University of Pittsburgh University of Utah School of Dentistry

Building a bridge to the future with informatics
Titus Schleyer, DMD, PhD April 17, 2013

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© Titus Schleyer, 2013

Outline
• Electronic dental records: A status report • Towards quality in healthcare (and dentistry) • Going forward: The journey of 1,000 steps

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Healthcare: The vision
“Our vision is for a healthcare system that draws on the best evidence to provide the care most appropriate to each patient, emphasizes prevention and health promotion, delivers the most value, adds to learning throughout the delivery of care, and leads to improvements in the nation’s health.”
Institute of Medicine, Roundtable on Value & Science-Driven Health Care
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Electronic health records: The reality

© The New Yorker, 2012

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Electronic dental records: A status report

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Dentrix Dental Systems
• founded: 1985, acquired by Henry Schein in 1997 • products: Dentrix, Easy Dental, Dentrix Enterprise, Specialty, LabNet, DDX, eServices, etc. • # customers/market share: 45,000/37% • cost: about $6,000 for base system

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Eaglesoft
• founded: 1993, acquired by Patterson in 1997 • products: Eaglesoft, CAESY, Dolphin Imaging, Dolphin Management, Patterson Imaging, eServices, etc. • # customers/market share: 24,500/18% • cost: free

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CareStream (formerly Kodak)
• founded: 1983, became Carestream Dental 2007 • products: PracticeWorks, SoftDent, etc. • market share: 20% • cost: as low as $6,000 for base system

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Smaller companies
• Mogo
(www.mogo.com)

• Curve Dental
(www.curvedental.com)

• Dental Symphony
(www.dentalsymphony.com)

• etc.
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Adoption of EDRs

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Usability problems in EDRs

Thyvalikakath T et al. Usability of four practice management systems, JADA, 2008 11 of 32

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Record a missing tooth – correct path

Record a missing tooth – user paths

Conclusions on usability
• Significant usability problems due to:
– complex information design – mismatch between system and user model

– difficulty in finding functionality

• Participants had to exert cognitive effort that did not contribute to task completion.

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Information content of (electronic) dental records

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Fields in dental record formats

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Dental record formats - conclusions
• Little agreement on content of dental records:
– BDR: 367 clinical data fields – paper and computer records: ~60% of BDR fields – 20 percent of all BDR fields in >= 5 paper records

• Paper records and CPRs correspond relatively well at the category, but not field, level:
– good agreement on categories except diagnosis and risk assessment – CPRs only contain 57% of fields in >= 5 paper records.

Schleyer TK, Spallek H, Hernandez P. A qualitiative investigation of the content of dental paper- and computer- based patient record (CPR) formats, JAMIA, 2007 17 of 32

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Why we love paper …

Paper is flexible. Have you ever done this to your iPad?
© http://www.flickr.com/flickrfavorites 2013

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Towards quality in healthcare

© http://www.flickr.com/photos/wasabifish/2386306318/, 2012 19 of 32

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iom.edu/bestcare

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Patient care improved

Patient data generated during clinical encounter

Learning Healthcare System
Clinical questions answered

Data captured in EHR

Data extracted and analyzed

https://vimeo.com/50843791
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How many studies have reused EDR data for dental clinical research? • literature review • 1,448 citations obtained through:
– MEDLINE and Embase – hand-searching selected journals – snowball sampling

• narrative synthesis

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Reuse of EDR Data for Dental Clinical Research

Song M et al. Reusing electronic patient data for dental clinical research: A baseline review, JoD (in print)

How much data in EDRs could be reused for research?
• dental research data
– dental PBRNs in existence for 8 years

– variety of studies on clinical topics such as caries, ONJ, outcomes of RCTs, etc.
– all research data elements catalogued

• EDR data
– dental record information content study – augmented by actual patient data
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Data sources and method
Dental Information Model (DIM) 986 (734 unique) data elements (DE) from: • 10 paper- and 4 computer-based dental record formats • 76 de-identified patient records from 9 dentists
match caDSR Common Data Elements 2,487 research data elements derived from: • 25 dental PBRN studies • 102 case report forms
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DIM to caDSR mapping results
DIM data elements that matched at least one caDSR data element:
complete 245 (33%) partial none 61 (8%) 428 (58%) 2 89

% of caDSR

9

Liu K et al. Use of clinical information for research in dental PBRNs: A data mapping study, JDR (in print) 27 of 32

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Going forward: The journey of 1,000 steps

Grand Tetons © T. Schleyer, 2013 28 of 32

© T. Schleyer, 2013

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Recommendations: EDR data
• start reusing EDR data, e.g. with DQA measures • develop a CQI approach for data • map and homogenize EDR data from various sources • leverage existing data for disease surveillance, comparative effectiveness research, disease registries, etc.
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Recommendations: Workforce
• successful reuse of data requires dentists, researchers, statisticians, informaticians, etc. • need to develop capacity – We have an “informatics competency shortage”! • existing programs
– dental informatics – biomedical informatics
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Last – a small advertisement

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Thank you for your attention!
Download this talk: Contact info:
• now: titus@pitt.edu • starting in June: schleyer@regenstrief.org

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References
• Schleyer T et al. Electronic dental record use and clinical information management patterns among practitioner-investigators in The Dental Practice-Based Research Network. J Am Dent Assoc, 2013 • Thyvalikakath T et al. A usability evaluation of four commercial dental computer-based patient record systems. J Am Dent Assoc 2008 Dec;139(12):1632-42 • Schleyer T et al. A qualitative investigation of the content of dental paper-based and computer-based patient record formats. J Am Med Inform Assoc 2007;14(4):515-26
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References
• Smith M et al. Best care at lower cost: The path to continuously learning health care in America, The National Academies Press, 2012 • Song M et al. Reusing electronic patient data for dental clinical research: A baseline review (in review) • Liu K et al. Reusing clinical data for research in dental PBRNs: A data mapping study (in review) • “Introduction to Health Information Technology in Dentistry” online course, http://dentalinformatics.org/blog/?p=617

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