Couched as a New Year’s prediction, my father issued a challenge to the industry to agree upon a unified standard for Electronic Dental Records. I’m an outsider, but as a programmer I do appreciate a good debate about well-structured data. Conversations between software engineers can sound less like they are about software and more like they are about rhetorical analysis. We discuss intention, meaning, semantics and clarity. What is the best way to express an idea? Software engineers grapple with that as much as anyone.
The Internet is not the product of mutual agreements. What file format are all your pictures? Do you mess around with a jpeg viewer, a gif viewer and a png viewer? When you watch a video, do you care whether it is flash or an mpeg? Or do you just double-click on it? A lot of work is done to keep the user happy, but any semblance of agreement in computing is an illusion. Ask your programmer friend whether they prefer vi or emacs, and you’ll see you’ve touched on a schism deeper than Catholic and Protestant.
That the dental world has an issue with competing and incompatible record formats is not surprising. Further, setting industry standards is very suspect to corporate politics. If the ADA or any other association of dentists starts pushing for unified record keeping, they will go up against the fact that Dentrix will want the standards to look like Dentrix and Eaglesoft will want it to look like Eaglesoft and progress will be slow. My outsider’s opinion is that there are two big reasons it is difficult to galvanize dentists about EDR, and one of them is that the status quo might look better than the risk and effort required to affect change.
The other reason would simply be a failure to understand what is at stake. I don’t know what makes a good dental record, but I can give a summary of what matters from a software perspective.
Why are there competing standards in the first place?
Because building things is fun, and building things from scratch is the most fun. Engineers can’t be faulted for, in the absence of standards, taking some joy in coming up with their own design. I’m sure the engineers behind each practice management suite could have a literature professor type of argument about why their expressed solution to dental records is better than the others.
What is the problem with this?
Arguing for unified EDR risks confusing the real issue. The real issue is that dentists cannot share records. Viewing yourselves as competitors, this isn’t always a bad thing, but if you are honest about wanting to provide good dental care, then you should recognize that obfuscating the exchange of information only hurts the progress of medical science. Unified EDR is but one solution to the problem. The alternative to EDR is the less bureaucratic Microsoft-Picture-Viewer approach where your software is prepared to read all record types. I understand that proprietary record formats keep this from being feasible, but as an engineering problem it is trivial.
What are the advantages of sharing records?
If I were a software company I would want my software to read the formats of my competitors and then push this as a selling point. If Dentrix can read SoftRix, but SoftRix can’t read Dentrix, Dentrix is going to have an easier time taking customers from SoftRix than the other way around. I assume the industry has time-of-sale mechanisms for allowing such a conversion anyway, but that is different from being able to just import anybody’s record at any time. As a dentist, I would want this feature because it means I can easily take on a new patient – for you it’s the same advantage; if your competitor’s patients can easily switch to your practice, but not the other way around, you win. If this one-way-street is leveraged enough, market competition will drive it to become a standard feature.
What are the advantages of unified EDR?
The biggest advantage is that it allows outsiders in. Data mining seems to be the obvious argument here, and it’s a good one, but once again the issue is getting confused: the issue is that information cannot be freely exchanged and this should be appreciated on its own merits. The last two decades should have demonstrated why sharing information is a good thing. The real advantages to a good EDR are probably things we can’t see yet. A more practical, economic advantage to an industry standard is that it makes new competition easier. As a customer in the practice management market, you should want this, as it will drive down the cost of your suite and drive up the features.
What about security and privacy?
Security and privacy risks are real, but hiding behind proprietary formats as a security solution is dishonest. This is like solving the safety issues on airplanes by simply refusing to let any of them fly. Inconvenience is not a security solution. This isn’t meant to trivialize the problem, but medical professions don’t get some special privilege to technophobia just because there are privacy concerns; security and privacy are problems for all of us, across the board. It’s a 21st century problem, not a special-case-only-in-medicine problem. Further, fears that your patients won’t tolerate the privacy risks are overblown. Today’s young people are, if anything, too unconcerned for their privacy. In 20 years your typical patient might not even care what the risks are.
The final take away here is that dentists should recognize that they are customers in a software market, and are thus empowered to affect change. Knowing what is at stake will better guide the change.