Are Oral Health Providers Using Electronic Dental Records?

Ira Lamster DDS, MMSc, Editor-in-Chief, Fiona Collins BDS, MBA, MA, FPFA

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Are Oral Health Providers Using Electronic Dental Records?

The use of electronic dental records (EDR) has increased significantly over the last decade. In one report on the utilization of EDR among US dentists in practice, 75% of 476 respondents perceived that the cost-benefit was positive, and 44% perceived that use of EDR improved patient care.1Acharya A, Schroeder D, Schwei K, Chyou PH. Update on electronic dental record and clinical computing adoption among dental practices in the United States. Clin Med Res 2017. For non-adopters, key barriers included cost, a perceived high cost/benefit ratio, the time required to convert and train staff, and poor usability.1Acharya A, Schroeder D, Schwei K, Chyou PH. Update on electronic dental record and clinical computing adoption among dental practices in the United States. Clin Med Res 2017. EDR use, however, continues to increase, and their integration into an electronic health record (EHR) offers significant potential benefits.

In an ideal situation, all health care data for an individual would be contained in a single EHR, including the patient’s health history, assessment of risk factors, charting, diagnostics, imaging, record of treatment and other important data such as a list of current medications and insurance details. As such, all health care providers would have access to the integrated records, permitting greater coordination of healthcare and offering advantages to patients and providers. However, there remain barriers to universal adoption and integration that need to be overcome.

In an ideal situation, all health care data for an individual would be contained in a single EHR.

Uses of EDR in Dental Settings

In addition to the efficiency, documentation options, ease of storage and access to digital imaging, integration with other digital technologies and support for administrative tasks, EDR can provide clinical support such as risk assessment tools2Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Base Dent Pract 2017;1-12. and aid decision-making. In one large group practice setting, 98% of respondents continued to use three EDR-based risk assessment tools after implementation.2Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Base Dent Pract 2017;1-12. At 15 months, respondents reported that these tools were useful in supporting evidence-based care and as a patient motivator, and that they increased job satisfaction and decreased emotional stress (p<0.001).2Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Base Dent Pract 2017;1-12.
EDR also provide a relatively inexpensive and readily available database for evaluation of practice-based treatment outcomes, quality of care, and the evidence-base for treatment in a non-research setting.
EDR have been used by the Dental Practice-Based Research Network (DPBRN) for several years for this purpose.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63. Automated queries of EDR/EHR databases can be used to evaluate adherence to current clinical guidelines, which is used as a measure of quality of care.4Neumann A, Kalenderian E, Ramoni R, Yansane A, Tokede B, Etolue J, Vaderhobli R, Simmons K, Even J, Mullins J, Kumar S, Bangar S, Kookal K, White J, Walji M. Evaluating quality of dental care among patients with diabetes: Adaptation and testing of a dental quality measure in electronic health records. J Am Dent Assoc 2017;148(9):634-643.e1.doi: 10.1016/j.adaj.2017.04.017. This enabled the identification of gaps in recommended care, using an EDR database incorporating data from 4 institutions, which included more than 13,000 patients with diabetes mellitus.4Neumann A, Kalenderian E, Ramoni R, Yansane A, Tokede B, Etolue J, Vaderhobli R, Simmons K, Even J, Mullins J, Kumar S, Bangar S, Kookal K, White J, Walji M. Evaluating quality of dental care among patients with diabetes: Adaptation and testing of a dental quality measure in electronic health records. J Am Dent Assoc 2017;148(9):634-643.e1.doi: 10.1016/j.adaj.2017.04.017. In another study, automated queries led to the conclusion that 6.6% fewer patients had received fluoride varnish based on EDR than indicated by a manual chart review.5Bhardwaj A, Ramoni R, Kalenderian E, Neumann A, Hebballi NB, White JM, McClellan L, Walji MF. Measuring up: Implementing a dental quality measure in the electronic health record context. J Am Dent Assoc 2016;147(1):35-40. doi: 10.1016/j.adaj.2015.06.023. The use of automated queries has been found to be reliable and accurate for evaluating treatment and specific measures of quality of care, with high positive and negative predictive values.4Neumann A, Kalenderian E, Ramoni R, Yansane A, Tokede B, Etolue J, Vaderhobli R, Simmons K, Even J, Mullins J, Kumar S, Bangar S, Kookal K, White J, Walji M. Evaluating quality of dental care among patients with diabetes: Adaptation and testing of a dental quality measure in electronic health records. J Am Dent Assoc 2017;148(9):634-643.e1.doi: 10.1016/j.adaj.2017.04.017.,5Bhardwaj A, Ramoni R, Kalenderian E, Neumann A, Hebballi NB, White JM, McClellan L, Walji MF. Measuring up: Implementing a dental quality measure in the electronic health record context. J Am Dent Assoc 2016;147(1):35-40. doi: 10.1016/j.adaj.2015.06.023.
Automated queries of EDR/EHR databases can be used to evaluate adherence to current clinical guidelines, which is used as a measure of quality of care.

