A qualitative investigation of the content of dental paper-based and computer-based patient record formats

Evaluating and Extending the Informed Consent Ontology for Representing Permissions from the Clinical Domain

The purpose of this study was to evaluate, revise, and extend the Informed Consent Ontology (ICO) for expressing clinical permissions, including reuse of residual clinical biospecimens and health data. This study followed a formative evaluation design and used a bottom-up modeling approach. Data were collected from the literature on US federal regulations and a study of clinical consent forms. Eleven federal regulations and fifteen permission-sentences from clinical consent forms were iteratively modeled to identify entities and their relationships, followed by community reflection and negotiation based on a series of predetermined evaluation questions. ICO included fifty-two classes and twelve object properties necessary when modeling, demonstrating appropriateness of extending ICO for the clinical domain. Twenty-six additional classes were imported into ICO from other ontologies, and twelve new classes were recommended for development. This work addresses a critical gap in formally representing permissions clinical permissions, including reuse of residual clinical biospecimens and health data. It makes missing content available to the OBO Foundry, enabling use alongside other widely-adopted biomedical ontologies. ICO serves as a machine-interpretable and interoperable tool for responsible reuse of residual clinical biospecimens and health data at scale.

BigMouth: development and maintenance of a successful dental data repository

Few clinical datasets exist in dentistry to conduct secondary research. Hence, a novel dental data repository called BigMouth was developed, which has grown to include 11 academic institutions contributing Electronic Health Record data on over 4.5 million patients. The primary purpose for BigMouth is to serve as a high-quality resource for rapidly conducting oral health-related research. BigMouth allows for assessing the oral health status of a diverse US patient population; provides rationale and evidence for new oral health care delivery modes; and embraces the specific oral health research education mission. A data governance framework that encouraged data sharing while controlling contributed data was initially developed. This transformed over time into a mature framework, including a fee schedule for data requests and allowing access to researchers from noncontributing institutions. Adoption of BigMouth helps to foster new collaborations between clinical, epidemiological, statistical, and informatics experts and provides an additional venue for professional development.

Developing and Testing Electronic Health Record-Derived Caries Indices

Caries indices, the basis of epidemiologic caries measures, are not easily obtained in clinical settings. This study's objective was to design, test, and validate an automated program (Valid Electronic Health Record Dental Caries Indices Calculator Tool [VERDICT]) to calculate caries indices from an electronic health record (EHR). Synthetic use case scenarios and actual patient cases of primary, mixed, and permanent dentition, including decayed, missing, and filled teeth (DMFT/dmft) and tooth surfaces (DMFS/dmfs) were entered into the EHR. VERDICT measures were compared to a previously validated clinical electronic data capture (EDC) system and statistical program to calculate caries indices. Four university clinician-researchers abstracted EHR caries exam data for 45 synthetic use cases into the EDC and post-processed with SAS software creating a gold standard to compare the -VERDICT-derived caries indices. Then, 2 senior researchers abstracted EHR caries exam data and calculated caries indices for 24 patients, allowing further comparisons to VERDICT indices. Agreement statistics were computed among abstractors, and discrepancies were resolved by consensus. Agreement statistics between the 2 final-phase abstractors and the VERDICT measures showed extremely high concordance: Lin's concordance coefficients (LCCs) >0.99 for dmfs, dmft, DS, ds, DT, dt, ms, mt, FS, fs, FT, and ft; LCCs >0.95 for DMFS and DMFT; and LCCs of 0.92-0.93 for MS and MT. Caries indices, essential to developing primary health outcome measures for research, can be reliably derived from an EHR using VERDICT. Using these indices will enable population oral health management approaches and inform quality improvement efforts.

