Dental Data Exchange, published by Payer/Provider Information Exchange Work Group. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/dental-data-exchange/ and changes regularly. See the Directory of published versions

Background

Currently, there is no standard for the exchange of discrete dental observations between dental providers. While some dental electronic health record (EHR) systems have implemented C-CDA for data exchange, that standard was primarily built for medical care and does not include most structured data elements needed by dental providers.

The Department of Defense (DoD) and the American Dental Association (ADA) recognized the need for foundational dental data exchange between medical and dental practices and among dental practices. The DoD wishes to support the dental health of service members and their readiness for deployment. The ADA wishes to support a continued, industry-wide, drive to promote and enhance standardized and structured dental data for seamless interoperability using CDA and FHIR. Lantana Consulting Group and the CareQuest Institute for Oral Health have collaborated to develop this FHIR Dental Data Exchange Implementation Guide in parallel to the CDA Dental Data Exchange Implementation Guide.

Representatives from the DoD, ADA, and industry leaders convened the Dental Data Exchange Project in late Summer 2019. The first project milestone was identifying key data concepts that could successfully transmit a dental referral between two dental systems, or between a medical and a dental system. The project focused on adding structure to unstructured dental data elements while maintaining alignment with FHIR US Core Implementation Guide, HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes R2.1 Companion Guide, Release 2 - US Realm, and HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm.

Independently, the CareQuest Institute for Oral Health identified a need for communication and coordination of care between oral health providers and other health care disciplines. The inability of health information systems to meaningfully share data limits the healthcare system’s ability to address whole-person care across the lifespan, and therefore is detrimental to health outcomes. The electronic communication of clinically relevant medical or dental information when referring a patient to a dental provider, and the ability to close the referral loop, via a dental consultation note to the referring healthcare providers is vital to improving care coordination and provider collaboration. The CareQuest Institute for Oral Health joined this project in Fall 2019, bringing their requirements to the development of standard dental referral and dental consultation notes.

Current Project

This project defines FHIR artifacts to extend the C-CDA on FHIR Referral Note and Consultation Note to include dental specific data concepts called for in the ANS/ADA 1084 standard and the CareQuest Institute’s MORE Care and Oral Health Value-Based Care initiatives.

The project references value sets set by the Systematized Nomenclature of Dentistry (SNODENT) working group, under SNOMED-CT. SNODENT is an official subset of SNOMED-CT that provides standardized terms for describing dental disease, captures clinical detail and patient characteristics, supports analysis of patient care services and outcomes, and is interoperable with electronic health record (EHR) and electronic dental record (EDR) systems. Additionally, SNODENT is mapped to ICD-10-CM for reporting diagnoses for billing. SNODENT includes a web-based search browser (ADA Browser®, where implementors can browse dental related terms and code sets.

The project uses the ADA 1084 as the authoritative reference for dental data inclusion because the ADA created it through consensus across dental providers about what shared dental concepts could be exchanged. The work group compared the ADA 1084 to the FHIR R4 standard, identifying gaps in FHIR representation of dental data concepts. The project prioritized ADA 1084 dental data elements within data domain categories and grouped the data domains by Dental Referral Note (referral sent to another system, requesting dental services) and Dental Consult Note (referral outcome sent back to requester).

Dental Use Case Scenarios

Use cases can bridge understanding between conceptual interpretations and technical implementation of this guide. Four use cases were tested at the May 2020 FHIR Connectathon: Dental Summary Exchange Track, and further refined by the project.

The use cases outlined in this IG show the complexity of the information that can be exchanged between a dental and medical system or two dental systems. Fully-formed XML sample files representing the data included in each of these scenarios are published with this implementation guide. Additional use cases are available on the CareQuest Institute website.

The figure below represents the high-level workflow described across Scenarios 1 (Medical to Dental Referral Note) and 2 (Dental to Medical Consultation Note).

Scenario 1: Medical to Dental Referral Note

Patient A is a 30-year-old male who has mild hypertension, Type 1 Diabetes, and has an insulin pump. He sees his primary care physician, Dr. John M at Good Health Clinic, for a routine, annual check-up. Aside from medical concerns, Patient A mentions increasing pain in his left lower jaw and some occasional bleeding from his gums. Dr. John M makes an urgent referral to a dentist for further evaluation and discusses the plan with Patient A, who agrees with the plan. Dr. John M generates a Patient Referral Note that includes data describing the dental related findings. Before Patient A leaves, the referral coordinator at the front desk schedules an appointment for him to see Dr. Drew Dentist for the next day.

Capability Statement references: Medical office system is the Document Source (i.e., server) that generates the Dental Referral Note and the Dental office application is the Document Consumer (i.e., client) that consumes the Dental Referral Note.

Patient has pain in his lower left jaw and occasional bleeding from his gums - referring for dental evaluation.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 1: Medical to Dental Referral Note.