EDR for almost 32,000 dental patients from 8 dental offices were integrated into an EHR database.6St. Sauver JL, Carr AB, Yawn BP, Grossardt BR, Bock-Goodner CM, Klein LL, Pankratz JJ, Finney Rutten LJ, Rocca WA. Linking medical and dental health record data: a partnership with the Rochester Epidemiology Project. BMJ Open 2017;7:e012528. The data was used to evaluate use of antibiotic prophylaxis prior to dental procedures, which decreased from 62% to 7% for patients with moderate-risk cardiac conditions, after the American Heart Association’s revised guidelines were published.6St. Sauver JL, Carr AB, Yawn BP, Grossardt BR, Bock-Goodner CM, Klein LL, Pankratz JJ, Finney Rutten LJ, Rocca WA. Linking medical and dental health record data: a partnership with the Rochester Epidemiology Project. BMJ Open 2017;7:e012528. In addition, one study highlighted racial disparities in care.7Boehmer U, Glickman M, Jones JA, Orner MB, Wheler C, Berlowitz DR, Kressin NR. Dental care in an equal access system valuing equity: are there racial disparities? Med Care 2016;54(11):998-1004. Such data can be used to improve education and health care equity. (Table 1)

Table 1. Uses of EDR in Dental Settings
Patient documentation Access and storage of digital images
Integration of digital technologies Support for administrative tasks
Clinical support tools Evaluation of practice-based treatment outcomes, quality of care, evidence-based treatment
Identification of gaps in care Assessment of disparities

EDR Use in Educational Institutions

EDR can be mined to assess student knowledge and quality of care, and to help inform strategic initiatives. In one dental school clinic, inadequate documentation by students was found.8Thierer TE, Delander KA. Improving documentation, compliance, and approvals in an electronic dental record at a U.S. dental school. J Dent Educ 2017;81:442-9. After additional training, 81% of documentation met requirements compared to 61% prior to this intervention. In a collaborative study involving three dental schools, standardized terminology and a joint data repository enabled an evaluation showing that only 41% of patients with chronic moderate periodontitis received evidence-based care.9Kalenderian E, Tokede B, Ramoni R, Khan M, Kimmes N, White J, Walji M. Dental clinical research: an illustration of the value of standardized diagnostic terms. J Public Health Dent 2016;76(2):152-6.
Recently, one dental school used findings from an analysis of EDR data for strategic planning purposes, to determine where satellite clinics might be placed in order to improve the level of care for underserved individuals and to provide students with training in this environment.10Filker PJ, Cook N, Kodish-Stav J. Electronic health records: a valuable tool for dental school strategic planning. J Dent Educ 2013;77:591-7.
Utilization of EDR is rapidly expanding in dental schools.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63.,4Neumann A, Kalenderian E, Ramoni R, Yansane A, Tokede B, Etolue J, Vaderhobli R, Simmons K, Even J, Mullins J, Kumar S, Bangar S, Kookal K, White J, Walji M. Evaluating quality of dental care among patients with diabetes: Adaptation and testing of a dental quality measure in electronic health records. J Am Dent Assoc 2017;148(9):634-643.e1.doi: 10.1016/j.adaj.2017.04.017.,8Thierer TE, Delander KA. Improving documentation, compliance, and approvals in an electronic dental record at a U.S. dental school. J Dent Educ 2017;81:442-9. This will mean that new graduates will have familiarity with these systems and likely not have utilized paper-based records, leading to increased use of EDR in private practice and public health settings.
Utilization of EDR is rapidly expanding in dental schools.

