2020-05 Dental Data Exchange

**UPDATED Virtual Connectathon information** 

May 13-15th, 2020

Registration cost: $100 for HL7 Members; $150 for non-members

Registration link: Connectathon 24 Confluence page

'Dental' Zulip stream (chat.fhir.org): https://chat.fhir.org/#narrow/stream/179292-dental

Dental Track Orientation: 5/11/2020 1:00pm EST.

Orientation Slides: 

Dental Exchange Track_Orientation_FHIR Connectathon 24.pptx

Recording from Orientation session: 

https://us02web.zoom.us/rec/share/7NFoKLbS9FpJRpXsq37UGaJ4IKP1eaa82yAb_qZZxBs9yyYXLBw-wk7rfyLJPrB0

Access Password: 1o+f+P71

Daily Connectathon schedule

Wednesday, May 13th

• HL7 Kick Off Call    4:00  pm
• Track kick-off Call   5:00 pm EST (Following HL7 KickOff Call)

https://zoom.us/j/4675587926

Personal Meeting Room ID: 467 558 7926

Agenda: Kick off, roll call, and office hours to answer general questions about what to expect and how to get set up and familiar with all of the dense FHIR resources and documentation. If you feel comfortable and ready to hit the ground running Thursday am, feel free to skip this session

Thursday 5/14: starting @10:00am EST (same Zoom link)

Goals for Thursday am session

• • Developers: download FHIR validator and prepared resources, work to programmatically update and validate locally (see below Testing Resources links)
  • Non-developers: download postman & FHIR Validator, interact with ‘dental’ resources - See Non-developer exercises. Also consider joining General FHIR Intro this time (on General Zoom info)

Thursday: meeting @1:30pm (EST): Goals for Thursday afternoon session (will have periodic checkins throughout afternoon)

• Developers: data creation, exchange (HAPI or others), parsing and/or validation
• Non-developers: Apply skills as FHIR handlers to analyze sample FHIR resources against spec and use cases. Document feedback on IG directly in Jira.
  • Areas of interest (teams?): Oral Findings, General RiskAssessment, Caries RiskAssessment, 1084 gap analysis, ServiceRequest/In-Fulfillment-Of extension on Consult Note

Thursday Day 1 wrap-up: 6:00 pm EST

Friday 5/15: meeting @ 10:00 am EST (same Zoom link)

Goals for Friday am session

• Give everyone opportunity to pair up in small teams or continue with current team.
  • Goals: continue to review spec, exchange and validate data, and build Jira.

Friday 2:00pm: Review Jira tickets and prep for final track readout 

6:00pm EST General Closing meeting on the general meeting

Dental Data Exchange FHIR IG: https://build.fhir.org/ig/HL7/dental-data-exchange/

Testing Resources:

•  Using the FHIR Validator
• https://github.com/HL7/dental-data-exchange/tree/master/input/resources
• http://hl7.org/fhir/downloads.html
• Post questions and issues on Zulip (Dental stream link above)
• CCDAonFHIR IG: https://build.fhir.org/ig/HL7/ccda-on-fhir-r4/artifacts.html

Submitting WG/Project/Implementer Group

Payer/Provider Information Exchange WG

Justification and Objectives

This track aims to demonstrate the exchange of information between dental and medical providers for a patient. Relevant FHIR resources will be based largely on existing US Core and CCDA on FHIR. This work will inform the development of more comprehensive implementation guides and profiles for interoperability between dental to medical and dental to dental domains based on FHIR Release 4, which is the primary target for the dental exchange testing in this track.

This track will use the R4 version of FHIR.

Clinical input requested

Clinical input has been gathered from medical and dental stakeholders throughout the development of this track proposal and is reflected in the scenarios (use cases) below.

Targetted Questions

1. The following concepts are not included in the C-CDA Referral Note definition - are they really needed and useful:
1. Chief Complaint (is this necessary given inclusion of Dental Findings, Service Request, and the referral narrative?)
2. Encounters - will this be relevant for most referrals?  Are there particular referral situations where this would be important for the consulting Dentist to know?
3. Payers - if the appointment itself will be scheduled separately, will the Consulting Dentist really benefit from receiving this info in the Referral Bundle?
2. Risk Assessments - do we need to model these as structured assessment with interpretations (how RiskAssessment resource is modelled), or would it make more sense to simply share the ultimate risk classification as a Finding (Observation resource) without all of the detailed assessment components and interpretations.

