Position Summary
Digital health records are widely used in the practice of dentistry and digital communication of health information is commonplace. The use of these technologies must include provisions to prevent unauthorised access to sensitive information, and appropriate back-up of data.
1. Background
1.1. Dentists are obliged to maintain accurate, contemporaneous records of health and personal information about their patients in accordance with the Board’s Dental Records Guidelines.
1.2. All health records must be managed in accordance with relevant legislative requirements such as privacy and eHealth legislation, and the Board’s Codes, Policies and Guidelines.
1.3. A majority of dentists participate in Digital Health as they receive, retain and transfer patient records via various digital means.
1.4. Communication of accurate and relevant health information is a vital part of effective healthcare.
1.5. The practice of dentistry is unique compared with other professional health practice and so will need distinctive applications.
1.6. Dentists require a comprehensive health summary/medical history to provide quality and safe dental care.
1.7. The Personally Controlled Electronic Health Record (PCEHR) was launched on the 1st July 2012 and in September 2015 it was renamed My Health Record (MyHR).
1.8. The Grey Report 2014, Advancing eHealth Education for the Clinical Health Professions recommended the need to incorporate eHealth and clinical informatics competencies in health profession training.
1.9. The MyHR opt in system was replaced with an opt out system for patients in 2019.
Definitions
1.10. BOARD is the Dental Board of Australia.
1.11. CLINICAL INDICATOR is a measure, process, or outcome used to judge a particular clinical situation and indicate whether the care delivered was appropriate.
1.12. DATA GOVERNANCE is an aspect of clinical governance and involves a system of decision rights and accountabilities for information-related processes, executed according to agreed-upon models which describe who can take what actions with what information, and when, under what circumstances, using what methods.
1.13. DENTAL HEALTH is the secure electronic collection, storage and transference of patient health information and has two elements, health informatics and telehealth.
1.14. DENTAL INFORMATICS is a specialisation within Health Informatics.
1.15. DENTAL RECORD is an accurate and concise documentation of a patient’s details, clinical details including dental and medical histories, examination findings, radiographs and diagnostic data, treatment plans, dental treatment and care provided and communications with the patient and other health providers.
1.16. HEALTH INFORMATICS is a discipline at the intersection of information science, computer science, social science, behavioural science and health care. It deals with the resources, devices, and methods required for optimising the acquisition, storage, retrieval, and use of information in health and biomedicine.
1.17. PATIENT is a person receiving health care or any substitute authorised decision maker for those who do not have the capacity to make their own decisions.
2. Position
2.1. Safeguards must be employed to protect the privacy of every patient’s Digital Health records.
2.2. Safeguards must be employed to protect the integrity of the practitioner’s own records.
2.3. Digital Health measures that ensure secure communication of health information should be adopted.
2.4. The ADA Schedule and Glossary must remain the only reference for defining dental treatments provided in Australia.
2.5. Dentists must be professionally responsible for creating and maintaining records of treatment they provide.
2.6. Dentists must retain the ownership of their records, though patients shall have the right to access their records.
2.7. Digital Health systems must use national standards, not create an onerous administrative burden and be simple to install and operate.
2.8. The dental profession must define the functional requirements of dental software and of technical support systems for dental Digital Health.
2.9. The provenance of entries in the MyHR must be clearly stated.
2.10. An opt-out system for patients should be used for the MyHR.
2.11. Patients may choose which practitioners have access to their MyHR.
2.12. Patients should not withhold any medical information from their MyHR.
2.13. Practitioners must be protected from legal action if they act correctly on the information in the MyHR where the relevant information has been altered, sealed or blocked by the patient.
2.14. Dentist should have access to ePrescribing.
2.15. Dental practices should receive financial assistance to adopt the changes required to implement any Digital Health measures that are proposed by Government.
2.16. Access to Digital Health technology, once tested and proved effective, must be universal and not geographically influenced.
2.17. Data used in forming future clinical indicators pertaining to dentistry should be interpreted and assessed by a dentist.
2.18. Dental schools should include Dental Informatics and Digital Health training in their courses.
2.19. Dentists should take account of the advice of the ADA before embracing new Digital Health technology.
