electronic dental records 2nd edition

Educational ObjectivesFollowing this unit of instruction, the practitioner should be able to:

1. Describe to what extent general dentists are using electronic dental records (EDRs).

2. Discuss reasons that limit adoption of EDRs in general dentistry.

3. Identify aspects in which EDRs differ from paper records with respect to their information pre-sentation and storage capabilities.

4. Describe the concept of usability with respect to EDRs.

5. Discuss task outcomes of a recent usability study and their implications.

6. List considerations for choosing an EDR system.

Introduction

Electronic dental records (EDRs) have become a topic of increasing interest for practicing dentists, especially now that the administrative

functions in practice management systems have matured to the degree that they barely warrant mention. Marketed under names such as the digital dental office, integrated clinical solutions, paperless systems, and electronic patient or health records, EDRs represent the next frontier for the dental information technology industry in the quest to digitize (almost) every aspect of dental practice.

Vendors have been advertising plenty of offerings for quite some time and adoption has accelerated in recent years. As of early 2005, only 1.8% of all general dentists in the U.S. were paperless, while 25% had a computer at chairside.1 By 2007, those figures had risen to 9.2% and 55.5%, respectively, for all dentists according to a survey conducted by the American Dental Association.2 New dentists, i.e.

dentists who graduated from dental school within the past ten years, had adopted paperless systems to an even larger degree, 13.4%. While EDRs are increasingly adopted by the practitioner community, many obstacles remain.

Many practitioners approach “going paperless” with the goal of “getting rid of paper.” However, implementing EDRs is much more than just eliminating paper; it requires a profound change in the way offices operate, record patient data, train staff, and manage information and information technology. Few offices manage to undergo this complex transformation quickly and easily. Those who fail or are less than successful are frequently cited by their peers as a justification for waiting just a little bit longer.

This guide focuses on a narrow set of questions regarding EDRs: How are general dentists, who have adopted EDRs, using them, and what are their opinions about them? How appropriate are EDRs for representing information that is typically stored in paper records? And, how does the user interface of current EDRs impact dentists’ ability to work with them? The answers to those questions come from several studies1,3,4,5 conducted by the Center for Dental Informatics at the University of Pittsburgh as well as other sources.

General Dentists’ Use and View ofElectronic Dental Records (EDRs)In our first study, we surveyed 102 randomly sampled U.S. general dentists who were using a computer at chairside about their use of, opinions about and attitudes toward their systems.1 A majority of the respondents (80%) had implemented such systems at chairside within the last 10 years. The average age of our respondents was 50 years, with a standard deviation of 10 years. Eighty percent of the respondents used one of four systems: Dentrix (Dentrix

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Quality Resource GuideSECOND EDITION

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 AcknowledgementsTitus Schleyer, DMD, PhDDirector, Center for Dental Informatics School of Dental MedicineUniversity of PittsburghPittsburgh, PA

Dr. Schleyer has no relevant financial relationships to disclose.

The following commentary highlights fundamental and commonly accepted practices on the subject matter. The information is intended as a general overview and is for educational purposes only. This information does not constitute legal advice, which can only be provided by an attorney.

© Metropolitan Life Insurance Company, New York, NY. All materials subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement.

Originally published March 2008 as “Computer-Based Patient Records”. Updated and revised July 2011. Expiration date: July 2014. The content of this Guide is subject to change as new scientific information becomes available.

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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

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Dental Systems, American Fork, UT), EagleSoft (Patterson Dental, St. Paul, MN), SoftDent or PracticeWorks (Carestream Health, Rochester, NY). Seventy percent used at least one other software application, e.g. for digital radiology and/or photography or Invisalign.

