The Case Against Inter-Operable eHRs

Let the Conversation Begin


By Darrell Kellus Pruitt; DDS

If someone says computerization in dentistry is inevitable, remind them that the metric system is inevitable as well.  Sometimes inevitable takes a long time though – even when it makes sense.  Interoperable dental records don’t.

Contrary to what healthcare IT stakeholders promise to win financing from a newbie Obama administration, interoperable eDRs will increase my cost of providing care, increase my liability as a businessman and endanger my patients’ health and welfare. Those are just three of many reasons why I intend to firmly stand in the way of their adoption until security problems are resolved to my satisfaction. I dare not grow discouraged, for there are far too many depending on me. 

If my grandchildren are to benefit from the miracles of trusted Open Source Evidence Based Dentistry, we must not allow today’s temporary collection of reckless stakeholders to burn consumers’ trust in eDRs even once. 

It is for these reasons that I watch very closely for the mention of eHRs on the Internet.  I am particularly alerted to danger when someone tells lawmakers that they have their own special plans for my patients’ dental records – without first discussing them with me.  I’m funny that way about my Hippocratic obligations and I don’t care what anyone thinks.

The Professor and IT Advocate

Valerie Powell, PhD., a professor of informatics at Robert Morris University, began commenting about dentistry and eHRs on in April.  She has posted five comments.  Her most recent appeared on November 25, and it was in response to my counterpoint titled “Dentistry EHRs not necessarily inevitable.”

I continued my point-by-point critique of her uninformed ideas right here on the Medical Executive-Post in an article titled “Dental eHR Controversy Continues.”

Valerie Powell never returned a response.

Today, Powell’s name popped up on my google-alert.  She was interviewed for an article posted on the Pittsburgh Tribune-Review, written by Allison M. Heinrichs and titled “Experts lobby to add key dental data to medical records.”

She and her lobby went over my head.  That was wrong, as well as foolish.

I must say this in defense of her courage, however. In the last two years, Valerie Powell PhD., is the only person in the US who is publicly pushing for interoperable health records in dentistry.  She continues to hopefully plod along even though there are no longer any dentists promoting them – from what I can tell.  The ADA long ago gave up on unwittingly pushing dentists to go paperless. In fact, because of the palpable resentment among membership over being misled about the NPI number, the ADA Department of Dental Informatics [ADA-DDI] no longer even suggests that members sign up for them.  Just ask the department for yourself at

Tell them I sent you. They know who I am.

Even the eHR debate that limped along on PennWell was seemingly unnoticed by not only representatives from the ADA Department of Dental Informatics [ADA-DDI] but also by software vendors whose very market awaited their responses.  There still must be a dozen or so unanswered questions about eHRs in dentistry featured on this thread.  Does it not seem strange to anyone else that dental software firms are not tripping all over each other to get the names of their products in front of thousands of dentists for virtually no cost?  Transparency on the Internet certainly beats traditional advertisement if a business can tolerate the matching accountability.

Other than Dr. Powell, why do you think healthcare IT stakeholders are so shy?  And when they do speak up, why do they continue to over-stretch worn out rationalizations rather than offer tangible reasons for eHR adoption in dentistry? 

For example, the lame Hurricane Katrina excuse for digitalization of dental records was stupid even before it was approved by some committee as a talking point.  For anyone here in west Texas, it sounds really, really silly.  Here is another almost extinct slow-moving talking-point I like to lampoon, “Someone can steal paper charts just as easily as they can steal digital records.”  Is there anyone in the nation who can argue that point successfully?  Please step forward; Your audience awaits. 

Recently, I heard a fresh, incredible reason why dentists should computerize – malpractice protection.  Someone who really should have known better told me with a straight face that there are not only more negligence lawsuits filed in dentistry than digital privacy breaches, but that if a dentist has a paperless practice, almost all malpractice lawsuits could be prevented.  I find it hard to believe that a dentist could be so naïve.  Or worse, that a dentist would assume a colleague is so naïve.

Regardless of bald lies mixed in with irrelevant talking points, some rationalizations for connectivity are better than others.  But that still does not mean dentists must computerize their practices to accomplish worthy goals.  For example, one thing Dr. Powell understands on a professional level is the importance of dental health in overall health.

“The research shows that there is a close relationship between diabetes and periodontal disease, also with stroke, respiratory disease, and kidney disease. Some research shows that certain oral diseases are associated with conditions that lead to low birth weight.  And yet dentists and physicians aren’t communicating. I really don’t believe we’re going to get an optimal improvement in clinical care until we take care of this problem.”

