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Electronic Dental Records 2nd Edition

Electronic Dental Records 2nd Edition

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Published by Titus Schleyer
This MetLife Quality Resource Guide provides an overview of electronic dental records. It describes current adoption in the dental profession, how dentists use them and what information they contain. This guide is useful for dentists who are considering implementing computer-based records in their practice.
This MetLife Quality Resource Guide provides an overview of electronic dental records. It describes current adoption in the dental profession, how dentists use them and what information they contain. This guide is useful for dentists who are considering implementing computer-based records in their practice.

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Published by: Titus Schleyer on Jan 06, 2012
Copyright:Attribution Non-commercial


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Educational Objectives
Following this unit of instruction, the practitionershould be able to:
Describe to what extent general dentists areusing electronic dental records (EDRs).
Discuss reasons that limit adoption of EDRs ingeneral dentistry.
Identify aspects in which EDRs differ from paperrecords with respect to their information pre-sentation and storage capabilities.
Describe the concept of usability with respect toEDRs.
Discuss task outcomes of a recent usabilitystudy and their implications.
List considerations for choosing an EDR system.
lectronic dental records (EDRs) have becomea topic of increasing interest for practicingdentists, especially now that the administrativefunctions in practice management systems havematured to the degree that they barely warrantmention. Marketed under names such as the digitaldental office, integrated clinical solutions, paperlesssystems, and electronic patient or health records, EDRsrepresent the next frontier for the dental informationtechnology industry in the quest to digitize (almost)every aspect of dental practice. Vendors have been advertising plenty of offeringsfor quite some time and adoption has acceleratedin recent years. As of early 2005, only 1.8% of allgeneral dentists in the U.S. were paperless, while25% had a computer at chairside.
By 2007, thosefigures had risen to 9.2% and 55.5%, respectively,for all dentists according to a survey conducted bythe American Dental Association.
New dentists, i.e.dentists who graduated from dental school withinthe past ten years, had adopted paperless systemsto an even larger degree, 13.4%. While EDRs areincreasingly adopted by the practitioner community,many obstacles remain.Many practitioners approach “going paperless” with thegoal of “getting rid of paper.” However, implementingEDRs is much more than just eliminating paper; itrequires a profound change in the way offices operate,record patient data, train staff, and manage informationand information technology. Few offices manage toundergo this complex transformation quickly and easily.Those who fail or are less than successful are frequentlycited by their peers as a justification for waiting just alittle bit longer.This guide focuses on a narrow set of questionsregarding EDRs: How are general dentists, whohave adopted EDRs, using them, and what are theiropinions about them? How appropriate are EDRs forrepresenting information that is typically stored inpaper records? And, how does the user interface ofcurrent EDRs impact dentists’ ability to work withthem? The answers to those questions come fromseveral studies
conducted by the Center forDental Informatics at the University of Pittsburgh aswell as other sources.
General Dentists’ Use and View ofElectronic Dental Records (EDRs)
In our first study, we surveyed 102 randomly sampledU.S. general dentists who were using a computerat chairside about their use of, opinions about andattitudes toward their systems.
A majority of therespondents (80%) had implemented such systemsat chairside within the last 10 years. The averageage of our respondents was 50 years, with astandard deviation of 10 years. Eighty percent of therespondents used one of four systems: Dentrix (Dentrix
Quality Resource Guide
Electronic Dental Records
MetLife designates this activity for1.0 continuing education credit
for the review of this Quality Resource Guideand successful completion of the post test.
Author Acknowledgements
Titus Schleyer, DMD, PhD
Director, Center for Dental InformaticsSchool of Dental MedicineUniversity of PittsburghPittsburgh, PA
Dr. Schleyer has no relevant financialrelationships to disclose.
