Oral
Evaluations (Exam, Diagnosis, Treatment Planning): Dentist vs. RDH vs.
Mid-Level Provider
After a four
day whirlwind of activity at the 2013 FNDC (“Florida National Dental Convention”)
this month, one concept became disturbingly clear to me, as it was discussed
numerous times throughout the convention. I heard it discussed in two separate
seminars, and by many dentists, hygienists, and administrative team members. I
further asked a few of my colleagues if they too have heard this concept
discussed recently among their fellow dentists, and many of them stated they
have indeed heard it. This officially makes it a “hot dental topic” with strong legal implications, which requires a
full understanding of the unspoken long-term impact of this disturbing concept.
So, here I am, ready to clear up this recent “hot dental topic”, and provide
you all with the necessary protective measures (protocols) that should be
maintained by every dentist. Curious? I
thought so. Let’s read on…
What's the main, foundational, difference
between dentists and dental hygienists? I, like many of my colleagues,
automatically know the clear legal, and educational, differences. They are
black and white with virtually no grey areas for misinterpretation, or so I
thought. Imagine my surprise upon hearing debates with several different
interpretations and scenarios to the contrary, not just from dentists, but
within the recent seminars at the FNDC. Really? I was floored. I thought this one was crystal clear, but apparently it is not. Holy Non-Delegable Disasters, Batman.....
The difference is this: The dentists’ ability, privilege, and primary
function to perform oral evaluations (all examinations), determine diagnoses,
prescribe and treatment plan needed procedures for their patients. That
sounds fairly straight forward, yes? That’s why dentists went through 4-10
additional years of education, at a cost of up to hundreds of thousands of
dollars, right? RDHs and Mid-level Providers (MLPs) did not. RDHs typically have a 2 year Associates Degree while Mid-Level Providers' education and training vary depending on the state's requirements in which they practice. MLPs, however, can have more of less education/training than RDHs in some states. To date, Florida has not approved any MLPs positions existing in this state. So, why is it
being so hotly debated and misinterpreted of late? Perhaps the economy put sufficient pressure on
dentists where protocols were changed in an effort to free up dentists’
schedules for other productive procedures? I’m not positive, and I really don’t want to
speculate, but what I will do, is provide some scenarios where it has become an
issue, and what the potential long-term ramifications could be if this isn’t
corrected.
Please try
to remember that my goal here is to focus on protecting dentists, and saving
dentistry from the threats that we are encountering on a regular basis;
to date, and in the near future. Those
threats may include the continual decline of private practice dentistry as a
viable model, the increasing scope of services and capabilities of dental
hygienists (RDH’s), and the current role of the Mid-Level Provider (MLP) as a potential future practitioner in the
state of Florida. That’s where this becomes important and that’s why I’d like us
ALL to read on and think very carefully about what is being
delegate out to staff members, and with whom patients get scheduled to see first in dental practices; the dentist or the RDH. Dentists’ actions regarding these
protocols will either FUEL the
movement for MLP’s in Florida or FIGHT that movement. What Florida dentists are doing NOW
most definitely impacts what dentists may not want to happen LATER. Therefore, this topic matters,
and it matters big time.
First things first; a definition is in
order for the terms “evaluation”,
and “clinical oral evaluations”. I’m sure some readers are in disbelief, as I
was (and still am) at this stage, but I
promise you, that the full scope of this controversial topic will be
VERY evident in just a bit, so hang on and read further. The definition can be
found on the American Dental Association’s (ADA) website under Glossary of Dental Clinical and
Administrative Terms. Here's the link.
“Evaluation: The patient assessment that may
include gathering of information through interview, observation, examination,
and use of specific tests that allows a dentist to diagnose
existing conditions. Please refer to specific oral evaluation code
descriptors for more complete definitions.”
It can also
be found in the ADA’s 2011-2012 Current Dental Terminology (CDT) (2011-2012),
Practical Guide to Dental Procedure Codes, under Clinical Oral Evaluations (pg.5) (Here's the 2013 version).
“Clinical Oral
Evaluations: The codes in this section recognize the cognitive skills
necessary for patient evaluation. The collection and recording of some data and
components of the dental examination may be delegated, however, the
evaluation, which includes diagnosis and treatment planning,
is the responsibility of the dentist. As with all ADA procedure
codes, there is no distinction made between the evaluations provided by general
practitioners and specialists..”
