Attachment M -- Public Comments

February 18, 2011
Doris Lefkowitz
Reports Clearance Officer
Agency for Healthcare Research and Quality
Sent as e-mail attachment
Dear Ms. Lefkowitz:
Re: Federal Register Notice -- “Barriers to Meaningful Use in Medicaid'' (FR Doc No:
2011-410)
The American Dental Association (ADA), Association of State and Territorial Dental
Directors (ASTDD), Children’s Dental Health Project (CDHP), Medicaid/SCHIP Dental
Association (MSDA), and National Network for Oral Health Access (NNOHA) have
joined together to provide these comments in response to the recent Federal Register
Notice announcing the intention of AHRQ to request that the Office of Management and
Budget (OMB) approve a proposed information collection project entitled “Barriers to
Meaningful Use in Medicaid.'' The ADA, ASTDD, CDHP, MSDA, and NNOHA oversee
or advocate for the provision of dental care to Medicaid beneficiaries and other
underserved populations for the meaningful use incentives. We strongly support the
implementation of health information technology (HIT) that enables care coordination,
which may be demonstrated by the degree to which outcomes involving complex, multiprovider and multi-specialty health care are improved.
This project proposes the use of nine focus groups to gather, analyze, and synthesize
information on the barriers to the meaningful use criteria experienced by Medicaid
providers. These focus groups would include 6-11 eligible professionals (EPs) per
group, containing a mix of pediatricians, other physicians, dentists, nurse practitioners
and certified nurse midwives. Focus groups with community health center (CHC) and
rural health center (RHC)-based providers would also include physician assistants and
administrators. Four of the focus groups would include providers in private practice
(excluding dentists), an additional four would include providers working in CHCs or
RHCs, and the final group would be comprised of private practice dentists. Private
practice dentists are proposed to be considered separately “due to the fact that their
practice patterns are likely to vary substantially from those of primary care physicians
and non-physician providers.”
We believe that one of the major barriers to meaningful use in Medicaid by dental
providers, and one that should be considered by the focus groups, is the absence of
Electronic Health Records (EHRs)—particularly between medical and dental providers--

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that are fully interoperable with each other. If private practice dentists are left out of the
mix with other private health care practitioners, it is tantamount to saying that because
we think that the practice of dentistry in a private practice setting is so different than the
practice of other types of health care, we are going to exclude private practice dentists
from meaningful discussions about an ideal HIT/HIE world. We believe this would be to
the detriment of medical and dental professionals and would especially be counter to
the best interests of the patients they serve.
We are concerned that without the support of both medical and dental providers and the
government for fully interoperable EHRs, dentistry will be ignored, because there will be
little interest by dental software manufacturers to market a product to a relatively small
group of dentists.
We remind AHRQ that many reports have found that access to dental care for Medicaid
beneficiaries is substantially less than their access to medical care. For this reason,
CMS recently proposed a Strategy for Improving Access to and Utilization of Oral
Health Care Services for Children in Medicaid and CHIP Program and launched an
initiative this year with a goal of increasing the rate of low-income children and
adolescents enrolled in Medicaid or CHIP who receive any preventive dental services
by 10 percentage points over a 5-year period. A second goal, to be phased in, will seek
to increase by 10 percentage points over 5 years the rate of low-income children ages
6-9 enrolled in Medicaid or CHIP who receive a dental sealant on a permanent molar
tooth. To achieve these goals, CMS is partnering with states and stakeholder
organizations (including AHRQ) to recruit more dentists into Medicaid and CHIP
programs.
Clearly, anything that can be done to reduce barriers to dentists’ ability to qualify for and
use meaningful use incentives will help CMS attain the above goals. To help AHRQ
identify these barriers for dental providers, we propose that AHRQ make “meaningful
use” of dentists in their proposed focus groups. This includes:
Include at least one dentist on each of the focus groups that include other private
practice providers. Including private practice dentists on the other focus groups will
allow them to explore with their colleagues how their patients would benefit from the
wealth of information that can be obtained beyond their own practice. This will also help
assure that the oral health needs of Medicaid patients are given the same consideration
as their other health care needs and that interoperability of EHRs does not overlook the
inclusion of oral health information.
Include representatives of dental software manufacturers on all of the focus
groups. Because most dental applications are developed for stand-alone private dental
practices, integrating or interfacing with medical practice management and EHRs is
rarely addressed. Developing and maintaining interfaces can be cost-prohibitive unless
both systems are built on a standards-based or open platform. A recent review of EHR
systems used by community clinics found very few dental systems that supported
standard messaging protocols and fewer still that are fully integrated with an EHR. As

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noted above, without the support of both medical and dental providers and the
government for fully interoperable EHRs, dentistry will be ignored, because there will be
little interest by dental software manufacturers to market a product to a relatively small
group of dentists. These issues can be better understood and explored more
collaboratively if dental software manufacturers are at the table.
Continue with the plan to have one focus group comprised of only private
practice dentists. Because private dental practices provide the vast majority of dental
care to Medicaid beneficiaries and we concur with AHRQ that their practice patterns
differ from those of other health care providers, we agree that there will be value to
including at least one focus group comprised of only private practice dentists, so long as
there are also opportunities for their participation in other multidisciplinary focus groups
as noted above.
Thank you for your consideration of our comments.
Sincerely,

American Dental Association
Association of State and Territorial Dental Directors
Children’s Dental Health Project
Medicaid/SCHIP Dental Association
National Network for Oral Health Access