The following commentary highlightsfundamental and commonly acceptedpractices on the subject matter. Theinformation is intended as a generaloverview and is for educational purposesonly. This information does not constitutelegal advice, which can only be provided byan attorney.© Metropolitan Life Insurance Company,New York, NY. All materials subject to thiscopyright may be photocopied for thenoncommercial purpose of scientific oreducational advancement.Originally published March 2008 as“Computer-Based Patient Records”.Updated and revised July 2011. Expirationdate: July 2014. The content of this Guideis subject to change as new scientificinformation becomes available.MetLife is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals inidentifying quality providers of continuingdental education. ADA CERP does not approveor endorse individual courses or instructors,nor does it imply acceptance of credit hours byboards of dentistry.Concerns or complaints about a CE provider maybe directed to the provider or to ADA CERP atwww.ada.org/goto/cerp. Accepted Program Provider FAGD/MAGDCredit 01/01/09 - 12/31/12. Address comments to:dentalquality@MetLife.comMetLife DentalQuality Initiatives Program501 US Highway 22Bridgewater, NJ 08807
Dental Systems, American Fork, UT), EagleSoft(Patterson Dental, St. Paul, MN), SoftDent orPracticeWorks (Carestream Health, Rochester,NY). Seventy percent used at least one othersoftware application, e.g. for digital radiologyand/or photography or Invisalign.Figure 1 shows that most practices store patientinformation in a mix of paper/hard copy andcomputer formats. Information commonlyassociated with billing and practice operations,such as treatment procedures and patientappointments, tended to be most frequentlystored on computers, followed by images andintraoral charting. Information that was storedleast frequently on the computer included themedical and dental history, progress notes andthe chief complaint. The figure also illustratesthat a large proportion of information isduplicated on both paper and the computer.Clearly, maintaining information in two places hasmultiple drawbacks. First, duplicate informationstorage consumes unnecessary resources.Second, inconsistencies in information betweenthe two types of storage can potentially lead toincomplete diagnosis/treatment, clinical errorsand/or legal complications.
When asked aboutthe duplication, several respondents indicatedthat they were in a period of transition, and thatthey would eliminate paper-based records assoon as they had mastered the correspondingelectronic functions and/or felt completelycomfortable with the computer as a storagemedium. Some also provided another reason:the EDR they used was not able to store allinformation that the practice wanted to store,and this information therefore remained confinedto paper. This finding prompted us to explore theinformation representation capabilities of EDRsfurther in the second study we describe below.Relatively few of the respondents used what wouldbe considered advanced techniques for dataentry/retrieval during clinical care: touchscreensand voice input. About 13% each used oneof those two technologies. Importantly, whilethree percent had tried to use a touchscreenand abandoned it, 16% had done so with voice.Judging from these data, voice input does notseem to be mature enough to serve the needsof many practitioners who have tried using it. A small fraction of respondents used specializedinput devices, such as barcode scanners andelectronic dental probes. Some vendors haveupgraded their voice input systems since ourstudy, but adoption still appears to be limited.In general, respondents appreciated the valueand benefits they derived from having adoptedEDRs. Charting, treatment planning and imagingfunctions were seen as particularly useful, andone quarter of respondents could not identifyanything in their EDRs that they disliked.Efficiency, convenient information access andpatient education were seen as the majoradvantages of EDRs. Despite this positiveview, our study identified several barriers andopportunities for improvement. For instance,usability, functionality and charting were amongthe main features that respondents disliked,and insufficient operational reliability, programlimitations, the learning curve and cost wereseen as major barriers to EDR use. Issues withinfection control and the need for better userinterfaces were recurrent themes.In sum, our study on chairside computingshowed that at present, full adoption of the EDRremains limited among general practitioners.Our survey demonstrated that the dentists whouse EDRs tend to derive significant value, butthat EDRs as a technology have to maturefurther in many respects before they will enterthe mainstream.
Representation of ClinicalInformation in EDRs
In a second study, we pursued the question ofhow well EDRs represent information typicallystored in paper-based records.
Because nodetailed standard for the content of dental recordsexists, we first compiled and categorized a list ofdata fields from a purposive sample of 10 dentalrecords obtained from vendors, practitionersand dental schools. We termed this list theBaseline Dental Record (BDR). We then mappedthe information contained in each of the fourmarket-leading dental EDRs in the United Statesto the information in the BDR. We only focused onclinical, not administrative, data fields.The BDR contained 20 information categories.Most of them, such as “Chief complaint,”“Medication history,” “Hard tissue andperiodontal chart,” and “Radiographic history
