurora Health. He previously served as the executive director of Marshfield Clinic Research Institute and the chief dental informatics officer of Family Health Center of Marshfield. He was the founding director of the Institute for Oral and Systemic Health at the Marshfield Clinic Health System (MCHS) and helped integrate MCHS' electronic dental record with its propriety electronic medical record. His research interests lie in the design and architecture of electronic health records and data warehouses, artificial intelligence, machine learning, clinical decision supports and expert systems, information modeling, and the oral-systemic disease relationship.

References
1.
Harnagea  H, Couturier  Y, Shrivastava  R,  et al.  Barriers and facilitators in the integration of oral health into primary care: a scoping review.  BMJ Open. 2017;7(9):e016078.Google ScholarCrossref
2.
Shimpi  N, Schroeder  D, Kilsdonk  J,  et al.  Medical providers' oral health knowledgeability, attitudes, and practice behaviors: an opportunity for interprofessional collaboration.  J Evid Based Dent Pract. 2016;16(1):19–29.Google ScholarCrossref
3.
Shimpi  N, Jurich  I, Panny  A, Acharya  A.  Knowledgeability, attitude, and practice behaviors of primary care providers toward managing patients' oral health care in medical practice: Wisconsin statewide survey.  J Am Dent Assoc. 2019;150(10):863–872.Google ScholarCrossref
4.
Atchison  KA, Rozier  RG, Weintraub  JA.  Integration of oral health and primary care: communication, coordination and referral.  NAM Perspect. October 8 , 2018. Accessed November 10, 2021. https://nnoha.org/nnoha-content/uploads/2019/12/Integration-of-Oral-Health-and-Primary-Care.pdfGoogle Scholar
5.
US Department of Health and Human Services.  Oral Health in America: A Report of the Surgeon General.  National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed November 8, 2021. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
6.
Azarpazhooh  A, Leake  JL.  Systematic review of the association between respiratory diseases and oral health.  J Periodontol. 2006;77(9):1465–1482.Google ScholarCrossref
7.
DeStefano  F, Anda  RF, Kahn  HS, Williamson  DF, Russell  CM.  Dental disease and risk of coronary heart disease and mortality.  BMJ. 1993;306(6879):688–691.Google ScholarCrossref
8.
Petersen  PE, Ogawa  H.  The global burden of periodontal disease: towards integration with chronic disease prevention and control.  Periodontol 2000. 2012;60(1):15–39.Google ScholarCrossref
9.
Mealey  BL.  Periodontal disease and diabetes. A two-way street.  J Am Dent Assoc. 2006;137(suppl):26S–31S.Google Scholar
10.
Shimpi  N, Ashton  J, Sorenson  C,  et al.  Interdisciplinary care model: diabetes and oral health.  In: Acharya  A, Powell  V, Torres-Urquidy  M, Posteraro  R, Thyvalikakath  T, eds.  Integration of Medical and Dental Care and Patient Data. 2nd ed. Springer Nature; 2019:47–61.Google Scholar
11.
Rowley  WR, Bezold  C, Arikan  Y, Byrne  E, Krohe  S.  Diabetes 2030: insights from yesterday, today, and future trends.  Popul Health Manag. 2017;20(1):6–12.Google ScholarCrossref
12.
 Diabetes, gum disease and other oral health problems.  National Institute of Diabetes and Digestive and Kidney Diseases. Reviewed September 2014. Accessed June 20, 2021. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems
13.
Jeffcoat  MK, Jeffcoat  RL, Gladowski  PA, Bramson  JB, Blum  JJ.  Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions.  Am J Prev Med. 2014;47(2):166–174.Google ScholarCrossref
14.
 Vulnerable populations: who are they?  Am J Manage Care. 2006;12(13)(suppl):S348–S352.Google Scholar
15.
Simon  L, Obadan-Udoh  E, Yansane  AI,  et al.  Improving oral-systemic healthcare through the interoperability of electronic medical and dental records: an exploratory study.  Appl Clin Inform. 2019;10(3):367–376.Google Scholar
16.
Hughes  RG.  Tools and strategies for quality improvement and patient safety.  In: Hughes  RG, ed.  Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality; 2008:chap 44.Google Scholar
17.
Greene  SM, Tuzzio  L, Cherkin  D.  A framework for making patient-centered care front and center.  Perm J. 2012;16(3):49–53.Google Scholar
18.
Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the 21st Century.  National Academy Press; 2001.
19.
Fridsma  D.  Interoperability vs health information exchange: setting the record straight.  Health IT Buzz blog. January 9 , 2013. Accessed January 16, 2021. https://www.healthit.gov/buzz-blog/meaningful-use/interoperability-health-information-exchange-setting-record-straightGoogle Scholar
20.
