There are lofty expectations for the NHII. Recent reports cited potential benefits such as avoiding medical errors, improving the use of health care resources, accelerating the diffusion of knowledge, supporting the delivery of evidence-based care, advancing the consumer role, strengthening privacy and data protection, and promoting public health and preparedness.^7,8 While there is some evidence that the use of computer systems can help promote these goals, many of the benefits of the NHII will accrue slowly until it is close to being implemented and adopted universally. Unfortunately, the exact effects of the NHII are difficult to predict, as no models to simulate societal and technical changes on this scale exist. However, many studies evaluating technology implementation in health care have shown positive outcomes, and cautious optimism regarding similar effects of the NHII is therefore warranted.^9–14

Dentistry is a significant part of the health care system, and, therefore, it makes sense to consider the NHII’s implications for this health care domain as well. In 2004, national health expenditures are estimated to reach $1.8 trillion while dental expenditures are expected to be $78 billion (a 4.4 percent share).¹⁵ In 1997, 61 percent of the population had at least one dental visit.¹⁶ A total of 164 million work hours and 51 million school hours are lost annually owing to dental-related illness.¹⁷ Approximately 166,000 dentists practice in an estimated 120,000 practices in the United States.¹⁸ The significant breadth of the dental care system and its extensive contact with patients and the population makes it advisable to consider whether dentistry should become a part of the NHII.

The purpose of this article is threefold. First, I explain what the NHII is and how it is intended to work. Second, I discuss its potential benefits, drawbacks, barriers and risks. Lastly, I describe some steps that the dental profession could take to become an integral part of the NHII.

	WHAT IS THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE?

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Before describing what the NHII is, I will discuss what it is not. The NHII is not a government plan to establish a central repository for all medical records. It also is not a proposed law to mandate the use of computers for storing patient information. On the other hand, it is an initiative to help establish a national, electronic information network for health care that serves patients, providers and the public better than our current system.⁸ A public-private sector partnership, consisting of federal government agencies, standards organizations, hospitals, hospital organizations, primary care associations, third-party payers, purchasers of health care and informatics organizations (such as the American Medical Informatics Association), is working toward planning and implementing the NHII. The NHII will be the result of a voluntary, national collaboration among all stakeholders in health care, not a centralized, top-down project as is common in other countries.¹⁹

The NHII rests on four concepts:

– a comprehensive, longitudinal electronic health record for all patients;

– a knowledge-based network that connects clinical, public health and personal health information;

– mechanisms that allow care providers to access all or part of a patient’s electronic health record;

– a technical, social and legal infrastructure.

A comprehensive, longitudinal electronic health record for all patients. In 1991, an IOM report³ described the computer-based patient record, or CPR, as a complete, electronic compilation of health data over a patient’s life. The two main characteristics of this compilation are that it is longitudinal and that it integrates information from any care provider the patient has seen. This record begins with a patient’s birth and continues until the patient dies. All of the health care providers with whom a patient comes in contact, such as physicians, dentists, nurses and pharmacists, contribute information to this "virtual" CPR. I call this patient record "virtual" because it likely will be assembled on demand from the decentralized patient record databases that are common today.

A knowledge-based network that connects clinical, public health and personal health information. If the CPR is viewed as the central core of information in the NHII, then public health and other clinical information can be considered concentric rings around it. In the IOM’s and the NHII’s vision, the CPR connects personal health information intimately and seamlessly with other information needed to deliver health care. This additional information can consist of public health statistics, clinical guidelines, diagnosis- or treatment-related information and evidence-based clinical resources. The computer presents this information in the context of the patient, his or her health problems and the care episode and, thus, helps the health care provider make optimal health care decisions based on appropriate information.

Mechanisms that allow care providers to access all or part of a patient’s electronic health record. Once a comprehensive collection of a patient’s health information has been established, mechanisms must be available that enable various health care providers to access those portions of the record that are relevant to the patient’s care. The need for access must be balanced with the requirement for confidentiality. The Health Insurance Portability and Accountability Act, or HIPAA, regulations provide a much-needed legal framework for this goal, limiting the unauthorized or serendipitous disclosure of health information, while at the same time preserving the free flow of information for treatment, payment and health care operations, research and public health.