Development an Electronic Oral Health Record application for educational dental setting

AIM

Worldwide, the adoption of electronic patient recording system is increasing among many parts of the health sectors. Although paper-based recording of patients' information was a routine in many departments of dental schools, easy destruction of collected information and the costs of its conversion to electronic data, limited the availability of updated data at the department of dental public health. This paper aimed to explain the project of designing a system for Electronic Oral Health Recording (EOHR) in Isfahan dental school. The initial testing of system among dental students is reported too.

METHODS

A situation analysis was conducted among the faculty members and dental students dealing with the Department of Oral Public Health. The content of EOHR was developed based on the WHO STEPwise model for chronic disease surveillance systems. The system was developed as an application for smartphone and a web-based database. The spiral model was applied in software development which was accomplished by the object-oriented programming method. After that, alpha and beta testing were done in target population. Data were compiled during the interview and oral examination by 40 dental students among 200 schoolchildren. It has been stored as a data bank following the network connection. The pitfalls of the system during its usage in dental public health course were evaluated as well.

RESULTS

The baseline analysis of situation generally revealed a perception of need to change the existing paper-based recording system among the dental students and the academic members; it was summarized in five areas as follows: benefits restrictions, structural barriers, perceived advantages and feasibility. The application was designed and completed as six pages interface including demographic and follow-up page, socioeconomic status of family, oral health-related behavior, dental and gingival status, and quality of life. Drawbacks, such as nonresponded items, common assumptions, student registration page on the mobile, and modification in the output Excel file for analysis variables, have been resolved.

CONCLUSION

A software application and web-based database were designed regarding the characteristics of Agile Unified Process development and educational dental setting. This system should be improved and established gradually.

Using a stakeholder-engaged approach to develop and validate electronic clinical quality measures

Objective

To describe the stakeholder-engaged processes used to develop, specify, and validate 2 oral health care electronic clinical quality measures.

Materials and Methods

A broad range of stakeholders were engaged from conception through testing to develop measures and test feasibility, reliability, and validity following National Quality Forum guidance. We assessed data element feasibility through semistructured interviews with key stakeholders using a National Quality Forum-recommended scorecard. We created test datasets of synthetic patients to test measure implementation feasibility and reliability within and across electronic health record (EHR) systems. We validated implementation with automated reporting of EHR clinical data against manual record reviews, using the kappa statistic.

Results

A stakeholder workgroup was formed and guided all development and testing processes. All critical data elements passed feasibility testing. Four test datasets, representing 577 synthetic patients, were developed and implemented within EHR vendors' software, demonstrating measure implementation feasibility. Measure reliability and validity were established through implementation at clinical practice sites, with kappa statistic values in the "almost perfect" agreement range of 0.80-0.99 for all but 1 measure component, which demonstrated "substantial" agreement. The 2 validated measures were published in the United States Health Information Knowledgebase.

Conclusion

The stakeholder-engaged processes used in this study facilitated a successful measure development and testing cycle. Engaging stakeholders early and throughout development and testing promotes early identification of and attention to potential threats to feasibility, reliability, and validity, thereby averting significant resource investments that are unlikely to be fruitful.

An electronic oral health record to document, plan and educate

The University of British Columbia (UBC) in collaboration with a software developer (Planmeca Oy, Finland) created an electronic oral health record based on the principles of cognitive ergonomics rooted in the European research and development project 'ORQUEST' to guide students through medical, dental, social histories, examinations, treatment planning and progress notes. Clinicians in each dental specialty of the Faculty of Dentistry and software engineers cooperated to define the clinical content and workflow of clinical procedures in three phases: (i) development of a radiographic module, (ii) development of medical, dental, social and family histories, intra- and extra-oral examinations, progress notes and treatment planning and (iii) development of the orthodontic section accompanied by an optimisation phase to correct technical problems and clinical content issues. From a practical perspective, this EOHR enhances the clinical performance of students and the quality assurance capacity of the institution. It facilitates audits of clinical productivity and research, and it can be modified with relative ease to suit similar educational and clinical environments in either public or private healthcare settings.

