A patient-centered nurse-supported primary care-based collaborative care program to treat opioid use disorder and depression: Design and protocol for the MI-CARE randomized controlled trial

BACKGROUND

Opioid use disorder (OUD) contributes to rising morbidity and mortality. Life-saving OUD treatments can be provided in primary care but most patients with OUD don't receive treatment. Comorbid depression and other conditions complicate OUD management, especially in primary care. The MI-CARE trial is a pragmatic randomized encouragement (Zelen) trial testing whether offering collaborative care (CC) to patients with OUD and clinically-significant depressive symptoms increases OUD medication treatment with buprenorphine and improves depression outcomes compared to usual care.

METHODS

Adult primary care patients with OUD and depressive symptoms (n ≥ 800) from two statewide health systems: Kaiser Permanente Washington and Indiana University Health are identified with computer algorithms from electronic Health record (EHR) data and automatically enrolled. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven CC intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group and is never contacted. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in "intent-to-treat" analyses.

CONCLUSION

MI-CARE addresses the need for rigorous encouragement trials to evaluate benefits of offering CC to generalizable samples of patients with OUD and mental health conditions identified from EHRs, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of the trial, currently underway.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05122676. Clinical trial registration date: November 17, 2021.

Preliminary evaluation of the Chest Pain Dashboard, a FHIR-based approach for integrating health information exchange information directly into the clinical workflow

Despite efforts aimed at improving the integration of clinical data from health information exchanges (HIE) and electronic health records (EHR), interoperability remains limited. Barriers due to inefficiencies and workflow interruptions make using HIE data during care delivery difficult. Capitalizing on the development of the Fast Healthcare Interoperability Resource (FHIR) specification, we designed and developed a Chest Pain Dashboard that integrates HIE data into EHRs. This Dashboard was implemented in one emergency department (ED) of Indiana University Health in Indiana. In this paper, we present the preliminary findings from a mixed-methods evaluation of the Dashboard. A difference-in-difference analysis suggests that the ED with the Dashboard implementation resulted in a significant increase in HIE use compared to EDs without. This finding was supported by qualitative interviews. While these results are encouraging, we also identified areas for improvement. FHIR-based solutions may offer promising approaches to encourage greater accessibility and use of HIE data.

A prototype mobile application for triaging dental emergencies

BACKGROUND

Evidence suggests that dental emergencies are likely to occur when preferred care is less accessible. Communication barriers often exist that cause patients to receive suboptimal treatment or experience discomfort for extended lengths of time. Furthermore, limitations in the conventional approach for managing dental emergencies prevent dentists from receiving critical information before patient visits.

METHODS

The authors developed a mobile application to mediate the uncertainty of dental emergencies. The development and study consisted of a needs analysis and quality assessment of intraoral images captured by smartphones, prototype development, refining the prototype through usability inspection methods, and formative evaluation through usability testing with prospective users.

RESULTS

The developed application successfully guided all users through a series of questions designed to capture clinically meaningful data by using familiar smartphone functions. All participants were able to complete a report within 4 minutes, and all clinical information was comprehended by the users.

CONCLUSIONS

Patient-provided information accompanied by high-resolution images may help dentists substantially in predicting urgency or preparing necessary treatment resources. The results illustrate the feasibility of patients using smartphone applications to report dental emergencies. This technology allows dentists to assess care remotely when direct patient contact is less practical.

PRACTICAL IMPLICATIONS

This study's results demonstrate that patients can use mobile applications to transmit clinical data to their dentists and suggest the possibility of expanding the use of mobile applications to enhance access to routine and emergency dental care. The authors addressed how to enable patients to communicate emergency needs directly to a dentist while obviating patient emergency department visits.

Integrating tobacco dependence counseling into electronic dental records: a multi-method approach

Dentistry has historically seen tobacco dependence as a medical problem. As a consequence, dentistry has not adopted or developed effective interventions to deal with tobacco dependence. With the expanded use of electronic dental records, the authors identified an opportunity to incorporate standardized expert support for tobacco dependence counseling during the dental visit. Using qualitative results from observations and focus groups, a decision support system was designed that suggested discussion topics based on the patient's desire to quit and his or her level of nicotine addiction. Because dental providers are always pressed for time, the goal was a three-minute average intervention interval. To fulfill the provider's need for an easy way to track ongoing interventions, script usage was recorded. This process helped the provider track what he or she had said to the patient about tobacco dependence during previous encounters and to vary the messages. While the individual elements of the design process were not new, the combination of them proved to be very effective in designing a usable and accepted intervention. The heavy involvement of stakeholders in all components of the design gave providers and administrators ownership of the final product, which was ultimately adopted for use in all the clinics of a large dental group practice in Minnesota.