Related tracks

Care Management Track

US Core Track

Proposed Track Lead

Dave deRoode - david.deroode@lantanagroup.com

Zabrina Gonzaga - zabrina.gonzaga@lantanagroup.com

Expected participants

• Rebekah Fiehn, DentaQuest
• Corporate Dental System (CDS)
• Cerner/Dentrix/Henry Schein One
• DSS (VA Dental Record Manager)
• Gregory Zeller (ADA)
• Jean Narcisi (ADA)
• Sharon Stanford (ADA)
• LTC Kevin Parker (U.S. Army)
• Add your name here

Track Orientation

A webinar will be hosted on date at time to share further participation information about this track.

System Roles

• Medical Provider (‘M’)/Referral Coordinator record system – POST and GET Referral request note to/from FHIR server (Medical to Dental)
• Dental Provider (‘T’) record system – POST and GET ‘Dental Referral Treatment Report to/from FHIR server (Dental to Medical; Dental to Dental)

Your system should be capable of handling/supporting FHIR bundle containing some of the entries listed within the tables

Scenarios

Scenario 1: Medical to Dental referral

Patient A is a 21-year-old white Hispanic male with mild hypertension who is a full time white-collar worker, recently graduated from college. He is seeing Dr. M at Good Health Clinic, his established primary care physician for a routine, annual check-up.

Upon arrival, the receptionist

1. reviews his insurance card, a commercial plan offered through his employer;
2. provides Patient A with a routine oral health assessment questionnaire;
3. updates the patient demographic (update Patient resource);
4. updates insurance information (update Coverage); ***clarify health vs. dental insurance; presumably, dental insurance info might be used for exchange between dentist/endodontist (use cases 3/4)***
5. collects patient's co-pay.

The medical assistant takes the patient to the examination area calls the patient back and 

1. obtains Patient A’s vital signs (create Observations),
2. obtains medical history (Hypertension diagnosis/Condition);
3. obtains current medications (update Medication);
4. asks for any concerns (create Condition) to discuss with the provider today (e.g. such as 'bleeding gums'). 

Among the issues raised by Patient A is increasing pain in his left lower jaw and some occasional bleeding from his gums (Conditions, Observations).

Note that the standard sections of the electronic health record (EHR) contain the routine oral health information formerly captured in the Oral Health Risk Assessment (18+). (RiskAssessment)

***Need to discuss codes for various riskAssessments in scope; Also, need to complete outcome prediction elements***

During the visit, Dr. M

1. reviews the information with Patient A;
2. performs an exam of his oral and paraoral areas health. Upon oral examination, Dr. M finds the patient has swollen gums, significant plaque buildup and significant tenderness near left lower molar (Condition, Observation); 
3. confirms the patient has not visited a dentist or received fluoride treatments in the past four years while away at college;
4. advises (Communication) Patient A to see a dentist regularly, brush his teeth twice a day with fluoride toothpaste, and floss daily;
5. makes an urgent referral (ServiceRequest, Referral Note) to a dentist for further evaluation and discusses the plan with Patient A, who concurs;
6. generates a ‘CCDAonFHIR Referral note’ (Bundle.type=document) that includes the below FHIR coded information as well as the accompanying narrative (CCDA-on-FHIR Composition) describing the dental-related findings.

Before leaving, the practice’s referral coordinator schedules an appointment for Patient A to see Dentist D for the next day.

The patient checks out and schedules a follow-up appointment with Dr. M in three months (Encounter, planned).  Bundle.type=document is generated by Dr. M’s EHR system and is received by Dentist D’s system.