Research using integrated EHR

EDR/EHR can serve as a database that can be used for epidemiological, public health and health outcomes research.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63.,9Kalenderian E, Tokede B, Ramoni R, Khan M, Kimmes N, White J, Walji M. Dental clinical research: an illustration of the value of standardized diagnostic terms. J Public Health Dent 2016;76(2):152-6.,11Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001.,12Pearson JF, Brownstein CA, Brownstein JS. Potential for electronic health records and online social networking to redefine medical research. Clin Chem 2011;57(2):196-204.,13Wilke RA, Berg RL, Peissig P, Kitchner T, Sijercic B, McCarty CA, et al. Use of an electronic medical record for the identification of research subjects with diabetes mellitus. Clin Med & Res 2007;5(1):1-7. Integrated EHR databases support clinical findings for the typical patient care environment rather than a research setting, and large sample sizes are readily available.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63. In addition, multiple confounders and comorbidities can be evaluated, and selection of subjects for clinical trials is aided.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63. The use of EHR as a database is, however, limited by variations in the information contained within the database. In contrast, clinical trials in research facilities require months or even years to complete, may include selection bias, and the findings may not be transferable to a clinic- or office-based patient population.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63.

Challenges to Universal Adoption of EDR/EHR

There are significant challenges to the universal introduction of an EHR with full integration of EDR. These challenges include inaccurate and missing data, varying standards for documentation, non-standardized terminology and diagnostic codes, lack of agreement on clinical measures, a multiplicity of electronic record systems with limited compatibility, the difficulty of using some interfaces and inconsistent access to patient records.3Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63.,11Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001. (Table 2)
Time constraints have been found to be a cause of inadequate entry of information into EDR.11Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001.
There is general agreement on the information required in EDR. However, while not unique to EDR, there is a lack of consensus on how frequently some of the information needs to be updated. Only 75% of respondents in one study agreed that medical histories should be updated at each visit. For tobacco use, 2% of respondents stated that documentation was required only at the initial visit, and the need to update stated by other respondents varied from every visit, to monthly, annually or only if tobacco use changed.11Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001.
Table 2. Challenges to Universal Adoption
Inaccurate data Missing/incomplete data
Non-standardized terminology Non-standardized diagnostic codes
Lack of agreement on clinical measures Numerous incompatibilities across HER
Difficulty of using interfaces Varying standards for documentation
Lack of consensus regarding the frequency of updates Inconsistent access to data

Recent Developments

EDR adoption and integration into the dental office continues to increase. Full integration of medical and dental records is an important next step.6St. Sauver JL, Carr AB, Yawn BP, Grossardt BR, Bock-Goodner CM, Klein LL, Pankratz JJ, Finney Rutten LJ, Rocca WA. Linking medical and dental health record data: a partnership with the Rochester Epidemiology Project. BMJ Open 2017;7:e012528. This linkage already exists in some larger health systems and institutions such as the Marshfield Clinic, and the Veterans Administration system.7Boehmer U, Glickman M, Jones JA, Orner MB, Wheler C, Berlowitz DR, Kressin NR. Dental care in an equal access system valuing equity: are there racial disparities? Med Care 2016;54(11):998-1004.,14Acharya A, Shimpi N, Mahnke A, Mathias R, Ye Z. Medical care providers' perspectives on dental information needs in electronic health records. J Am Dent Assoc 2017;148:328-37.