A technical, social and legal infrastructure. Many of the challenges in implementing the NHII are not of a technical nature, but instead are of social and legal natures.²⁰ While implementing the NHII is far from trivial from a technical standpoint, many of its required components exist. Much of the United States is blanketed with a high-speed network infrastructure; many hospitals, physicians and dentists already are using computers in their practices; and standards that facilitate the exchange of health information are available. For the NHII to work, we must develop a health care culture in which the free, but protected, flow of information for patient care, research and public health purposes is much more common than it is now. Social and legal issues to be addressed include the willingness of providers to share information, mechanisms for authenticating and updating health information, the influence of more easily available and comprehensive information on decision making for both patients and providers, and how information from different care providers about a patient is aggregated and where it is stored.

Many of the challenges in implementing the National Health Information Infrastructure are not of a technical nature, but instead are of social and legal natures.

Colloquially, the NHII could be called the "Internet of health care," though it will be much more controlled and structured than its namesake. While plenty of arguments can be made for and against the NHII, the commitment and progress toward implementing it make it likely that it will become a reality in one form or another. While I cannot address those arguments exhaustively here, the following sections present the NHII’s potential benefits, as well as barriers, drawbacks and risks.

	POTENTIAL BENEFITS

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The potential benefits of the NHII have been discussed extensively elsewhere.⁸ Here, I briefly discuss these benefits and their implications for dentistry.

Transparency of health information across health care providers. In 1996, the ADA House of Delegates passed Resolution 92H-1996, which called for the seamless availability of patient health information across health care professions, specialties and care delivery environments.²¹ The NHII now provides a unique opportunity to make the ADA’s vision a reality. While many dentists collaborate closely with their medical colleagues while caring for their patients, the health care system is not designed to deliver patient-centered care. Sometimes, missed care opportunities are apparent only after adverse sequelae have occurred; for example, in cases of osteomyelitis subsequent to radiation therapy due to previous, unaddressed oral health problems. Another example is smoking cessation, which is demonstrably more successful when reminders and reinforcement are provided multiple times in multiple settings. Such efforts should be coordinated among physicians, nurses, dentists and other health care providers. Today, this is the exception rather than the rule. The NHII also has the potential to facilitate collaboration among general dentists and specialists.

Increased patient involvement in their care. During the last several decades, dentistry has made significant strides in stimulating and maintaining patients’ interest in their oral health. Tools used successfully in this context include intraoral cameras, digital radiology, patient education software and awareness campaigns. The NHII places significant emphasis on "personalizing" care by providing patients with access to their own health records, thereby helping them take on a greater role in managing their own wellness and making optimal health care decisions. Dentists could provide patients with rich information about their care, combining clinical data, images, radiographs and text with patient-specific instructions and educational materials about disease and treatment.

Reduced effort in collecting complete and correct data. Significant time, money and effort in the delivery of health care are spent on compensating for poor information flow and exchange.²² Day by day, tens of thousands of dentists throughout the country collect information, such as the medical and dental history, medication history, radiographs and basic intraoral findings, that often already is in records at hospitals and other offices. Accessing this information electronically not only is faster, but also often is more complete, correct and readable than relying on copies of handwritten materials or a patient’s recollection. Corrections to erroneous information could be back-propagated and, thus, increase the quality of patient care documentation.

Increased emphasis on analysis and decision making. The time saved on information collection could be spent on more important patient care tasks, such as review and analysis. Dentists typically focus on the "here and now" of a patient’s problems, often because historical information is not easily available. Longitudinal information may influence care decisions in positive ways. Computer programs could help practitioners absorb and interpret this richer background information by presenting summaries that are compiled automatically, such as a three-dimensional graph of a patient’s periodontal findings over time. The practitioner can access detailed information when he or she needs it.

An effective and efficient emergency response to bioterrorist attacks requires real-time information from various sources to identify incidents correctly early on.

Connecting a patient’s problems automatically with evidence-based information resources. The patient care provider is the main link between a patient’s problems and the clinical and scientific evidence needed to address those problems. With the rapidly growing knowledge about disease and therapy, it becomes even more difficult for practitioners to use the best evidence for all patient cases.²³ Computer programs that automatically retrieve evidence-based information relevant to a patient’s problems can help practitioners with this problem. Rather than focusing on retrieving or recalling relevant information, practitioners can concentrate on analyzing and evaluating the clinical situation in light of the most up-to-date information. These information retrieval mechanisms do not substitute for the general knowledge, decision-making capacity and continuing professional development of the practitioner. Rather, they function as a detail-oriented assistant that helps answer narrow and well-defined questions.