Figure 1 shows that most practices store patient information in a mix of paper/hard copy and computer formats. Information commonly associated with billing and practice operations, such as treatment procedures and patient appointments, tended to be most frequently stored on computers, followed by images and intraoral charting. Information that was stored least frequently on the computer included the medical and dental history, progress notes and the chief complaint. The figure also illustrates that a large proportion of information is duplicated on both paper and the computer. Clearly, maintaining information in two places has multiple drawbacks. First, duplicate information storage consumes unnecessary resources. Second, inconsistencies in information between the two types of storage can potentially lead to incomplete diagnosis/treatment, clinical errors and/or legal complications.6 When asked about the duplication, several respondents indicated

that they were in a period of transition, and that they would eliminate paper-based records as soon as they had mastered the corresponding electronic functions and/or felt completely comfortable with the computer as a storage medium. Some also provided another reason: the EDR they used was not able to store all information that the practice wanted to store, and this information therefore remained confined to paper. This finding prompted us to explore the information representation capabilities of EDRs further in the second study we describe below.

Relatively few of the respondents used what would be considered advanced techniques for data entry/retrieval during clinical care: touchscreens and voice input. About 13% each used one of those two technologies. Importantly, while three percent had tried to use a touchscreen and abandoned it, 16% had done so with voice. Judging from these data, voice input does not seem to be mature enough to serve the needs of many practitioners who have tried using it. A small fraction of respondents used specialized input devices, such as barcode scanners and electronic dental probes. Some vendors have upgraded their voice input systems since our study, but adoption still appears to be limited.

In general, respondents appreciated the value and benefits they derived from having adopted EDRs. Charting, treatment planning and imaging functions were seen as particularly useful, and one quarter of respondents could not identify anything in their EDRs that they disliked. Efficiency, convenient information access and patient education were seen as the major advantages of EDRs. Despite this positive view, our study identified several barriers and opportunities for improvement. For instance, usability, functionality and charting were among the main features that respondents disliked, and insufficient operational reliability, program limitations, the learning curve and cost were seen as major barriers to EDR use. Issues with infection control and the need for better user interfaces were recurrent themes.

In sum, our study on chairside computing showed that at present, full adoption of the EDR remains limited among general practitioners. Our survey demonstrated that the dentists who use EDRs tend to derive significant value, but that EDRs as a technology have to mature further in many respects before they will enter the mainstream.

Representation of Clinical Information in EDRsIn a second study, we pursued the question of how well EDRs represent information typically stored in paper-based records.3 Because no detailed standard for the content of dental records exists, we first compiled and categorized a list of data fields from a purposive sample of 10 dental records obtained from vendors, practitioners and dental schools. We termed this list the Baseline Dental Record (BDR). We then mapped the information contained in each of the four market-leading dental EDRs in the United States to the information in the BDR. We only focused on clinical, not administrative, data fields.

The BDR contained 20 information categories. Most of them, such as “Chief complaint,” “Medication history,” “Hard tissue and periodontal chart,” and “Radiographic history

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Quality Resource Guide: Electronic Dental Record 2nd Edition

FIGURE 1

Appointments

Treatment PlansCompleted Treatment

Oral Health Status

Intraoral Images

Extraoral Images

Diagnoses

Radiographs

Dental History

Medical History

Progress Notes

Chief Complaint

PaperComputerBothNot at all

50 60 70 80 90 9740302010010203055 50 40

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


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and findings” were related to obtaining clinical data necessary to determine the patient’s oral health status. Categories such as “Systemic diagnoses,” “Dental diagnoses” and “Problem list” served to describe the patient’s current oral health status, while “Treatment plan” was used to represent the necessary treatment. Finally, “Progress notes” and “Prescriptions” documented care delivered. On average, each paper record contained between 23 and 32% of the fields in the BDR, demonstrating that although dental records collectively tend to contain a relatively large number of fields, there is little agreement on what those fields should be.

Table 1 shows how well the four EDRs covered the information contained in the BDR. In terms of information categories, the EDR’s coverage (mean: 14; range: 11-16) was comparable to that of paper records (mean: 13.9; range: 8-18). The average number of fields in paper records (107) was somewhat higher than that in EDRs (90). More than averages, however, Table 1 illustrates how EDRs compare to paper-based records in terms of information presentation. For three information categories, i.e. the “Chief complaint,” “Systemic diagnoses” and “Problem list,” EDRs’ provide no corresponding data fields at all. In others, such as “Prognosis, risk assessment and etiology,” only some EDRs provide data fields. Table 1 also shows that in areas that all EDRs cover, the number of data fields is typically significantly lower than in the BDR. This is not surprising given the fact that the BDR is a “superset” of all data fields contained in the corresponding paper records. Comparing the number of data fields within a category provides some insight to how many data items different EDRs can accommodate. For instance, compared to Dentrix and PracticeWorks, EagleSoft and SoftDent seem to have more comprehensive health histories; however, how well each health history format matches the recordkeeping requirements of a practice is a decision of the individual practitioner.