Scenario 2: Dental to Medical Consult Note

Patient A sees Dr. Drew Dentist on February 16th for an urgent evaluation based on a referral from Dr. John M, his primary care provider. Patient A is a new patient at Dr. Dentist’s office, so a new patient record is created. Dr. Dentist reviews the risk assessment, the Dental Referral Note from Dr. John M, and the rest of the information that was pre-populated in the dental EHR. Dr. Dentist performs an oral evaluation and two PA radiographs. He identifies two areas of concern: patient has a significant, non-restorable caries lesion (decay) on the left lower back molar (tooth #18) with signs of infection, and early signs of decay on the right upper incisor (tooth #7).

Dr. Dentist 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). Dr. Dentist explains the importance 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).

Before Patient A leaves, the receptionist schedules an appointment for the extraction of tooth #18 on February 23rd, another appointment for restoration of tooth #7 on March 3rd, and a follow-up appointment for a complete examination, including radiographs and prophylaxis on March 10th.

Dr. Dentist reviews Patient A’s current medication list, notes an allergy to penicillin that is a counter-indication for his typical recommendation of amoxicillin, prescribes Erythromycin 500 mg every six hours for the infection and recommends alternating over-the-counter Ibuprofen and Acetaminophen for pain. Also, he generates a Dental Consultation Note back to Dr. John M with a summary of Patient A’s visit including the new prescription, planned procedures, future appointment dates, and patient specific dental goals.

Capability Statement references: The Dental office system is the Document Source (server) that generates the Dental Consult Note and the Medical office application is the Document Consumer (i.e., client) that consumes the Dental Consult Note.

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. Significant decay on the left lower second molar (tooth #18) with signs of infection. Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7). Recommend an extraction of the left lower second molar (tooth #18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 2: Dental to Medical Consult Note.

Scenario 3: Dental to Dental (Endodontist) Referral

Patient B has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking Azithromycin in accordance with the current American Dental Association Clinical Practice Guidelines for the infection (since there will be a delay in definitive conservative dental treatment due to the referral, and he is allergic to penicillin), and alternating acetaminophen and ibuprofen as needed for pain control.

Patient B has a history of hypertension and takes Lisinopril 10mg tablet once daily. He is also taking Azithromycin in accordance with the current American Dental Association Clinical Practice Guidelines for the infection (since there will be a delay in definitive conservative dental treatment due to the referral, and he is allergic to penicillin), and alternating acetaminophen and ibuprofen as needed for pain control.

Dr. Dentist records Patient B’s diagnostic test results and clinical impressions and sends a referral to the endodontist for an evaluation and appropriate treatment for tooth #30. The referral included medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations.

Capability Statement references: General Dentist office system is the Document Source (i.e., server) that generates the Dental Referral Note and the Dental specialist office application is the Document Consumer (i.e., client) that consumes the Dental Referral Note.

Diagnosis for tooth #30: pulpal necrosis and chronic apical abscess (with a draining sinus tract). #30 has a potentially cracked DB cusp. Use of Tooth Slooth appeared to rule out vertical root fracture. Clinical impression is that tooth #30 is restorable with a good long-term prognosis. #29 D has a moderate active carious lesion. On exam of the lower right quadrant, tooth #30 was very sensitive to percussion and non-responsive to cold or EPT testing. Minor sensitivity to palpation elicited in this area, but pain experienced on biting with relief on opening for tooth #30. No evidence of new caries on distal. Missing tooth #28 was replaced with an endosteal implant with a porcelain fused to metal crown. Tooth #32 is impacted (possible full-bony impaction). Minimal swelling present on lower right buccal vestibule around #29 and #30 with sinus tract present on #30B. Periodontal probing depths in lower right quadrant were all less than or equal to 3 millimeters. Pt is taking Azithromycin (500 mg loading dose and 250 mg each day for 4 additional days) for the infection and alternating 600 mg of ibuprofen and 1000 mg of acetaminophen every 6 hours for pain and swelling.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 3: Dental to Dental (Endodontist) Referral.

Scenario 4: Dental (Endodontist) to Dental (General Dentist) Consult Note

Patient A was experiencing pain that started two 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, and his last dose was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.

Previous medical and dental history verified by Endodontist: One month ago, patient 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.

Endodontist also verifies intraoral and paraoral findings from referring Dentist. At the end of the visit, a Dental Consultation Note is generated including medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations and sent from the Endodontist to the General Dentist.

Capability Statement References: Dental specialist office system is the Document Source (i.e., server) that generates the Dental Consult Note and the general Dental office application is the Document Consumer (i.e., client) that consumes the Dental Consult Note.

Verified suspected 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.

This table maps the FHIR resources to CDA sections and entries and to data values for Scenario 4: Dental (Endodontist) to Dental (General Dentist) Consult Note.