Improved oral health care outcomes. With the publication of a 2000 report,²⁴ medical errors became a focal point of discussion in national health care policy. In several studies, computer-based systems have been shown to reduce medical errors and improve patient care outcomes.^14–12 In dentistry, death due to error is a rare occurrence. However, studies have found significant variations in treatment decisions that could not be explained by variations in patient morbidity.^25–27 Given the positive experience with some medical decision support systems,^13,14 it is likely that appropriately designed computer systems can improve health outcomes in dentistry.

Learning from clinical outcomes data. There is a dearth of valid and reliable evidence for clinical decision making in dentistry.²⁸ The National Institute of Dental and Craniofacial Research’s recent initiative—dental practice-based research networks, or PBRNs²⁹—is designed to change that. Dentists in PBRNs will conduct clinical research in dental practices and, thus, accumulate evidence from data collected in the field. PBRNs will be more effective and efficient if they can rely on a large-scale, seamless infrastructure for data collection. With the NHII in place, dental practices can participate easily in research data collection and, thus, contribute to generating much-needed clinical evidence.

Enhanced bioterrorism defense. An effective and efficient emergency response to bioterrorist attacks requires real-time information from various sources to identify incidents correctly early on. As a result, several biosurveillance systems have been implemented.³⁰ These systems gather health-related data, such as the chief complaint of patients in the emergency room and sales data for over-the-counter medications, from hospitals, pharmacies and medical practices. The data are made anonymous, aggregated and analyzed for possible signals of a bioterrorist attack (such as a significant increase in respiratory symptoms subsequent to dispersal of inhalation anthrax spores). We do not know to what degree data gathered in dental practices could contribute to the early detection of bioterrorist attacks. However, the NHII can make gathering and analyzing such data easier if a need is identified.

Cost savings. Potential cost savings for the health care system as a whole also are cited as a benefit of the NHII. One report estimates national savings of $77.8 billion annually after fully accounting for implementation costs.³¹ Many of the efficiencies from the NHII are more likely to appear as increased productivity and improved services, as has been the case in many other industries, rather than as explicit cost savings.

	BARRIERS, DRAWBACKS AND RISKS

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A discussion of the merits of the NHII would not be complete without considering the barriers, drawbacks and risks inherent in this endeavor. The success of other countries, such as Great Britain and the Netherlands, in implementing national health information infrastructures has been mixed. While those experiences should not deter us from trying to implement the NHII, it is hoped that our planning and decision making will be informed by the lessons learned by others. The following is a brief discussion of the most obvious problems in implementing the NHII. For space reasons, this list is abbreviated and not inclusive.

Limited adoption of CPRs. Widespread adoption of CPRs is a precondition for implementing the NHII. The more health information that is available electronically, the more successful our attempts at connecting and exchanging it will be. Data about the adoption of CPRs are unreliable,³² not least because a universally accepted definition of a CPR does not exist. A previous study estimated that CPRs are used in between 5 and 13 percent of inpatient settings and in between 2 and 39 percent of physician offices.³² In dentistry, chairside computer use often is used as a proxy for adopting CPR. Studies have estimated the percentage of dentists using a computer at chairside to be between 20 and 30 percent.^33,34 In an ongoing study, the University of Pittsburgh Center for Dental Informatics has determined that approximately 25 percent of all general dentists in the United States use a computer at chairside and that slightly less than 1 percent have paperless offices. Figure 1 shows the distribution of paper- versus computer-based storage of patient information in practices with chairside computers; the data are from the ongoing study at the University of Pittsburgh Center for Dental Informatics. It is obvious that even in practices with chairside computers, much information still is on paper.

View larger version (56K): [in this window] [in a new window]   Figure 1. Use of storage media for different types of clinical information in general dental offices with chairside computers. (Data are from an ongoing study at the University of Pittsburgh Center for Dental Informatics.)