Findings and procedures on hard tissue and periodontal charts are typically documented as numbers, text or free-form graphical

annotations. Therefore, we could not use the approach of matching data fields in analyzing the corresponding information content in EDRs. Instead, we selected a sample of 26 hard tissue and 28 periodontal conditions, as well as 20 procedures, and checked whether they could be charted in each EDR. Information coverage was 46-88% for hard tissue findings, 45-85% for procedures and 39-64% for periodontal conditions.

The corresponding paper published in the Journal of the American Medical Informatics Association3 provides additional details about comparative information coverage at the field level. Several fields that occur very frequently in paper records, such as the chief complaint, a list of current medications, allergies and physician information tend to be poorly represented, while others, such as diabetes, hepatitis/liver disease, high/low blood pressure

3

8

120

78

n/a

26

7

32

18

6

2

6

7

313

3

9

7

3

22

18

9

1

10

363

20

0

0

36

2

n/a

9

1

9

1

0

1

0

3

62

0

2

0

1

3

5

5

1

6

76

14

0

2

70

14

n/a

11

1

9

1

2

1

0

6

117

0

1

0

0

1

7

4

1

5

130

15

0

1

19

4

n/a

7

1

3

0

0

1

0

0

36

0

0

0

0

0

7

4

1

5

48

11

0

3

52

6

n/a

9

2

11

1

2

1

2

4

93

0

2

0

0

2

6

5

1

6

107

16

Dent

rix

Eagl

esof

t

Prac

ticeW

orks

Soft

Dent

BDR CPRs

Average # of categories

Average # of fields

14

90

BDR Categories

Chief complaint

Medication history

Medical history

Dental/social history

Hard tissue and periodontal chart

Intraoral soft tissue examination

Extraoral head and neck examinations

Temporomandibular joint/occlusion

Radiographic history and findings

Physician information

Alert/Summary box

Medical history update

Consultations

Subtotal

Systemic diagnoses

Dental diagnoses

Problem list

Prognosis, risk assessment and etiology

Subtotal

Treatment plan

Progress notes

Prescriptions

Subtotal

Total fields

Total categories

Table 1: Information coverage of the fields in the Baseline Dental Record in Dentrix, EagleSoft, Practice-Works and SoftDent. Data fields are not reported for the category “Hard tissue and periodontal chart” since paper forms combine a limited number of fields with free-form entries (data from 2007).

TABLE 1

and rheumatic fever/heart murmur, tend to be well represented in EDRs.

In sum, today’s EDRs do not mirror the information content of paper records very well. As our study showed, there is quite a large variability in the information content of paper records, which can also be observed in EDRs. An additional observation was that EDRs typically organized information differently from paper records. One reason for this finding is that a computer screen has a much lower resolution than paper, and thus relatively more space is needed to display the same amount of information.

An additional aspect of EDRs to consider is the ability to add, change and delete data fields. Documentation requirements in dental practice are dynamic and practitioners must constantly strive to accommodate new data elements, such as information about bisphosponates on the medication history or DiagnoDent scores for caries diagnosis. An EDR that facilitates changes to the content of the clinical record will be a valuable tool to ensure that the best information for clinical decisions is available at any time.

Usability of EDRsThe third and last area we examine in this guide is the usability of EDRs. Both studies described above, as well as a third study reporting a heuristic evaluation of dental software4, hinted at the fact that usability might be a significant problem with EDRs. In our survey study, many participants commented about the - in their view - poor usability of many EDRs. In the record content study, it became obvious that the way information is organized on a computer screen, which is very different from the way it is typically organized on paper, may have important implications for usability.

