The University of California San Francisco has worked to enhance patient care with integrated medical and dental records through Epic.
In 2022, UCSF Health and UCSF Dentistry integrated patients' oral health and medical records into Epic's EHR system, making UCSF the first academic health system in the West to merge oral health and medical records into an EHR.
Brian Bast, DMD, MD, recently spoke with Becker's about how the initiative has changed patient care, what he's learned through this process and the advantages of integrated records.
Editor's note: Responses were lightly edited for clarity and length.
Question: What would you say are some of the biggest results you've seen from this initiative so far?
Dr. Brian Bast: It's just the right way to provide patient care. It incorporates dentistry as part of the healthcare team of a patient. It's always been that way, but it hasn't been very efficient. When I started treating patients and we'd see a patient who had a complex medical condition or even not a common medical problem like diabetes or hypertension, we would have to communicate with their physician before providing even simple care. That communication would often be on a piece of paper and we would write down on a consultation form what we were seeing the patient for and what our concerns were with their medical history. We'd give that to the patient. The patient would then have to make an appointment with their doctor, and the physician would sit down and answer these questions on the piece of paper, give it back to the patient and then the patient would bring it. The patient ended up doing all the legwork to get even just a simple dental problem addressed ... Sometimes that works, but sometimes there's some complications that could have easily been avoided if there was just a simple dialogue between the dentist and the MD that was treating the patient.
When we're on the same EMR, all of that communication is immediate. We write a note to their clinician and oftentimes within the same appointment we'll get a response. It is just an effective way for everyone treating that patient to see what's happening.
Q: What do you think prevented institutions from integrating records in past years?
BB: It took awhile for electronic health records to mature. Now we have Epic, and that's sort of widespread. I've worked in the hospital for a long time and it used to be that each hospital had their own EMR. So you would see a patient, [that] patient would have gone into an emergency room in a different hospital, and then they would come in to see you and you wouldn't be able to see what happened in the emergency room. It would be that same level of inefficiency. Now, we can see a patient goes to an emergency room in Colorado and then they come in to see us in San Francisco, and you can see exactly what happened. Oftentimes, you can see the images taken at that outside hospital. You can see that level of efficiency and why it's so important.
When dentistry was able to hop onto the same health record, all of that became just a much more smooth process. It's the same patient. They're just in and out of different clinics, but everyone can see what care they've received and what conditions they have. As these electronic health records have matured and become much more effective and almost universal across the country, that was a logical point for dentistry to hop on. And it wasn't easy. A health record that was set up for medicine has to really have significant modifications to allow accurate documentation for dentists. That was a little bit of a barrier, and I think Epic has really addressed that pretty well.
There's so much detail dentists require in terms of documenting their examination and evaluation of the oral cavity. There's a different way to look at X-rays. Looking at a dental X-ray is very different from looking at a chest X-ray or a CT scan. So being able to put an EMR together that looks similar to a dental chart that dentists are very comfortable using, that took some effort and it wasn't that these electronic health records weren't built that way. They were initially built just for medicine. So to adapt those, it took a lot of teamwork. It took many people working with the EMR teams to design health records that were effective for dentistry.
Q: What challenges came up during the process of integrating records through Epic?
BB: It was probably a year in planning to happen and then a significant amount of training for all the personnel. When it starts, it's very difficult. There's a steep learning curve from all aspects of it, from the front desk [and] how they intake patients and how scheduling occurs, [to] how documentation occurs when the patient comes from the waiting room into the clinics, how we view our X-rays, how we write our notes, how we write orders. All of that is just very different. It's pretty comprehensive training that's required for the entire organization, but I would say it's definitely worth it. At the end of the day, you have a product that's just so much better, better for the provider and better for the patient. It's worth it, but there is that one significant barrier that there has to be buy-in by the entire organization.
Q: What have patients learned from this initiative?
BB: They engage. They can see my notes for the first time. They can see what my thought process was when I was treating or evaluating them. My notes are available in MyChart, so they can see the interpretation of their X-rays in MyChart. They can see when referrals were made, they can see when their prescriptions were put in and what pharmacy they went to. It's not like this closed wall. They have access to their health record now in a way that wasn't really there before, particularly in dentistry. The way the records were set up, patients just really didn't have access to them unless they were copied and provided for them.
Q: What lessons have you learned from the integration?
BB: The thing that was most striking to me is we have all of these faculty who have been in practice for forever, and I would say were a little bit resistant to change. That was the hard sell, to get people who were very set in their ways and had this one way to provide care. But when we saw our learners, like the very least experienced people, the ones who are in school or in residency, it almost wasn't even a blip. They were able to just adapt almost within a day. It's just getting people where they're comfortable with this type of change. People who have been brought up in this digital environment where things are changing so rapidly, any little change is so easily accommodated, whereas folks who are a bit further along in their career, this type of change is significant. That was the biggest eye opener for me.
Q: What is the most important thing to know about medical-dental integrated care?
BB: I would say the most important thing for me was just the impact on providing safe care. The whole reason we're doing all of this is for the patients. So anything we can do to improve the care we offer, that's the most important thing to think about. So when people are saying, "This is really challenging. Why do we need their physicians to be able to see what we're doing in dentistry?," or "Why do I need to see all of their health history?," that's why. It's really to provide optimal safe care in every setting where we're touching patients.