Standards and their adoption. A significant number of health care messaging and terminology standards have been developed in the United States.³⁵ Messaging standards such as Health Level Seven, or HL7³⁶; X12N³⁷; and Digital Imaging and Communications in Medicine, or DICOM,³⁸ define how health care information should be transmitted. Terminology standards, such as the Current Dental Terminology, or CDT³⁹; Current Procedural Terminology⁴⁰; and Systemized Nomenclature of Medicine⁴¹ determine how information should be represented. A few standards, such as the CDT (for dental treatment), DICOM (for communicating digital images in medicine and dentistry) and HL7 (for exchanging health information) are used universally. In addition, the ADA Standards Committee on Dental Informatics, or SCDI, has developed American National Standards Institute, or ANSI/ADA Specification No. 1000: Standard Clinical Data Architecture for the Structure and Content of an Electric Health Record,⁴² which facilitates interoperability among electronic health records. For the NHII to work efficiently, the majority of participants must adopt a few complementary standards, such as DICOM, HL7 and the ANSI/ADA Specification No. 1000.

Recent progress demonstrates that the health care system at large is getting serious about implementing the National Health Information Infrastructure.

Perceived threats to privacy and confidentiality. Many stakeholders are afraid that the NHII has the potential to compromise severely the privacy and confidentiality of health information. The fear of threats to privacy even has led the federal government to prohibit the implementation of a national patient identifier.⁴³ Those concerns ignore the fact that HIPAA has strengthened the safeguards for privacy, confidentiality and security of health information significantly. HIPAA provides a strict framework for the free exchange of health information relating to treatment, payment and health care operations. At the same time, it prohibits or severely limits the disclosure of health care information to parties who are not involved in a patient’s care or research. The HIPAA is a precondition for the successful development of the NHII, not an obstacle to it.

The U.S. Department of Health and Human Services has recognized some of these barriers and has begun to take steps to address them.⁸ These include plans to promote the adoption of CPRs and best practices, encourage commitments to a defined set of standards by federal agencies and others, develop mechanisms to coordinate planning and implementation of the NHII, and educate stakeholders in the NHII about its purpose, design and operation.

The question of whether the NHII is beneficial, neutral or detrimental for the nation’s oral health and its dental care system will remain unanswered for some time. Experts estimate that we need at least 25 percent penetration of the NHII to begin generating objective measures of its effectiveness and efficiency. Regardless of one’s view of technology in health care, however, recent progress demonstrates that the health care system at large is getting serious about implementing the NHII. The question then becomes how dentistry can most effectively contribute to and help shape the development of the NHII to serve our patients and the profession best. There are many possible steps to help achieve that goal.

	THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE IN DENTISTRY: GETTING THERE

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Making the NHII a reality in dentistry faces some challenges. For one, dental care is delivered by approximately 166,000 dentists, most of whom practice independently. Educating dentists about and creating buy-in for the NHII is a tremendous undertaking, as dentists need to be convinced one at a time. Second, there are more than 100 dental practice management systems on the market. Almost none of them are designed to exchange health information with other systems, and even fewer use standard protocols, such as HL7 and specifications developed by the SCDI, to do so. Third, only 25 percent of general dental practices use computers at chairside, and approximately only 1 percent of general dental practices with computers have paperless offices. Many dentists are overwhelmed by the array of technology available for dental practices, and most of them manage the implementation and maintenance of the information technology, or IT, infrastructure in their practices themselves. While many of these dentists use consultants and vendors to assist in this process, IT tends to consume significant time, effort and resources. Lastly, the dearth of data representation standards in dentistry is another obstacle. The only universal standard in dentistry is the CDT, but it covers only dental treatment procedures. Vendors are beginning to implement DICOM, the standard for the exchange of digital images in medicine and dentistry. Systematic Nomenclature of Dentistry, or SNODENT, is the ADA’s first draft of a clinical vocabulary and has not been evaluated formally or used on a large scale.

Practicing dentists need to be educated about the National Health Information Infrastructure so they understand how it can serve them and their patients.

Despite these challenges, there are indications that practicing dentists intuitively understand the benefits of the NHII. In the ongoing study of general dentists using computers at chairside, my colleagues and I asked participants whether they considered the NHII to be useful in dentistry. Eighty-six percent of the 73 respondents to this question said yes, 10 percent said maybe, and 4 percent said no. Given this background, the profession and industry could take the following steps to promote the development of the NHII in dentistry.