Advancing cognitive engineering methods to support user interface design for electronic health records

BACKGROUND

Despite many decades of research on the effective development of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow, especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practitioners in the United States. A critical reason for slow adoption is the poor usability of clinical systems, which makes it difficult for providers to navigate through the information and obtain an integrated view of patient data.

OBJECTIVE

In this study, we documented the cognitive processes and information management strategies used by dentists during a typical patient examination. The results will inform the design of a novel electronic dental record interface.

METHODS

We conducted a cognitive task analysis (CTA) study to observe ten general dentists (five general dentists and five general dental faculty members, each with more than two years of clinical experience) examining three simulated patient cases using a think-aloud protocol.

RESULTS

Dentists first reviewed the patient's demographics, chief complaint, medical history and dental history to determine the general status of the patient. Subsequently, they proceeded to examine the patient's intraoral status using radiographs, intraoral images, hard tissue and periodontal tissue information. The results also identified dentists' patterns of navigation through patient's information and additional information needs during a typical clinician-patient encounter.

CONCLUSION

This study reinforced the significance of applying cognitive engineering methods to inform the design of a clinical system. Second, applying CTA to a scenario closely simulating an actual patient encounter helped with capturing participants' knowledge states and decision-making when diagnosing and treating a patient. The resultant knowledge of dentists' patterns of information retrieval and review will significantly contribute to designing flexible and task-appropriate information presentation in electronic dental records.

Reusing electronic patient data for dental clinical research: a review of current status

OBJECTIVES

The reuse of electronic patient data collected during clinical care has received increased attention as a way to increase our evidence base. The purpose of this paper was to review studies reusing electronic patient data for dental research.

DATA SOURCES

1527 citations obtained by searching MEDLINE and Embase databases, hand-searching seven dental and informatics journals, and snowball sampling.

STUDY SELECTION

We included studies reusing electronic patient data for research on dental and craniofacial topics, alone or in combination with medical conditions, medications and outcomes. Studies using administrative or research databases and systematic reviews were excluded. Three reviewers extracted data independently and performed analysis jointly

RESULTS

The 60 studies reviewed covered epidemiological (32 studies), outcomes (16), health services research (10) and other (2) topics; were primarily retrospective (58 studies); varied significantly in sample size (9-153,619 patients) and follow-up period (1-12 years); often drew on other data sources in addition to electronic ones (25); but rarely tapped electronic dental record (EDR) data in private practices (3). Type of research was not associated with data sources used, but research topics/questions were. The most commonly reported advantages of reusing electronic data were being able to study large samples and saving time, while data quality and the inability to capture study-specific data were identified as major limitations.

CONCLUSIONS

Dental research reusing electronic patient data is nascent but accelerating. Future EDR design should focus on enhancing data quality, begin to integrate research data collection and implement interoperability with electronic medical records to facilitate oral-systemic investigations.

CLINICAL SIGNIFICANCE

Measuring and improving the quality of dental care requires that we begin to reuse electronic patient data collected in practice for clinical research. Practice data can potentially serve as a useful complement to data collected in traditional research studies.

Development and initial validation of a content taxonomy for patient records in general dentistry

OBJECTIVE

Develop and validate an initial content taxonomy for patient records in general dentistry.

METHODS

Phase 1 - obtain 95 de-identified patient records from 11 general dentists in the United States. Phase 2 - extract individual data fields (information items), both explicit (labeled) and implicit (unlabeled), from records, and organize into categories mirroring original field context. Phase 3 - refine raw list of information items by eliminating duplicates/redundancies and focusing on general dentistry. Phase 4 - validate all items regarding inclusion and importance using a two-round Delphi study with a panel of 22 general dentists active in clinical practice, education, and research.

