2022 - 09 Dental Data Exchange

Detailed 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 Dental Bundle Creator: Generate bundle (referral note) above and successfully POST to a test server

For Dental Bundle Consumer: Retrieve and process bundle (referral note) above, incorporate and/or render data received

Bonus point

Process and store computable data out of entries

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 Dental Bundle Creator: Generate bundle (consult note) above and successfully POST to a test server

For Dental Bundle Consumer: Retrieve and process bundle (consult note) above, incorporate and/or render data received

Bonus point

Process and store computable data out of entries

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 Bundle Creator: Generate bundle (referral note) above and successfully POST to a test server

For Dental Bundle Consumer: Retrieve and process bundle (referral note) above, incorporate and/or render data received

Bonus point

Process and store computable data out of entries

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 Bundle Creator: Generate bundle (consult note) above and successfully POST to a test server

For Dental Bundle Consumer: Retrieve and process bundle (consult note) above, incorporate and/or render data received

Bonus point

Process and store computable data out of entries

Reasons for Referral Valueset