So, where’s
the issue, you’re saying, right? Let’s look at a few scenarios, and if they are
similar to what’s occurring in your dental practice, take a step back and think
long and hard about the impact.
Scenario #1: Dr. Q is
a general dentist with a very busy practice. His 2 full time hygienists see
8-10 patients per day, with many of them needing periodic oral exams (ADA CDT Code D0120).
Dr. Q is not able to stay on schedule with his own patients if he has to
perform periodic oral exams on the hygiene patients that need them. He trusts
his RDHs and lets them decide which x-rays to take and to do a visual assessment
of the patients and present the “findings” to the dentist later.
So, the RDHs take the x-rays that they
feel their patients need or are due for, and leave the x-ray images, intraoral
camera images, plus a note of their “findings”, on Dr. Q’s desk at the end of
the day, and wait for Dr. Q to review the patients’ charts and chart notes from
the RDH they saw, over the next 24-48 hours. If Dr. Q agrees with the RDHs “findings”
on the patient after reviewing the x-rays & photos taken by the RDH, then
Dr. Q advises the RDH to treatment plan the procedures, give the chart to the
appointment coordinator to schedule the patient’s appointment with Dr. Q for
the needed procedure, and advises the insurance coordinator to bill out the
periodic oral evaluation (ADA CDT Code D0120) along with the RDHs prophy and x-rays completed
24-48 hours ago. Dr. Q feels this is a much more efficient way to do things.
Scenario #1
Issues: Remember the definitions
of evaluation and clinical oral evaluations? This is what
dentists went to school for and RDHs did not. This is our predominant argument against RDHs and MLPs being able,
educated, and skilled to do without a dentist or a dentist’s vast education.
So, if we truly believe that they are not
capable, skilled, or educated to be able to do this then why is it
being willingly delegated by dentists
to RDHs in the practice TODAY?? Isn’t that what we are trying to NOT have taken away from us? Hmmm…..and herein lies the dilemma.
There are a
number of issues with this scenario, as you can now see. This scenario FUELS the successful argument for
MLPs and advanced RDHs with little or no supervision. Only dentists
can prescribe what x-rays are to be taken on each and every patient. That
action is NEVER to be delegated to
an RDH to decide. The dentist
performs the periodic oral exam on each
and every patient that needs one, according to the dentist’s qualified decision. That means that ONLY the dentist should be coded out in the patient’s chart as the provider that completed that
procedure. ONLY the dentist
can complete that procedure; not an RDH. If a dentist requests x-rays be taken
on a patient (BEFORE they are taken
by an EFDA or an RDH), then the x-rays must be viewed and interpreted by the dentist before that patient leaves
the office, or before the procedure (periodic oral exam) is completed and posted to the patient’s
ledger/chart. The dentist prescribes the needed x-rays be taken, then reviews
them and performs the periodic oral exam, then treatment plans the oral conditions
that required additional services. The dentist then documents the chart for all
of the above actions, and signs off on the completed status of the patient’s
chart before the end of the day.
This is clearly stated in Florida Administrative Code Ch. 64B5-9.010 Prescriptions for the
Services of a Dental Hygienist (Here's the link. ). That is the order in which these actions should
take place, and by whom, as stated by the ADA's Council on Scientific Affairs, U.S. Dept. of Health and Human Services in
2012
Dental Radiographic Examinations: Recommendations for Patient Selection and
Limiting Radiation Exposure (Here's the link.).
We either decide to endorse an RDHs capability
to evaluate, diagnose, interpret and treatment plan patients without the
dentist, or we remain staunch in the defense of the ability for dentists and
only dentists to evaluate, diagnose, interpret and treatment plan patients
as their ability, privilege, and education has distinguished them to. One set of action fuels, while the other fights.
The ball is directly in the courts of dentists on this one. So, choose wisely
when delegating out those procedures which cannot be legally or ethically delegated
to RDHs or MLPs (in Florida) at this time (See link in above paragraph: F.A.C. Ch64B5-9.010).