Design a strategy and focused educational campaign. As this article shows, the planning, design and implementation of the NHII are well under way in the nation’s health care system at large. Dentistry must participate actively in developing its portion of the NHII, as it has begun to do; for instance, the ADA was one of the official sponsoring organizations of the recent NHII 2004 meeting in Washington. The strategy for implementing the NHII in dentistry should address what infrastructure and capabilities already are in place, what the scale and scope of the NHII in dentistry should be, and what developments and investments need to be made to make it a reality. This strategy should be developed in a collaborative process that involves professional organizations, dental education, industry and other stakeholders. At the same time, practicing dentists need to be educated about the NHII so they understand how it can serve them and their patients.

Develop the technical infrastructure. The design and development of the technical infrastructure for the NHII primarily is the responsibility of the dental IT industry. The dental IT industry should take a leadership role in pioneering the development, testing and implementation of an increasingly sophisticated dental portion of the NHII. Messaging standards provide tested and reliable methods for the exchange of health data. The dearth of standards in dentistry for data representation like the ANSI/ADA Specification No. 1000 need not be an obstacle to early implementation of the dental portion of the NHII. Basic dental information, such as tooth designations, tooth surfaces, periodontal and restorative findings, and questions on health history already are relatively standardized. The industry could begin with a minimum data set for data exchange and then work with other stakeholders such as the ADA’s SCDI to develop more comprehensive standardized representations for dental data.

Accelerate the development of data representation standards. The ADA has a long history of developing standards.⁴⁴ The ADA’s SCDI was accredited by the ANSI in 2000. Since then, the SCDI has developed standards for the architecture of computer-based records in dentistry, the communication of dental images in DICOM and the design of educational software. The SCDI is composed of 60 voting members from 60 organizations from the profession, dental industry, academia and the government. The SCDI would be the most logical choice to help develop standards relevant to the implementation of the dental portion of the NHII. Both the ANSI/ADA Specification No. 1000 and the dental extensions to DICOM are essential building blocks that already exist. Much work, however, remains to be done in areas such as controlled vocabularies for clinical findings and diagnoses and message content for information interchange. Standards that are developed should be evaluated rigorously before they are implemented, as has happened with many standards in medicine.^45–47

Implement and evaluate testbed applications. Research for implementing and evaluating testbed applications, which evaluate specific aspects of the NHII, should be given high priority. The federal government recently allocated an additional $100 million for NHII demonstration projects.⁸ Only a few large-scale demonstration projects in medicine exist,⁴⁸ and no projects describing the exchange of patient information between dental practices or between dental and medical facilities exist. The Department of Veterans Affairs, or VA, is one of the few organizations in which dental and medical information about the same patient are available through one interface. Figure 2 shows that the VA’s Computer-based Patient Record System seam-lessly integrates with the Dental Patient Record Manager. However, since the VA is a closed system, it only approximates the proposed NHII.

View larger version (50K): [in this window] [in a new window]   Figure 2. Seamless integration between the Computer-based Patient Record System and the Dental Patient Record Manager of the Department of Veterans Affairs (screenshots used with permission of the Department of Veterans Affairs).

	CONCLUSIONS

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Implementing the NHII in dentistry will be a significant challenge, both for the health care system in general and dentistry in particular. Many dentists may fear that outside interference, the government or both will try to force the NHII on the traditionally independent profession of dentistry. As I discussed previously, there is no danger of the NHII becoming law. However, there is the danger of dentistry’s being left out in the cold in the planning and implementation phases for the NHII. Intensive discussions about the NHII in dentistry should begin now, as NHII’s design and implementation in medical care are rapidly getting under way. Should dentistry be part of the NHII? The answer is simply yes, on its own terms.

View larger version (48K): [in this window] [in a new window]   Dr. Schleyer is an associate professor and the director, Center for Dental Informatics, University of Pittsburgh, School of Dental Medicine, Salk Hall, 3501 Terrace St., B21 Salk Hall, Pitts-burgh, Pa., 15261-1933, e-mail "titus{at}pitt.edu". Address reprint requests to Dr. Schleyer.