Page 2
Quality Resource Guide:Electronic Dental Record 2nd Edition
 AppointmentsTreatment PlansCompleted TreatmentOral Health StatusIntraoral ImagesExtraoral ImagesDiagnosesRadiographsDental HistoryMedical His
Progress NotesChief Com
PaperComputerBothNot at all
506070809097403020 10010203055 5040
Respondents use of paper and/or computer for storing patient information. Orange bars: informa-tion stored only on paper; blue bars: information stored only on the computer; green bars: informa-tion on paper duplicated on the computer; gray textured bars: information not recorded at all.
Number of offices using paper
Number of offices using paper and computer, or computer
Quality Resource Guide:Electronic Dental Record 2nd Edition
Page 3
and findings” were related to obtaining clinicaldata necessary to determine the patient’s oralhealth status. Categories such as “Systemicdiagnoses,” “Dental diagnoses” and “Problemlist” served to describe the patient’s current oralhealth status, while “Treatment plan” was usedto represent the necessary treatment. Finally,“Progress notes” and “Prescriptions” documentedcare delivered. On average, each paper recordcontained between 23 and 32% of the fields inthe BDR, demonstrating that although dentalrecords collectively tend to contain a relativelylarge number of fields, there is little agreementon what those fields should be.Table 1 shows how well the four EDRs coveredthe information contained in the BDR. In termsof information categories, the EDR’s coverage(mean: 14; range: 11-16) was comparable to thatof paper records (mean: 13.9; range: 8-18). Theaverage number of fields in paper records (107)was somewhat higher than that in EDRs (90). Morethan averages, however, Table 1 illustrates howEDRs compare to paper-based records in termsof information presentation. For three informationcategories, i.e. the “Chief complaint,” “Systemicdiagnoses” and “Problem list,” EDRs’ provide nocorresponding data fields at all. In others, suchas “Prognosis, risk assessment and etiology,”only some EDRs provide data fields. Table 1also shows that in areas that all EDRs cover, thenumber of data fields is typically significantlylower than in the BDR. This is not surprisinggiven the fact that the BDR is a “superset” ofall data fields contained in the correspondingpaper records. Comparing the number of datafields within a category provides some insightto how many data items different EDRs canaccommodate. For instance, compared to Dentrixand PracticeWorks, EagleSoft and SoftDent seemto have more comprehensive health histories;however, how well each health history formatmatches the recordkeeping requirements of apractice is a decision of the individual practitioner.Findings and procedures on hard tissue andperiodontal charts are typically documentedas numbers, text or free-form graphicalannotations. Therefore, we could not use theapproach of matching data fields in analyzingthe corresponding information content in EDRs.Instead, we selected a sample of 26 hard tissueand 28 periodontal conditions, as well as 20procedures, and checked whether they couldbe charted in each EDR. Information coveragewas 46-88% for hard tissue findings, 45-85%for procedures and 39-64% for periodontalconditions.The corresponding paper published in theJournal of the American Medical Informatics Association
provides additional details aboutcomparative information coverage at the fieldlevel. Several fields that occur very frequentlyin paper records, such as the chief complaint,a list of current medications, allergies andphysician information tend to be poorlyrepresented, while others, such as diabetes,hepatitis/liver disease, high/low blood pressure
     D    e    n     t    r     i    x     E    a    g     l    e    s    o     f     t
     P    r    a    c     t     i    c    e     W    o    r     k    s
     S    o     f     t     D    e    n     t
BDRCPRsAverage # o categoriesAverage # o felds1490BDR Categories
Chie complaintMedication historyMedical historyDental/social historyHard tissue and periodontal chartIntraoral sot tissue examinationExtraoral head and neck examinationsTemporomandibular joint/occlusionRadiographic history and fndingsPhysician inormationAlert/Summary boxMedical history updateConsultations
Systemic diagnosesDental diagnosesProblem listPrognosis, risk assessment and etiology
Treatment planProgress notesPrescriptions
SubtotalTotal feldsTotal categories
Table 1: Inormation coverage o the felds in the Baseline Dental Record in Dentrix, EagleSot, Practice-Works and SotDent. Data felds are not reported or the category “Hard tissue and periodontal chart”since paper orms combine a limited number o felds with ree-orm entries (data rom 2007).

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