Dental Data Exchange Federal Electronic Health Record Modernization

Dental Data Exchange Federal Electronic Health Record Modernization

Dental Exchange: Use Case Do. D MHS 1 Do. D Dentist determines patient needs a referral either because of volume limitations, or specialized care needed Purchased Care Provider 2 3 Dental Referral Note sent to external Dentist 5 4 Notification received in ADDP (through DART) indicating treatment is complete 7 Do. D Dentist receives Dental Consult Note and determines the right treatment plan and care for patient during follow-up visit. Treatment provided, diagnoses, and key measures captured during purchased care visit are ingested into the Dental EHR. 6 Dental Consult Note sent to Do. D Dentist immediately after completing visit Patient sees Dentist for requested referral services only Dentist summarizes visit in the EHR; generates Dental Consult Note

Standards Approach CCDA on FHIR Profiles C-CDA 2. 1 Referral Note C-CDA 2. 1 Consultation Note Dental Referral and Consult Profiles Dental Referral Note Dental Consultation Note § Project workspace: https: //confluence. hl 7. org/display/ATT/Dental+Summary+Exchange+Project

Compatibility with C-CDA 2. 1: Referral Note Section Advance Directives Section (etnries optional) (V 3) Allergies and Intolerances Section (entries required) (V 3) Assessment and Plan Section (V 2) Assessment Section Family History Section (V 3) Functional Status Section (V 2) General Status Section History of Present Illness Section Immunization Section (entries optional) (V 3) Medical Equipment Section (V 2) Medications Section (entries required) (V 2) Mental Status Section (V 2) Nutrition Section Past Medical History (V 3) Physical Exam Section (V 3) Plan of Treatment Section (V 2) Problem Section (entries required) (V 3) Procedures Section (entries optional) (V 2) Reason for Referral Section (v 2) Results Section (entries required) (V 3) Review of Systems Section Social History Section (V 3) Vital Signs Section (entries required) (V 3) Dental Findings Section Instructions Section (V 2) Payers Section (V 3) C-CDA 2. 1 Referral Note MAY SHALL MAY MAY SHOULD MAY MAY SHALL SHOULD MAY SHOULD SHALL MAY SHALL SHOULD MAY MAY Dental Referral Note SHALL SHOULD MAY

Compatibility with C-CDA 2. 1: Consultation Note Section Advance Directives Section (etnries optional) (V 3) Allergies and Intolerances Section (entries required) (V 3) Assessment and Plan Section (V 2) Assessment Section Chief Complaint and Reason for Visit Section Chief Complaint Section Family History Section (V 3) Functional Status Section (V 2) General Status Section History of Present Illness Section Immunization Section (entries optional) (V 3) Medical Equipment Section (V 2) Medications Section (entries required) (V 2) Mental Status Section (V 2) Nutrition Section Past Medical History (V 3) Physical Exam Section (V 3) Plan of Treatment Section (V 2) Problem Section (entries required) (V 3) Procedures Section (entries optional) (V 2) Reason for Visit Section Results Section (entries required) (V 3) Review of Systems Section Social History Section (V 3) Vital Signs Section (entries required) (V 3) Dental Findings Section Instructions Section (V 2) Payers Section (V 3) C-CDA 2. 1 Consultation Note MAY SHALL MAY MAY SHALL MAY MAY SHOULD MAY SHALL MAY SHOULD MAY MAY Dental Consultation Note SHALL SHALL MAY

Dental Findings Section The Dental Findings Section records clinically significant observations confirmed or discovered during a dental visit, but not broad medical findings that would appear in the Results Section, and not so significant that they would appear on the Patient's Problem List. The Result Organizer is used to captured discrete dental measurements e. g. , 3 mm Overjet e. g. , 6 mm Probing Depth, Tooth #3, Probing Spot #4 The Problem Observation is used to captured coded dental findings e. g. , Active Caries on Tooth #3 e. g. , Infection on Tooth #7

Integration of SNODENT § SNODENT is a “logical subset” of SNOMED CT § SNODENT is the preferred terminology of Dental EHRs § SNODENT has different identifiers than SNOMED CT: § SNODENT: 276453000 108723 D Teeth covered in plaque (finding) Recommended Practice: SNOMED value, SNODENT translation <value xsi: type="CD" code="276453000“ display. Name="Teeth covered in plaque (finding)“ code. System="2. 16. 840. 1. 113883. 6. 96“ code. System. Name="SNOMED CT"> <translation code="108723 D“ display. Name="Teeth covered in plaque (finding)“ code. System="2. 16. 840. 1. 113883. 3. 3150“ code. System. Name="SNODENT"/> </value>

Key Stakeholders Jean Narcisi Director of Dental Informatics American Dental Association (ADA) Col William Baez Chief Medical Information Officer United States Air Force LTC Kevin B. Parker Chief Dental Informatics Officer United States Army CDR Steve Stallings Chief Dental Informatics Officer United States Navy Nancy Orvis Business Architecture, Standards/Interoperability Defense Health Agency LCDR Michael Bohman Dental Capability Manager Defense Health Agency Rebekah Fiehn Healthcare Data Exchange Specialist Denta. Quest

Draft Standards Content (including sample files) § FHIR: https: //build. fhir. org/ig/HL 7/dental-data-exchange/ § CDA: https: //confluence. hl 7. org/display/ATT/Dental+Summary+Excha nge+-+Draft+Ballot+Content

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