Actor: Medical Provider

**For General Clinical terminology mappings to FHIR resources, see: https://www.hl7.org/fhir/resourceguide.html. For example, there is no Chief Complaint resource, so this information will be found in a Condition resource.

http://hl7.org/fhir/us/odh/StructureDefinition-odh-PastOrPresentJob.html

Success Criteria

For Medical systems: Medical Record (EHR) system able to generate bundle (referral note) above and successfully POST to test (HAPI) server

Medical Record (EHR) system able to GET bundle above bundle from test (HAPI) server

For Dental systems: Dental record system successfully GETs above bundle

Bonus point

Dental record system able to parse bundle entries and successfully store entry data

Scenario 2: Dental to Medical Consult Note

Patient A is a 21-year-old Hispanic male with mild hypertension who is seeing Dentist D for an urgent evaluation based on a referral from Dr. M, his primary care physician.

The receptionist

1. checks in Patient A;
2. since Patient A is new, creates a new patient record (create Patient)
3. verifies the patient’s demographic and insurance information from the electronic referral received.

The dental hygienist

1. calls the patient into the treatment area;
2. verifies patient identity;
3. obtains Patient A’s medical/social history;
4. reviews the current medications (read Medication & MedicationRequest) and allergies (read AllergyIntollerance) from the referral note;
5. confirms the reason (Composition.Reason for Referral) for this urgent visit.

Dentist D

1. reviews the Risk Assessment; **TODO: RiskAssessment Details; Caries vs. General vs. Perio**
2. reviews referral note from Dr. M;
3. reviews the information pre-populated in his EHR;
4. performs an oral evaluation (Procedures, generates Observations + new) - D0140, and exposed two PA radiographs (#18 D0220 and #7 D0230)
5. identifies two areas of concern: The patient has a significant, non-restorable caries lesion (decay) on the left lower back molar (tooth #18) with signs of infection and also has early signs of decay on the right upper incisor (tooth #7) (Conditions). Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment;
6. discusses findings with the patient;
7. recommends an extraction of the left lower molar (tooth #18) and restoration of the right upper lateral incisor (tooth #7) due to a caries lesion (decay) (Procedure);
8. educates (Communication) Patient A on the benefits of complete examination (dental home), of using a fluoride toothpaste when brushing twice daily with daily flossing, and of the need for bi-annual dental visits for examination and prophylaxis (cleaning).

Patient A agrees with the plan and agrees to schedule the follow-up procedures.

Dentist D

1. reviews the patient’s current medication list (reads MedicationRequest);
2. notes an allergy to penicillin (AllergyIntollerance) that is a counter-indication for his typical recommendation of amoxicillin;
3. prescribes (create new MedicationRequest) Patient A erythromycin 500 mg every six hours for the infection and recommends alternating over-the-counter ibuprofen and acetaminophen for pain.

Patient

1. schedules (create planned Encounter) the extraction of tooth #18 one week after initial appointment;
2. schedules an appointment for restoration of tooth #7 for one week after extraction;
3. schedules a follow-up for complete examination, including radiographs, and prophylaxis (cleaning) for one week after restoration of #7.

Dentist T generates a Dental Referral Treatment Report (Bundle.type=document) back to Dr. M with a summary of the visit which includes the new prescription (based on US Core Medication & MedicationRequest profile), planned procedures and dates (based on US Core Procedure profile).

Success Criteria

For Medical systems: Medical Record (EHR) system able to GET bundle (consult note) above from test (HAPI) server

For Dental systems: Dental record system successfully generates and POSTS above bundle to test (HAPI) server

Bonus point

Medical record system able to parse bundle entries and successfully store entry data

Scenario 3: Dental to Dental (Endodontist) Referral

Chief Complaint:  Patient A is a 24 yo reports to Dentist D pain on lower RQ. 

History of Present Illness:  Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days.  He is able to eat regular food but only chews on the left side.  He takes 400 mg ibuprofen every 8 hours for pain.  His last doses was 2 hours prior to this visit.

Medical History:    Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily.  Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain .

Allergies:  Patient is allergic to penicillin.

Dental History: One month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion).

Vital Signs: BP 130/86, Pulse = 92

Assessment:

Intraoral findings:  On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. 

Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.

Test performed:  Electric pulp test was positive for vitality #29 and 31 with #30 non-responsive.  Cold test responsive #30, lingering 15 sec.