Valerie Powell, PhD [Piittsburgh Tribune-Review]

Dr. Powell’s goal is sound, and I cannot argue with her about the urgent need for better communications between all healthcare providers.  In fact, with the sudden downturn in the economy, it so important that we quickly gain control of the expensive and preventable chronic illnesses she mentions, that the nation cannot afford to wait until dentists are paperless.  That could be decades.  The $25 billion bailout that the healthcare IT industry is requesting will be squandered in part for political favors by members of Dr. Powell’s lobby.  I call that churning profits.  That was the old, inefficient way of doing things in dentistry.

We need something now and we need something that will cost virtually nothing.  We need a system for better communications that can be erected in less than six months and will allow taxpayers to keep their $25 billion.  Above all, in order to make this work, we must avoid HIPAA as much as possible.

I’ve put some thought to the serious problem that Dr. Powell describes.  I think I have found a hybrid solution that will not require dentists to become HIPAA-covered entities to communicate more effectively with physicians’ computers.  In fact, physicians also don’t have to be covered entities.  And no, it is not a person-to-person phone call – an increasingly underrated form of communication in my opinion that also does not require HIPAA’s involvement. 

Do you know what the solution is yet? 

Keep reading. There’s more. A solution?

My solution would allow e-prescribing to occur in dentistry, without the dentist having to “volunteer” for a dangerous NPI number.  This would help Glen Tullman, the shy CEO of Allscripts – a monster stakeholder in e-prescriptions.  Otherwise, poor Glen is fresh out of ideas.

Committees just do not creative thinkers make.

That’s not all! The hardware necessary already exists in most dental offices, and can be obtained for less than $200 at any electronics store.  And just wait until my solution is combined with state-of-the-art voice-recognition capabilities.  All communications with physicians and pharmacies could be done chair-side in the presence of the dental patient without having to store their identifying information digitally anywhere.  All that is needed is a universally acceptable paper format and an acknowledgement that paper is going nowhere soon – thank goodness. 

So what is the revolutionary idea?  It is so simple it will knock you down.

(Drum roll)…  Make eDRs and eMRs compatible with common fax machines as a requirement for ONCHIT accreditation.

Wow!  Now how difficult was that?


I invite Dr. Valerie Powell, Dr. Franklin Din, or anyone else interested in finding a solution rather than funding, to discuss with me problems with my idea.  I happen to think it is a cheap, common sense solution that will give us all the benefits Powell promises without excessively endangering anyone other than dental software vendors looking for bailout money. Another difference is my plan has a chance in hell of working


And so, your thoughts and comments on this Medical Executive-Post are appreciated. What do you think? What is your plan? Let the conversation begin.

Note: Dr. Pruitt blogs at PenWell and others sites, where this post first appeared.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact:  or Bio:

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8 Responses

  1. More on Inter-operable Electronic Dental Records

    In addition to posting an announcement on PennWell, I posted this comment on a surrogate blog I have used in the past to drum up attention.

    Hope the New Year is going well for all my sports fans who don’t mind watching truth uncovered – hair and all.

    For anyone interested in seeing what I stepped in, I am involved in a couple of threads with both Dr. Marty Jablow and Dr. Valerie Powell on DrBicuspid.

    The subject is interoperable electronic dental records – good or bad. I think what we hear about them is just hype, and I am holding Jablow and Powell accountable for what they are telling other dentists on the Internet. I think it is incredible that neither one of them acknowledges even a single problem to going digital.

    Marty doesn’t seem to believe breaches occur at all from dental offices and they both see huge problems with paper, fax machines and telephone calls. To hear them talk about how bad paper records are, it is a wonder that the profession has survived for several decades with such remarkable safety. I think these two stakeholders are capable of world-class cognitive dissonance.

    It is my opinion that Dr. Marty Jablow and Dr. Valerie Powell are running out of wriggle room. I am considering presenting the unanswered questions from the abandoned debate on PennWell soon – just to tighten the squeeze chute another notch. (see “EHR / PACS – The Great Debate”)

    I bet it will cause either excitement or silence. Either way, my patients win. Please come visit us.

    D. Kellus Pruitt; DDS


  2. Dear Darrell,

    Well, Happy New Year! I think I have found my own way of causing trouble. There are lots of medical folks who just can’t seem to adjust to the research results that make it clear that they must regard their dentist colleagues as full-fledged and valuable members of the primary care team.

    So, Frank Din and I have plenty to keep us busy. It looks like we’ll be getting some help from Dr. Marjorie Jeffcoat, a well-known periodontist who is now Dean Emeritus in the dental school at the Univ. Penn. She co-authored IOM Report on Dental Education at the Crossroads, in 1995.

    One non-eHR approach that would be useful would be to encourage co-location of primary care physicians and general dentists in a joint practice (and correspondingly pediatricians and pediatric dentists). That would go a long way toward building the kind of chronic care I envision. That might be more effective than faxes.

