Removing wisdom teeth is a fairly routine procedure for an oral surgeon, except when the patient has complex health care needs.
“It used to take hours of phone calls to find the different specialists treating the patient so that we could identify all the necessary considerations,” says Brian Bast, DMD, MD, who presides over the Oral and Maxillofacial Surgery department at UCSF, and serves as the School of Dentistry’s chief dental officer.
That obstacle was removed seven months ago when UC San Francisco (UCSF) combined its dental and medical health records. Bast recently coordinated wisdom tooth extractions for a teenager with a serious heart condition and was able to find all the contact information he needed in an instant.
The common health record, powered by Epic Systems and referred to at UCSF as APeX, allowed him to pass messages directly to members of the patient’s care team for recommendations on an appropriate operating room, a cardiac anesthesiologist, prescribing antibiotics prior to the procedure, and care management for avoiding blood clots.
Ready for the Future
While using the system simplifies coordinating care in such cases, getting it online was not easy. Eunice Stephens, MPH, MHA, chief of staff and associate dean at the School of Dentistry, spearheaded the complex undertaking which took nearly 18 months.
Stephens has spent her career at UCSF in various clinical operations, research and public health roles. She understood the value of an integrated health record for clinicians and patients as well as the research community. When she joined the School of Dentistry, she got to work immediately to make it happen.
"It was a definite balancing act,” says Stephens. “I was guiding multiple stakeholder groups towards the finish line, making it as useful to Dentistry as possible while maintaining the integrity rules that UCSF Health had put in place so that, ultimately, Dentistry can join with our clinical colleagues on campus.”
Michael Reddy, DMD, DMSc, UCSF School of Dentistry dean and associate vice chancellor for Oral Health Affairs, saw the project as a building block for the future of dentistry and health care overall.
“The common health record system helps the whole care team – dentists, medical doctors, nurses, pharmacists and other providers – stay in lockstep. They now have access to more information about the patient which aids clinical decisioning.”
Improving Patient Health Outcomes
A big benefit of the connected records system is that providers can see what medications their patients are taking, which ensures they don’t prescribe anything contraindicated by current regimens. Additionally, the emergency room, not the dentist office, is often where patients first present with a dental related issue. The ability to quickly access all the notes and images taken during an ER visit makes follow-treatment easier and more effective.
UCSF’s ultimate goal in merging the health records is to improve health outcomes for patients. According to Mark Ryder, DMD, a faculty member and chair of the Division of Periodontology in the School of Dentistry, the system is a step closer to providing health care providers with a 360-degree view of their patients’ health.
“The mouth is a window into our body. The levels of inflammation you can get in certain diseases like periodontal disease show up in the rest of body, but that systemic inflammation is often most easily seen – and first seen – in the mouth,” says Dr. Ryder.
Declining health due to anything from HIV to diabetes and leukemia can be detected by the presence of certain types of oral lesions and inflammation. “A dentist might be the first person to notice some of these symptoms. If they're able to easily link over to the patient's primary care physician or specialist, the follow-up care becomes more proactive and expedient.”
The ease of making referrals is something Dr. Bast points out as well. "In our old system, the referring provider would either give the patient a paper written referral or walk the referral down to our clinic to get the patient scheduled. Now they simply put in a referral, it shows up on our front desk computer, and the patient is scheduled. Further, I can see all of the work that the prosthodontist has done, all of the X-rays they took in their clinic – they're all right in front of me when I see the patient. So, it's a much more efficient way to treat patients.”
The Next Horizon: Precision Health
The vast amounts data – past, current, and future – integrated into the system holds potential for research that will discover connections between oral health and medical health. Data driven patterns from the health records will lead to new discoveries, connections and, ultimately, better, precise care and outcomes for the patient.
“Dean Reddy’s leadership in integrating oral science and health into precision medicine will be impactful across biomedical research, public health and healthcare,” says Keith Yamamoto, PhD, director of UCSF Precision Medicine and vice chancellor for Science Policy and Strategy.
Yamamoto and colleagues are confident that the combined medical and oral health data will open new research possibilities. “Bringing together patient dental and medical data expands our knowledge network and begins to provide the patient with a quantum improvement in personalized care,” says Sharat Israni, PhD, chief technology officer at UCSF’s Bakar Computational Science Institute.
“Your genetic predisposition makes a big difference to your periodontal health, for example. But what other connections and associations are there that we’re not aware of? Our researchers and clinicians will use the data to find out, and ultimately deliver more precise health care to patients,” says Israni.
One researcher who has already gotten started is Sepideh Banava, DDS, MSc, MBA, MPH.
Dr. Banava, assistant professor in the Division of Oral Epidemiology and Dental Public Health, researches the link between orofacial injuries and intimate partner violence (IPV). Her goal is to use health record data to develop a clinical decision support system to streamline IPV screening and diagnosis. Often, dentists and other health care providers observe IPV signs and symptoms of IPV but are uncertain about the most appropriate course of action.
“Orofacial injuries are one of the main indicators of IPV,” Banava says. “One of the reasons IPV is underestimated and underresearched is that we haven’t had a comprehensive database.”
Dr. Banava has already queried medical health record data for IPV and IPV-related orofacial injuries using specific codes and keywords through the UCSF De-Identified Clinical Databases available for researchers. So far, her search has covered about 4.4 million records spanning the years 1982 to the present. The addition of oral health record data is a boon for research projects like hers.
“Current EHR lacks inclusive IPV screening tools to gather pertinent data to identify IPV incidents and enhance care quality,” she says. She is preparing to conduct a more refined search of the combined record data to give clinicians tools they need to identify an overlooked public health crisis.
Making a Difference
From coordinating care, providing a comprehensive view of patients’ health, to facilitating advances in research, the combined health records have yielded positive results in a short time.
As Dean Reddy explained, “The patients themselves enjoy having more control and a better understanding of how their care fits together. We’re already hearing from our clinicians, staff, and patients that the connected system is making a difference.”