Radiographic/Imaging: Two PA x-rays (URL to access?) (D0220 #29 area, D0230, #30 area)) of the affected teeth (29, 30, 31) were exposed in the office today. Panoramic radiograph (D0330) exposed. Radiographic results showed #32 full bony impaction, #28 endosteal (root form) implant with full crown restoration, and tooth #30 with small PA lesion mesial root. Radiographic caries lesion #29 distal caries lesion (ADA Caries Classification System moderate caries lesion). Other WNL

Primary Diagnosis:

• #30 pulpal necrosis and periapical pathosis with draining fistula
• Clinical impression is that possible vital pulp remnants remain

Secondary diagnosis

• #30 possible cracked DB cusp; rule out cracked tooth. Clinical impression is that tooth is restorable.
• #29 D caries lesion (ADA CCS moderate caries lesion)

Reason for Referral:

Referral to endodontist for evaluation of #30 and endodontic therapy #30.  Referral includes medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations to be sent from Dentist to Endodontist

(Map to 1084: 5.17 Plan of Care)

Success Criteria

For Dental systems: Record system able to successfully generate and POST bundle (referral note) above to test (HAPI) server

For Dental systems: Record system able to GET bundle (referral note) above from test (HAPI) server

Bonus point

Dental record system able to parse received bundle entries and successfully store entry data

Scenario 4: Dental (Endodontist) to Dental (General Dentist) Referral Result

Reason for Consult:  Referral to endodontist for evaluation of #30 and endodontic therapy.  

Referring Dx: Suspect irreversible pulpitis tooth #30 with necrotic pulp and periapical pathosis with draining fistula. Tooth is restorable despite possible incomplete fracture DB cusp #30.

Chief Complaint:  Patient A is a 24 yo reports to Endodontist upon referral with pain lower RQ, points to #30. 

History of Present Illness:  Patient A said the pain started 2 weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days.  He is able to eat regular food but only chews on the left side.  He takes 400 mg ibuprofen every 8 hours for pain.  His last doses was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.

Dental and Medical History, Allergies: See above as example, which was verified by Endodontist. (Previous Dental History from referring dentist: One month ago, pt. reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion (Previous Medical History and Allergies from referring dentist: Medical History: Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily. Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain. Allergies:  Patient is allergic to penicillin).

Exam: Endodontist confirmed above (exam code D0140 or D0160?). (from referring dentist: Intraoral findings:  On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to palpation, pain upon biting with relief upon opening. No evidence of new caries on distal; missing #28, replaced with endosteal (root form) implant with full crown tooth-colored restoration; #32 impacted with possible full boney impaction. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.)

Also performed transillumination and dye tests (blue dye) within pulp chamber during endodontic therapy and saw no evidence of cracks. Exposed one diagnostic periapical radiograph (charge D0220?) and confirmed radiographic findings above.

Vital Signs: BP 120/80, Pulse = 90

Procedures:  Endodontic therapy tooth #30 (D3330) with local anesthesia, gutta percha fill with sealer. (Dx: Irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining sinus tract on B.) No vertical fracture of root apparent during endodontic therapy (disorder). One preop PA and two postop PA radiographs exposed as part of endodontic treatment were returned with consult (referral) report to referring general dentist. Rx: Tylenol #3, 12 tabs, 1 or 2 q4-6 hrs prn pain. 

Prognosis: Good. Recommend restoration with full crown.  Note: Puff of sealer noted around M root; monitor for the next year, and, if sealer does not resorb, consider apicoectomy.

Radiographs: Images from endodontist (one pretreatment periapical and two postop periapical images of final fill) sent to referring general dentist. (and acquired via DART system?)

***Question: Did Endo wrist script for Tylenol?*** Yes- Tylenol #3, 12 tabs, 1 or 2 q 4-6 hours prn pain - see above.

A dental consult (referral) note is generated including medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations and sent from the Endodontist to the General Dentist.

Success Criteria

For Dental systems: Record system able to successfully generate and POST bundle (consult note) above to test (HAPI) server

For Dental systems: Record system able to GET bundle (consult note) above from test (HAPI) server

Bonus point

Dental record system able to parse received bundle entries and successfully store entry data

TestScript(s)

NA

Security and Privacy Considerations

NA

Reasons for Referral Valueset - 3/30 HOMEWORK: Please add rows and column data as possible for review