    BTWSince you like mysteries, have you ever looked at the acknowledgement list in Frank’s and my position paper at the very last entry in that list? What do you think that is about?



  3. Dear Valerie

    Many thanks for the reply.

    “One non-EHR approach that would be useful would be to encourage co-location of primary care physicians and general dentists in a joint practice (and correspondingly pediatricians and pediatric dentists). That would go a long way toward building the kind of chronic care I envision. That might be more effective than faxes.”

    Wow! If you thought interoperability is tough, you have no idea how difficult and expensive it would be to pair up dentists with physicians in the same location. I agree, that would be utopia for integrated care of patients, but outside of academia and institutional settings, it is simply not a realistic possibility. It will never fly, Valerie. As a friend, I would suggest you avoid the embarrassment of losing credibility, and keep that idea in your pocket; seriously.

    I’m glad I had the chance to once again review your paper, Valerie. I looked closer at the one-page “Wisconsin Diabetes Guidelines Diabetes Referral Form,” and it occurred to me that this would be a good place to start on our common goals – using the hybrid solution of a computer-fax interface to better handle chronic diseases instead of interoperable dreams.

    I know you and Frank have a lot invested in the idea of a digital platform for communications, but you are too far ahead of your time. In addition, it is my opinion that you cannot get there from here. Let’s be sensible instead of accomplishing nothing.

    And, it so happens that the fax machine is safer, cheaper and already in place in virtually all dental and physician offices. Consider the hybrid solution as not only an inexpensive stepping-stone to the (almost) universal digital interoperability that we both seek (on our own diverging terms), but also as a proving ground for your theories about the benefits of better communications between physicians and dentists. Do you have any better ideas for the research you desperately need at a better price?

    If you wanted to set up a pilot study using a limited amount of dental/medical patients, I would not only personally volunteer to participate, but I would help spread the word about your efforts. Now how can you possibly beat that offer?

    Now, imagine the influence you would win if you could exhibit hard data which irrefutably supports your contention that dentists and physicians need better communication. That works much better than educated guesses and hopeful fantasies.

    Once PII is removed from dental patients’ dental records, allowing progress at last towards interoperable eDRs, you will hit the ground running with the support of dentists in private practice instead of skepticism mixed with mistrust.

    Remember, information is the product -the computer a tool – and not the other way around.

    This is progress, Valerie.



  4. Dear Valerie,

    I am proud that you let me know that I am one of the four who you acknowledge anonymously. You recognized my desire, yet you still let me know that my input mattered. I am honored.

    Regarding causing neighborhood fire-fights between physicians and dentists; I assume the co-location is voluntary and not mandatory. However, California has a penchant for doing cutting-edge-stupid.

    Do you realize that 85% of dentists in private practice are solo (ADA News)? Do you also realize that all but three dentists in the nation like it that way (Darrell’s guess)?

    In today’s climate, I cannot imagine getting doctors and dentists in the same auditorium, much less a small office.

    Go for it, Valerie. But remember that I warned you against it.

    -Darrell K. Pruitt; DDS


  5. Some more Gossip about CCHIT

    A week ago, I sent a few questions to the Certification Commission for Healthcare Information Technology (CCHIT). Some got through, while others did not.

    I assumed the incomplete response was typical stonewalling and gave up. I may have been wrong to suspect traditional tricks of evasion. Evidently, the experts in healthcare IT who volunteer to determine the path of an incredibly complicated interoperable national healthcare digital network have been having problems with their website’s software – for quite some time now.

    I received a new and unexpected response from CCHIT representative DW this morning that I will share with you. Below, follows my response. This could get interesting if nobody tells CCHIT about this shamelessly unprofessional gossip that I am whispering behind their backs. I could get in trouble.

    Let’s see how patient CCHIT can be with one hell of a persistent dentist. And remember. Don’t say a thing. That would spoil the fun.

    D. Kellus Pruitt; DDS

    From: DW
    Sent: Thursday, February 05, 2009 1:27 AM
    Subject: Re: CCHIT representation

    Dear Darrell,

    Thanks for submitting your question or comment to us. Unfortunately the description field didn’t come through on your message — perhaps due to a problem with our web site form. We are working to remedy the problem, but in the meantime if you can re-send me your message directly by email, I will promptly forward it to the proper person for response. My apologies for this inconvenience.

    Certification Commission for Healthcare Information Technology

    From: Darrell []
    Sent: Thursday, February 05, 2009 8:00 AM
    To: DW
    Subject: RE: CCHIT representation

    Thanks for your reply, DW. I have to admit that I had already given up on a response. I wrongly assumed that CCHIT was just another insensitive bureaucracy that ignored questions – even as it invited dialogue. Your email was refreshing and encouraging.