Progress in terminology standardization has been made, including the establishment of the Dental Diagnostic System (DDS), which is mapped to standardized diagnostic codes (ICD), medical reference terminologies (SNOMED) and is used in the dental setting for EHR.12Pearson JF, Brownstein CA, Brownstein JS. Potential for electronic health records and online social networking to redefine medical research. Clin Chem 2011;57(2):196-204.,15Kalenderian E, Ramoni RL, White JM, Schoonheim-Klein ME, Stark PC, Kimmes NS, Zeller GG, Willis GP, Walji MF. The development of a dental diagnostic terminology. J Dent Educ 2011;75(1):68-76. DDS and the American Dental Association’s terminology (SNODENT) have been harmonized, thereby creating SNODDS which has become Standard No. 2000 of the American National Standards Institute (ANSI).16Schleyer T, Song M, Gilbert GH, Rindal DB, Fellows JL, Gordan VV, Funkhouser E, Electronic dental record use and clinical information management patterns among practitioner-investigators in The Dental Practice-Based Research Network. J Am Dent Assoc 2013;144(1):49-58. ANSI standards are used by industry in the design and manufacture of products, and ANSI accredits other standards bodies, including the American Dental Association Standards Committees for Dental Products (ADA SCDP) and Dental Informatics (ADA SCDI).
In a recent survey of more than 800 dental clinicians and staff, the majority strongly supported standardized terminology that would increase the usability of stored data as well as patient and interprofessional communication.17Ramoni RB, Walji MF, Kim S, Tokede O, McClellan L, Simmons K., Kalenderian E. Attitudes and beliefs toward the use of a dental diagnostic terminology A survey of dental providers in a dental practice. J Am Dent Assoc 2015;146(6):390-7. http://doi.org/10.1016/j.adaj.2015.02.007 Medical providers have also indicated a desire for greater interoperability and the ability to access information related to the EDR, in particular alerts regarding any special considerations.14Acharya A, Shimpi N, Mahnke A, Mathias R, Ye Z. Medical care providers' perspectives on dental information needs in electronic health records. J Am Dent Assoc 2017;148:328-37. Research and resolution of usability issues is being addressed incrementally. In one practical study, issues related to the entry of diagnostic terms in an EHR interface used by dental professionals were identified through observation, and working with vendors, an iterative corrective process was used to resolve issues.18Walji MF, Kalenderian E, Tran D, Kookal KK, Nguyen V, Tokede O, White JM, Vaderhobli R, Ramoni R, Stark PC, Kimmes NS, Schoonheim-Klein ME, Patel VL. Detection and characterization of usability problems in structured data entry interfaces in dentistry. Int J Med Inform 2013;82:128-38.
In a recent survey, dental clinicians and staff strongly supported standardized terminology that would increase the usability of stored data.

Conclusions

EDR/EHR has proven to be a reliable tool for storing patient information, and can provide interprofessional access to information. Further, electronic records are valuable tools for research and the development of interventions based on patient-care findings. In order to fully integrate and realize all of the potential of electronic records, remaining roadblocks must be resolved efficiently. This includes full resolution of issues related to terminology, system interfaces, and agreement on standardized clinical measures. In addition, clear guidelines are required related to information and the use of EHR.11Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001. In the future, integrated EHR can foster a learning system within healthcare, whereby comparative treatment efficacy can be determined, and quality of care continuously improved.5Bhardwaj A, Ramoni R, Kalenderian E, Neumann A, Hebballi NB, White JM, McClellan L, Walji MF. Measuring up: Implementing a dental quality measure in the electronic health record context. J Am Dent Assoc 2016;147(1):35-40. doi: 10.1016/j.adaj.2015.06.023.