Scenario #2: Dr. Z is a newer general dentist who saw all
new patients for their comprehensive oral exam (new patient exam) (ADA CDT Code D0150) on
her schedule in one hour appointment slots. Dr. Z completed and documented full
evaluation findings in her patients’ charts, including soft and hard tissue
charting. She prescribed the need for specific x-rays and intraoral images taken
to assist her in her diagnoses. She then diagnosed their oral health conditions,
and created a treatment plan for each new patient. Patients were then scheduled
for their next appointments with the RDH (usually first), and the dentist
thereafter.
Dr. Z continued to grow as a dentist and
her schedule became much fuller. In her 3rd year of practice, she
delegated out to the RDH to see all of the new patients first, take the FMX on
them all, complete the soft tissue charting, notate the existing treatment on
each new patient, and “clean up” those patients that needed it before Dr. Z came
in to meet the patient, be prepped by the RDH on the conditions of the patients,
and confirm the treatment needed, to the RDH. This saved Dr. Z significant time
by not having to see each new patient for an hour, and being able to more
easily conduct an exam on the new patients, especially those that were “cleaned
up” by the RDH first. Dr. Z feels this
is a much more efficient way to do things.
Scenario #2
Issues: Hopefully, after reading
the above issues, readers can get an “inkling” of what the problems are in this
scenario. Dr. Z veered off the path of delegable duties (years 1-2) to
non-delegable duties (year 3 & on), and is now an “after-thought” to the
patient, who has established a strong bond, and sense of trust with the first
provider they met; the RDH. Dr. Z spent minimum time with the patient, allowed
RDHs to decide and take “blanket” FMXs on all new patients without Dr. Z prescribing
what x-rays were needed on each patient. (Yes, there is a difference, and it is
stated in the ADA’s Council on Scientific Affairs, U.S. Dept. of Health and
Human Services’ 2012 Dental Radiographic
Examinations: Recommendations for Patient Selection and Limiting Radiation
Exposure.) Dr. Z asking her RDH to “clean up” patients before she meets
them is not a delegable duty, EVER, nor is a dentist confirming the RDH’s
findings for treatment needed. Again, the order on these actions is extremely
important.
Only Florida dentists can complete an
evaluation or exam, prescribe
what diagnostic x-rays or images should be taken and are needed on each individual patient, and only the dentist can diagnose the oral health condition of the patient with what
type of hygiene services are to be prescribed
and treatment planned for those conditions. Dentists don’t confirm Florida's RDH’s recommended
treatment plans; those are the
unique responsibilities of the
qualified, educated dentist.
The order in which these actions are
allowed to be taken, and by whom, is the crux of the matter, as you can see. Are we looking
to create efficiencies or are we inadvertently handing over these duties to RDHs
without realizing the implication so they can say “hey, we’ve been doing this
ourselves with no issues or objections from our Florida dentists for years now! So, why
can’t we be Mid-Level Providers? We’re already halfway there with the full
support of our dentists behind practice doors!” THIS is where we may want to step back and think about this more
closely before we delegate our educated expertise away, without meaning to.
While these
two scenarios might appear to be more efficient, and open up more time in a
dentist’s schedule for production (what I heard at the FNDC & from
colleagues), they are a direct violation of the clearly stated
responsibilities, competencies, and education of a dentist. We
cannot argue against the
competencies of our RDHs or MLPs as being
limited (due to lack of extensive educational requirements) when we willingly allow them to be
delegated to and trust/confirm those recommendations to our RDHs, in front of
our patients, or after they’ve left the office.
This is
where “walking the talk” is critical, and where the impact on this issue is
either going to help or hurt the
arguments for, or against, the evolution of advanced level, non-dentist
providers. Dentists literally have that ball in their court…..every single
day….and with every single action taken, or delegated, in their practices. So,
choose wisely, be clear in defining and owning the practice's protocols/responsibilities, and lead dental teams with a strong sense of the impact of those steps taken. In that way, dentists can protect their industry, their education, and their future, by themselves. Hopefully,
this is now much clearer, and we can all move forward with great pride and intended
purpose. Onward and upward, as I often say!
Well, there you have it. Thanks for stopping by, and remember; you only have to brush and floss the teeth that you ABSOLUTELY, POSITIVELY want to keep. That's it; nothing more.
Dr. Driscoll