RESULTS

Analysis of 76 patient records from 9 dentists, combined with previous work, yielded a raw list of 1509 information items. Refinement reduced this list to 1107 items, subsequently rated by the Delphi panel. The final model contained 870 items, with 761 (88%) rated as mandatory. In Round 1, 95% (825) of the final items were accepted, in Round 2 the remaining 5% (45). Only 45 items on the initial list were rejected and 192 (or 17%) remained equivocal.

CONCLUSION

Grounded in the reality of clinical practice, our proposed content taxonomy represents a significant advance over existing guidelines and standards by providing a granular and comprehensive information representation for general dental patient records. It offers a significant foundational asset for implementing an interoperable health information technology infrastructure for general dentistry.

Using electronic dental record data for research: a data-mapping study

Anecdotal evidence suggests that, during the clinical care process, many dental practices record some data that are also collected in dental practice based research network (PBRN) studies. Since the use of existing, electronically stored data for research has multiple benefits, we investigated the overlap between research data fields used in dental PBRN studies and clinical data fields typically found in general dental records. We mapped 734 unique data elements from the Dental Information Model (DIM) to 2,487 Common Data Elements (CDE) curated by the NIDCR's PBRNs in the Cancer Data Standards Registry and Repository (caDSR). Thirty-three percent of the DIM data elements matched at least one CDE completely and 9% partially, translating to about 9% and 2%, respectively, of all data elements used in PBRN studies. The most frequently used CDEs found in the DIM included data about dental anatomy, medications, and items such as oral biopsy and caries. Our study shows that a non-trivial number of data elements in general dental records can be mapped either completely or partially to data fields in research studies. Further studies should investigate the feasibility of electronic clinical data for research purposes.

Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities

PURPOSE

To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.

METHODS

Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level.

RESULTS

Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p<0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p<0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p<0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p<0.01), suggesting more items designed in a form, more information would be captured.

CONCLUSION

Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content.

Comparing four softwares based on ISO 9241 part 10

Evaluation of Iran’s HIS (hospital Information System) ergonomic quality using IsoMetric 9241 part 10 and compared results of that evaluation with results of ergonomic quality evaluation other softwares which evaluated by IsoMetric 9241 part 10. This research study was conducted in two stages. In the first stage, the researchers evaluated the HIS of 13 hospitals in Iran using ISO 9241 part 10, and in the second stage, they compared the evaluation results with the following softwares: a) IS-H*med (evaluated by Hamborg et al. 2004) b) SAP-HR (evaluated by Gruber 2000) c) Microsoft Word for Windows, Version 2 (evaluated by Gediga et al. 1999). For first stage used usability questionnaire called IsoMetrics which is based on the international standard ISO 9241 Part 10. This questionnaire is including 75 items based on the seven principles. Data analyzed using SPSS and Excel. The comparison between HIS and IS-H*med reveal that the former is significantly more usable than the latter in terms of all IsoMetrics sales. The HIS also proved to be significantly more applicable than SAP-HR in terms of such IsoMetrics scales as “suitability for task,” “suitability for learning”, “Error tolerance” and “learning ability”. However, HIS was found to be significantly less usable than Microsoft Word. The results of the study show that compared with the mentioned three softwares, Iran’s hospital information system enjoys an average ergonomic quality. Therefore, it is recommended that the users’ comments and expectations be considered more when information systems are designed and developed.

The training and support needs of faculty and students using a health information technology system were significant: a case study in a dental school

Health Information Technology Systems (HITS) are becoming more widely integrated into patient care in the dental school setting. The purpose of this study was to evaluate the impact of a chairside HITS on users in the dental school setting. Qualitative techniques, including interviews, focus groups and observations, were used. Using grounded theory, we saw 9 themes emerge. One theme of particular interest was that "training and support needs of end-users were significant." This paper explores this theme in detail and discusses the implications.