The International Standards Organization (ISO) defines usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context

of use.” In order to assess the usability of the four major EDRs, we conducted a lab experiment in which we asked five novice users each to complete nine clinical documentation tasks using the target software.5 The experiment measured whether the participants completed each task correctly, incorrectly or incompletely. In addition, we quantified the number of usability problems encountered by each participant while completing each particular task.

Table 2 provides an overview of the study results. Test participants completed between 16 and 64 percent of the tasks correctly, while they completed 18 – 38 percent incorrectly and 9 – 47 incompletely. A total of 286 usability problems were found in the experiments, which included: three unsuccessful attempts, i.e. three unsuccessful sequences of user actions when attempting to reach a goal (146); expression of negative affect (65); incorrect task completion (which is both a task outcome as well as a usability problem) (55); user gave up (13); and design suggestion (7). Our study found a statistically significant association between the number of usability problems in a task and task outcome, i.e. the more usability problems participants encountered, the less likely they were to complete a task correctly.

Our study indicates that usability of dental EDRs could be significantly improved. In addition, the high rate of errors in tasks that participants believed they had completed correctly raises potential concerns about the correctness and reliability of information stored in EDRs. Some

may argue that training users upfront would have resulted in much better performance in our experiment; however, our main objective was to measure out-of-the-box usability for the novice user. Frequently performed tasks should be easy to perform in any system. Clearly, our results show that this was not the case.

LessonsAfter reading about the three studies presented the reader may wonder whether it is worthwhile to adopt an EDR at this time. The answer is yes, provided the practice is willing to make the significant investment necessary to make the system work. Considering a few recommendations may help in this endeavor:

• Choosing an EDR is still a very individual decision. Available systems offer quite a large variety in terms of design and functionality. Practices should evaluate each system individually with respect to aspects such as information content (Does it accommodate the information typically recorded on paper?), usability (Is it intuitive and easy-to-learn?), efficiency (Are common tasks easy to perform with a minimum of mouse clicks/keystrokes?) and support for making clinical decisions (Is reviewing and synthesizing information easy and efficient?).

• The ability to customize the program and its information content, as well as its functionality to help the user prevent data entry errors, are important considerations. Some systems provide structured templates for clinical notes


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TABLE 2

EagleSoft

PracticeWorks

Dentrix

SoftDent

Average

64

58

33

16

43

18

33

29

38

30

18

9

38

47

28

60

44

96

86

286

CPR

% of tasks Correctlycompleted

Incorrectlycompleted

Incomplete Total # ofusability problems

Table 2: Task outcomes for nine usability tasks in each of the four software applications tested, sorted by the percentage of correctly completed tasks in descending order.

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Resources1. Schleyer TK, Thyvalikakath TP, Spallek H, Torres-Urquidy MH, Hernandez P, Yuhaniak J. Clinical computing in general dentistry. J Am Med Inform

Assoc. 2006; 13(3):344-52.

2. American Dental Association Survey Center. 2006 Technology Survey. Chicago, IL, 2007.

3. Schleyer T, Spallek H, Hernandez P. A qualitative investigation of the content of dental paper- and computer-based patient record (CPR) formats. J Am Med Inform Assoc 2007; 14(4):515-26.

4. Thyvalikakath TP, Schleyer TK, Monaco V. Heuristic evaluation of clinical functions. J Am Dent Assoc, Vol 138, No 2, 209-218 (2007).

5. Thyvalikakath TP, Monaco V, Thambuganipalle HB, Schleyer TK. A usability evaluation of four commercial dental computer-based patient records. J Am Dent Assoc, Vol 139, No 12,1632-42 (2008).

6. Stausberg J, Koch D, Ingenerf J, Betzler M. Comparing paper-based with electronic patient records: Lessons learned during a study on diagnosis and procedure codes. J Am Med Inform Assoc 2003; 10(5):470-477.

7. Ford EW, Menachemi N, Phillips MT. Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106-112.

8. Dick RS, Steen EB, Detmer DE. The Computer-Based Patient Record, National Academy Press, Washington, DC, 1997.


(sometimes called “Auto-notes”) and other

entries, which may help generate complete

and comprehensive documentation efficiently.