Institute of Medicine.  Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.  National Academies Press; 2013.
21.
 21st Century Cures Act, HR 34, 114 Cong, 2nd Sess, §4003 (2016).  Accessed February 20, 2021. https://www.congress.gov/114/bills/hr34/BILLS-114hr34enr.pdf
22.
Software.  Epic.  Accessed February 20, 2021. https://www.epic.com/software
23.
Shimpi  N, Ye  Z, Koralkar  R  et al.  Need for diagnostic-centric care in dentistry: a case study from the Marshfield Clinic Health System.  J Am Dent Assoc. 2018;149(2):122–131.Google ScholarCrossref
24.
Acharya  A.  Marshfield Clinic Health System: integrated care case study.  J Calif Dent Assoc. 2016;44(3):177–181.Google Scholar
25.
Nycz  G, Shimpi  N, Glurich  I,  et al.  Positioning operations in the dental safety net to enhance value?based care delivery in an integrated health?care setting.  J Public Health Dent. 2020;80(suppl 2):S71–S76.Google Scholar
26.
Shimpi  N, Glurich  I, Acharya  A.  Integrated care case study: Marshfield Clinic Health System.  In: Acharya  A, Powell  V, Torres-Urquidy  MH, Posteraro  RH, Thyvalikakath  T, eds.  Integration of Medical and Dental Care and Patient Data. 2nd ed. Springer Nature; 2019:315–326.Google Scholar
27.
Acharya  A, Shimpi  N, Mahnke  A, Mathias  R, Ye  Z.  Medical care providers' perspectives on dental information needs in electronic health records.  J Am Dent Assoc. 2017;148(5):328–337.Google ScholarCrossref
28.
Glurich  I, Schwei  KM, Lindberg  S, Shimpi  N, Acharya  A.  Integrating medical-dental care for diabetic patients: qualitative assessment of provider perspectives.  Health Promot Pract. 2018;19(4):531–541.Google ScholarCrossref
29.
Shimpi  N, Schroeder  D, Kilsdonk  J, Chyou  PH, Glurich  I, Acharya  A.  Assessment of dental providers' knowledge, behavior and attitude towards incorporating chairside screening for medical conditions: a pilot study.  J Dent Oral Care Med. 2016;2(1):1–7.Google Scholar
30.
Shimpi  N, Glurich  I, Schroeder  D, Katrak  C, Chyou  P-H, Acharya  A.  Patient awareness of association of diabetes and periodontal disease.  Health Promot Pract. 2020;21(3):464–472.Google ScholarCrossref
31.
Hegde  H, Shimpi  N, Panny  A, Glurich  I, Christie  P, Acharya  A.  Development of non-invasive diabetes risk prediction models as decision support tools designed for application in the dental clinical environment.  Inform Med Unlocked. 2019;17:100254.Google ScholarCrossref
32.
Kautter  J, Pope  GC, Leung  M,  et al.  Evaluation of the Medicare Physician Group Practice Demonstration.  Centers for Medicare and Medicaid Services; 2012. Accessed November 11, 2021. https://downloads.cms.gov/files/cmmi/medicare-demonstration/PhysicianGroupPracticeFinalReport.pdf
33.
Shimpi  N, Hegde  H, Glurich  I, Ryan  M, Acharya  A.  Establishing a quality improvement culture within a large integrated medical-dental health system with a population based focus.  J Evid Based Dent Pract. Published online June 18 , 2021.Google Scholar
34.
World Health Organization.  Integrated health services—what and why?  May 2008. Accessed November 11, 2021. https://www.who.int/healthsystems/technical_brief_final.pdf
35.
McKeown  A, Cliffe  C, Arora  A, Griffin  A.  Ethical challenges of integration across primary and secondary care: a qualitative and normative analysis.  BMC Med Ethics. 2019;20:42.Google ScholarCrossref
36.
Hodgson  J, Mendenhall  T, Lamson  A.  Patient and provider relationships: consent, confidentiality, and managing mistakes in integrated primary care settings.  Fam Health. 2013;31(1):28–40.Google ScholarCrossref
37.
Raus  K, Mortier  E, Eeckloo  K.  The patient perspective in health care networks.  BMC Med Ethics. 2018;19:52.Google ScholarCrossref
38.
Crampton  L.  American's rural crisis triggers calls for Biden to name rural czar.  Politico. January 25 , 2021. Accessed June 21, 2021. https://www.politico.com/news/2021/01/25/america-rural-economy-health-biden-czar-461326Google Scholar
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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