A preliminary model of work during initial examination and treatment planning appointments

Objective This study's objective was to formally describe the work process for charting and treatment planning in general dental practice to inform the design of a new clinical computing environment.Methods Using a process called contextual inquiry, researchers observed 23 comprehensive examination and treatment planning sessions during 14 visits to 12 general US dental offices. For each visit, field notes were analysed and reformulated as formalised models. Subsequently, each model type was consolidated across all offices and visits. Interruptions to the workflow, called breakdowns, were identified.Results Clinical work during dental examination and treatment planning appointments is a highly collaborative activity involving dentists, hygienists and assistants. Personnel with multiple overlapping roles complete complex multi-step tasks supported by a large and varied collection of equipment, artifacts and technology. Most of the breakdowns were related to technology which interrupted the workflow, caused rework and increased the number of steps in work processes.Conclusion Current dental software could be significantly improved with regard to its support for communication and collaboration, workflow, information design and presentation, information content, and data entry.

Evaluating the effectiveness of modeling principles for data models

We evaluated the effectiveness of modeling principles intended to harmonize the information representation between terminology-ontology models and information models. Our study utilized dental clinical statements and sample dental record questions. We asked experts to define the equivalency (mapping) of these elements and measured their agreement. We modified the data elements and asked the experts to conduct subsequent mappings. We measured the agreement and compared the levels of agreement before and after changes, expecting that agreement would increase. The level of agreement (Kappa) before modeling was 0.3 to 0.4 and after was 0.5 (p<0.05). The difference was small but statistically significant. Our results suggest that the modeling principles improve information representation since agreement increased.

A usability evaluation of four commercial dental computer-based patient record systems

BACKGROUND

The usability of dental computer-based patient record (CPR) systems has not been studied, despite early evidence that poor usability is a problem for dental CPR system users at multiple levels.

METHODS

The authors conducted formal usability tests of four dental CPR systems by using a purposive sample of four groups of five novice users. The authors measured task outcomes (correctly completed, incorrectly completed and incomplete) in each CPR system while the participants performed nine clinical documentation tasks, as well as the number of usability problems identified in each CPR system and their potential relationship to task outcomes. The authors reviewed the software application design aspects responsible for these usability problems.

RESULTS

The range for correctly completed tasks was 16 to 64 percent, for incorrectly completed tasks 18 to 38 percent and for incomplete tasks 9 to 47 percent. The authors identified 286 usability problems. The main types were three unsuccessful attempts, negative affect and task incorrectly completed. They also identified six problematic interface and interaction designs that led to usability problems.

CONCLUSION

The four dental CPR systems studied have significant usability problems for novice users, resulting in a steep learning curve and potentially reduced system adoption.

CLINICAL IMPLICATIONS

The significant number of data entry errors raises concerns about the quality of documentation in clinical practice.

The feasibility of a three-dimensional charting interface for general dentistry

BACKGROUND

Most current paper- and computer-based formats for patient documentation use a two-dimensional dental chart, a design that originated almost 150 years ago in the United States. No studies have investigated the inclusion of a three-dimensional (3-D) charting interface in a general dental record.

METHODS

A multidisciplinary research team with expertise in human-computer interaction, dental informatics and computer science conducted a 14-week project to develop and evaluate a proof of concept for a 3-D dental record. Through several iterations of paper- and computer-based prototypes, the project produced a high-fidelity (hi-fi) prototype that was evaluated by two dentists and two dental students.

RESULTS

The project implemented a prototypical patient record built around a 3-D model of a patient's maxillofacial structures. Novel features include automatic retrieval of images and radiographs; a flexible view of teeth, soft tissue and bone; access to historical patient data through a timeline; and the ability to focus on a single tooth.

CONCLUSIONS

Users tests demonstrated acceptance for the basic design of the prototype, but also identified several challenges in developing intuitive, easy-to-use navigation methods and hi-fi representations in a 3-D record.

CLINICAL IMPLICATIONS

Test participants in this project accepted the preliminary design of a 3-D dental record. Significant further research must be conducted before the concept can be applied and evaluated in clinical practice.