However, clinicians should not simply rely

on boilerplate notes, but ensure that all

clinically relevant, patient-specific information

is recorded.

• Practitioners should not expect that the EDR

will be a mirror image of their paper record.

As evident from the discussion above, it

cannot be. The best strategy is to pick a

system that resembles the practice record

most closely from an information content and

layout perspective, and then ensure that every

team member receives adequate training to

understand and use the new format.

• Staff buy-in and training are crucial in making an EDR implementation a success. Staff participation should start on Day 1 of selecting a system. Top-down decisions by “management” carry the greatest risk of failure.

Putting an EDR in place is a daunting endeavor for most practices, since doing so affects everyone and everything. To help with this transition, MetLife recently published “Transitioning from paper to electronic records: A process guide” in its Quality Resource Guide series. As this guide explains, dentists should follow a comprehensive implementation strategy that takes into account how an office operates, records patient data, trains staff, and manages information and information technology. Only then will the EDR deliver the benefits it promises to yield.

SummaryEDRs appear to perform acceptably and provide value to their early adopters in general dentistry. Current adoption rates are limited but growth seems to be accelerating, in line with projections for medicine.7 At the same time, vendor products can be expected to mature significantly in the future. While the primary focus of the industry to date has been to simply translate paper records into computer format, tomorrow’s systems will offer many advanced functions, such as patient-specific decision support, on-demand retrieval of evidence-based literature, customized patient education and seamless data exchange with other systems, such as those of physicians and

hospitals.8 The question for many dentists therefore

becomes not whether to invest in an EDR, but when.

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9. The largest number of fields in the baseline dental Record (BDR) is found in the information category:a. dental/social history.b. temporomandibular joint/occlusion.

c. medical history.d. intraoral soft tissue examination.

4. General dentists duplicate a significant portion of paper-based clinical information on the computer, because duplication increases the reliability of data. a. The first statement is true; the second statement is false.b. The first statement is false; the second statement is true.

c. Both statements are true.d. Both statements are false.

7. About 13% of the survey respondents used touchscreen or voice input for data entry, but 16% had tried to use a touchscreen and abandoned it.a. The first statement is true; the second statement is false.b. The first statement is false; the second statement is true.

c. Both statements are true.d. Both statements are false.

6. Among the usability problems found in the study, the second highest number was found in the category:a. user gave up.b. incorrect task completion.c. three unsuccessful attempts.

d. expression of negative affect.e. design suggestion.

1. Electronic dental records can easily be customized to replicate the information and layout of a specific paper record. a. Trueb. False

2. For information typically recorded in the patient record, information coverage in EDRs was worst for:

a. hard tissue findings.b. periodontal conditions.

c. procedures.d. all of the above.

10. Three patient information categories that general dentists store most frequently on the computer include: 1. oral health status 4. progress notes 2. radiographs 5. chief complaint 3. treatment plans a. 1, 2 and 5 only

b. 1, 3 and 4 onlyc. 2, 3 and 5 onlyd. 1, 2 and 3 only

5. Among the EDRs most frequently used by general practitioners are: 1. Dentrix 4. Dentec 2. Mogo 5. Dental.com 3. SoftDent

a. 1 and 3 onlyb. 2 and 4 only

c. 1, 4 and 5 onlyd. 3 and 4 only

8. As defined by the International Standards Organization (ISO), usability includes the following aspects (check all that apply): 1. efficiency 3. satisfaction 2. error rate 4. effectiveness

a. 1, 2 and 3 onlyb. 2 and 4 only

c. 1, 3 and 4 onlyd. 3 and 4 only

3. A usability study of a software program assesses whether it:a. is easy for someone to use it without training.b. is appropriate for clinical decision-making.

c. helps complete tasks with the minimum number of keystrokes.d. all of the above.

POST TEST: Internet Users: This page is intended to assist you in fast and accurate testing when completing the “Online Exam.” We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam. (1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade.


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electronic dental records 2nd edition

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