References

  • 1.Acharya A, Schroeder D, Schwei K, Chyou PH. Update on electronic dental record and clinical computing adoption among dental practices in the United States. Clin Med Res 2017.
  • 2.Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Base Dent Pract 2017;1-12.
  • 3.Song M, Liu K, Abromitis R, Schleyer TL. Reusing electronic patient data for dental clinical research: a review of current status. J Dent 2013;41:1148-63.
  • 4.Neumann A, Kalenderian E, Ramoni R, Yansane A, Tokede B, Etolue J, Vaderhobli R, Simmons K, Even J, Mullins J, Kumar S, Bangar S, Kookal K, White J, Walji M. Evaluating quality of dental care among patients with diabetes: Adaptation and testing of a dental quality measure in electronic health records. J Am Dent Assoc 2017;148(9):634-643.e1.doi: 10.1016/j.adaj.2017.04.017.
  • 5.Bhardwaj A, Ramoni R, Kalenderian E, Neumann A, Hebballi NB, White JM, McClellan L, Walji MF. Measuring up: Implementing a dental quality measure in the electronic health record context. J Am Dent Assoc 2016;147(1):35-40. doi: 10.1016/j.adaj.2015.06.023.
  • 6.St. Sauver JL, Carr AB, Yawn BP, Grossardt BR, Bock-Goodner CM, Klein LL, Pankratz JJ, Finney Rutten LJ, Rocca WA. Linking medical and dental health record data: a partnership with the Rochester Epidemiology Project. BMJ Open 2017;7:e012528.
  • 7.Boehmer U, Glickman M, Jones JA, Orner MB, Wheler C, Berlowitz DR, Kressin NR. Dental care in an equal access system valuing equity: are there racial disparities? Med Care 2016;54(11):998-1004.
  • 8.Thierer TE, Delander KA. Improving documentation, compliance, and approvals in an electronic dental record at a U.S. dental school. J Dent Educ 2017;81:442-9.
  • 9.Kalenderian E, Tokede B, Ramoni R, Khan M, Kimmes N, White J, Walji M. Dental clinical research: an illustration of the value of standardized diagnostic terms. J Public Health Dent 2016;76(2):152-6.
  • 10.Filker PJ, Cook N, Kodish-Stav J. Electronic health records: a valuable tool for dental school strategic planning. J Dent Educ 2013;77:591-7.
  • 11.Tokede O, Ramoni RB, Patton M, Da Silva JD, Kalenderian E. Clinical documentation of dental care in an era of EHR use. Evid Based Dent Pract 2016;16(3):154-60. doi:10.1016/j.jebdp.2016.07.001.
  • 12.Pearson JF, Brownstein CA, Brownstein JS. Potential for electronic health records and online social networking to redefine medical research. Clin Chem 2011;57(2):196-204.
  • 13.Wilke RA, Berg RL, Peissig P, Kitchner T, Sijercic B, McCarty CA, et al. Use of an electronic medical record for the identification of research subjects with diabetes mellitus. Clin Med & Res 2007;5(1):1-7.
  • 14.Acharya A, Shimpi N, Mahnke A, Mathias R, Ye Z. Medical care providers' perspectives on dental information needs in electronic health records. J Am Dent Assoc 2017;148:328-37.
  • 15.Kalenderian E, Ramoni RL, White JM, Schoonheim-Klein ME, Stark PC, Kimmes NS, Zeller GG, Willis GP, Walji MF. The development of a dental diagnostic terminology. J Dent Educ 2011;75(1):68-76.
  • 16.Schleyer T, Song M, Gilbert GH, Rindal DB, Fellows JL, Gordan VV, Funkhouser E, Electronic dental record use and clinical information management patterns among practitioner-investigators in The Dental Practice-Based Research Network. J Am Dent Assoc 2013;144(1):49-58.
  • 17.Ramoni RB, Walji MF, Kim S, Tokede O, McClellan L, Simmons K., Kalenderian E. Attitudes and beliefs toward the use of a dental diagnostic terminology A survey of dental providers in a dental practice. J Am Dent Assoc 2015;146(6):390-7. http://doi.org/10.1016/j.adaj.2015.02.007
  • 18.Walji MF, Kalenderian E, Tran D, Kookal KK, Nguyen V, Tokede O, White JM, Vaderhobli R, Ramoni R, Stark PC, Kimmes NS, Schoonheim-Klein ME, Patel VL. Detection and characterization of usability problems in structured data entry interfaces in dentistry. Int J Med Inform 2013;82:128-38.