    I am a dentist in private practice in Fort Worth, Texas. I have been following the progress of eHR adoption among physicians, while trying to predict how eHRs will affect my practice. Quite frankly, I cannot see how interoperability will benefit dental patients. Is there anyone working for CCHIT who can describe the benefits of interoperability with dental records?

    Thanks again for your attention.
    Darrell K. Pruitt; DDS


  6. Hi Darrell,

    Let me get this straight.

    The CCHIT website was down, or email communications was otherwise corrupted? And, these are the same folks that are supposed to lead the way in our domestic healthcare eHR initiatives! What am I missing?



  7. Felix, et al.

    I posted this comment here, and elsewhere, under the rubric of gossip. Nevertheless, it is interesting indeed.

    From: SR
    Sent: Thursday, February 05, 2009 12:08 PM
    Cc: DW
    Subject: Certification of Dental EHRs

    Dr. Pruitt:

    DW has forwarded your question to me. As noted in my email to you, the Commission has not yet taken up the development of certification for software products used in dentistry. While one cannot deny the value of dental information in the management of health, it is not currently within the scope of the Commission’s work to undertake the development of criteria and test scripts that inspect the data compatibility between physician office EHRs and dentistry records. As our work progresses, it may become a future consideration.

    I reiterate my earlier description of the progress of our work:

    When HHS contracted with CCHIT in September of 2005 to develop an inspection and certification process for health information technology, ONC specified primary care physician offices – where most Americans get their care – followed by acute hospitals in year two, and health information exchanges in year three. That contract ended in September 2008. Our initial development process was largely dictated by that contract. ONC also specified a range of shareholder groups that should be included in our Commission and volunteer work groups. Dentistry was not among those priorities or stakeholders mandated by the contract.

    However, since the launch of our first inspection program in May 2006, we have seen demand from many other care settings, patient populations and professional specialties. In response to that we have conducted open calls for requests for expansion, in November 2007 and December 2008. Those calls were published in press releases and carried in the health IT trade press. We also included the calls on our Web site and in our own electronic news letter, CCHIT eNews. We have never had a response to those public calls for expansion from dentistry.

    In both cases, the Commission has reviewed and prioritized the submissions and added programs to our future development cycles. As a result, child health, emergency medicine and cardiovascular medicine programs were launched in 2008. Long term care and behavioral health will be added in 2010.

    As I described in the email, our current proposed expansion roadmap closes for public comment today, Feb 5. You may add your comments for the Commission’s consideration at

    The Commission’s public comment process is an open and transparent one. They review and publish all comments submitted through this public process.

    We encourage you to sign up for our electronic newsletter at

    That newsletter will keep you informed of all upcoming opportunities for participation in the Commission’s work.

    Certification Commission for Healthcare Information Technology

    From: Darrell []
    Sent: Thursday, February 05, 2009 3:06 PM
    To: SR
    Cc: DW, Powell, Valerie (
    Subject: RE: Certification of Dental EHRs

    Dear S and D:

    S, you did indeed thoroughly answer my question last week, and I apologize for not sending a thank you note. You were very accommodating. Thank you.

    I’m sorry that you were inadvertently bothered again, but today’s was a different question to a different person … or so I thought. It may have been wrong for me to take this liberty, but DW’s email arrived out of the blue this morning in response to my hit-and-miss efforts at communication a while back. Since it is admittedly difficult to reliably get a response from the CCHIT website, I thought – why not? DW was available and offering to answer a question. What difference would it make to him if I slip in a different one, a week later? Who’d know?

    Though I may be a pain, please understand that whatever CCHIT decides about EHRs for the nation, it will have a serious impact on my dental practice – possibly adding tremendous expense and danger to the care I give my patients. This is not a hobby. This is serious. I want to know what is happening.

    Ever since you informed me the first time that interoperability in dentistry has not yet been considered by CCHIT, and then added that I am virtually the first person to even mention it, I have been understandably concerned. As if the revelation of a huge information vacuum for my profession at CCHIT were not enough, I now question the interoperability of the CCHIT staff with each other.

    Of course, I knew beforehand that Dr. Valerie Powell, PhD., had established contact with CCHIT in June of 2008 concerning the importance of dentistry in EHR plans. What happened to that information? Please let us know if her concerns need to be repeated for CCHIT. We are in touch.

    My still unanswered question that I posed to DW – How will EHRs benefit dental patients? – is an attempt to find out how much CCHIT actually knows about dentistry. That gives me an idea about the baseline level of knowledge I have to start with in a long education process that I assume has been left up to Valerie Powell and me to complete.

    CCHIT is way behind where it should be if dentists are to be interoperable by 2014. Trust me. We know more about this than you do.

    Darrell K. Pruitt; DDS


  8. A very good point, Felix. I have received a reply from CCHIT which should be posted soon. In my response to a CCHIT representative, I pointed out the irony.


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