Computer-assisted guidance for dental office tobacco-cessation counseling: a randomized controlled trial

BACKGROUND

Decreases in smoking prevalence from recent decades have slowed, and national goals to reduce tobacco use remain unmet. Healthcare providers, including those in physician and dental teams, have access to evidence-based guidelines to help patients quit smoking. Translation of those guidelines into practice, however, remains low. Approaches that involve screening for drug use, brief intervention, and referral to treatment (SBIRT) are a promising, practical solution.

PURPOSE

This study examined whether dentists and dental hygienists would assess interest in quitting, deliver a brief tobacco intervention, and refer to a tobacco quitline more frequently as reported by patients if given computer-assisted guidance in an electronic patient record versus a control group providing usual care.

DESIGN

A blocked, group-randomized trial was conducted from November 2010 to April 2011. Randomization was conducted at the clinic level. Patients nested within clinics represented the lowest-level unit of observation.

SETTING/PARTICIPANTS

Participants were patients in HealthPartners dental clinics.

INTERVENTION

Intervention clinics were given a computer-assisted tool that suggested scripts for patient discussions. Usual care clinics provided care without the tool.

MAIN OUTCOME MEASURES

Primary outcomes were post-appointment patient reports of the provider assessing interest in quitting, delivering a brief intervention, and referring them to a quitline.

RESULTS

Patient telephone surveys (72% response rate) indicated that providers assessed interest in quitting (control 70% vs intervention 87%, p=0.0006); discussed specific strategies for quitting (control 26% vs intervention 47%, p=0.003); and referred the patient to a tobacco quitline (control 17% vs intervention 37%, p=0.007) more frequently with the support of a computer-assisted tool integrated into the electronic health record.

CONCLUSIONS

Clinical decision support embedded in electronic health records can effectively help providers deliver tobacco interventions. These results build on evidence in medical settings supporting this approach to improve provider-delivered tobacco cessation.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.govNCT01584882.

Detection of disease outbreaks by the use of oral manifestations

Oral manifestations of diseases caused by bioterrorist agents could be a potential data source for biosurveillance. This study had the objectives of determining the oral manifestations of diseases caused by bioterrorist agents, measuring the prevalence of these manifestations in emergency department reports, and constructing and evaluating a detection algorithm based on them. We developed a software application to detect oral manifestations in free text and identified positive reports over three years of data. The normal frequency in reports for oral manifestations related to anthrax (including buccal ulcers-sore throat) was 7.46%. The frequency for tularemia was 6.91%. For botulism and smallpox, the frequencies were 0.55% and 0.23%. We simulated outbreaks for these bioterrorism diseases and evaluated the performance of our system. The detection algorithm performed better for smallpox and botulism than for anthrax and tularemia. We found that oral manifestations can be a valuable tool for biosurveillance.

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.

Heuristic evaluation of clinical functions in four practice management systems: a pilot study

BACKGROUND

Dentists report that the complexity and poor usability of practice management systems (PMSs) are factors in the slow adoption of computers at chairside.

METHODS

Three dental informatics researchers performed heuristic evaluations of four PMSs to identify potential usability problems that may be encountered during the clinical care process. Each researcher performed three common clinical documentation tasks on each PMS and examined the clinical user interface of each system using a published list of 10 software heuristics. An observer recorded all findings, summarized the results and totaled the heuristic violations across all programs.

RESULTS

The authors found 229 heuristic violations. Consistency and Standards, Match Between System and the Real World, and Error Prevention were the heuristics that were violated most commonly. The patterns of heuristic violations across software packages were relatively similar.

CONCLUSIONS

The findings provide an initial assessment of potential usability problems in four PMSs. The identified violations highlight aspects of dental software that may present the most significant problems to users.

CLINICAL IMPLICATIONS

Heuristic violations in PMSs may result in usability problems for dentists and other office personnel, reducing efficiency and effectiveness of a software implementation. Vendors should consider applying user-centered design methodologies to reduce the number of potential usability problems.

Clinical computing in general dentistry

OBJECTIVE

Measure the adoption and utilization of, opinions about, and attitudes toward clinical computing among general dentists in the United States.

DESIGN

Telephone survey of a random sample of 256 general dentists in active practice in the United States.

MEASUREMENTS

A 39-item telephone interview measuring practice characteristics and information technology infrastructure; clinical information storage; data entry and access; attitudes toward and opinions about clinical computing (features of practice management systems, barriers, advantages, disadvantages, and potential improvements); clinical Internet use; and attitudes toward the National Health Information Infrastructure.

RESULTS

The authors successfully screened 1,039 of 1,159 randomly sampled U.S. general dentists in active practice (89.6% response rate). Two hundred fifty-six (24.6%) respondents had computers at chairside and thus were eligible for this study. The authors successfully interviewed 102 respondents (39.8%). Clinical information associated with administration and billing, such as appointments and treatment plans, was stored predominantly on the computer; other information, such as the medical history and progress notes, primarily resided on paper. Nineteen respondents, or 1.8% of all general dentists, were completely paperless. Auxiliary personnel, such as dental assistants and hygienists, entered most data. Respondents adopted clinical computing to improve office efficiency and operations, support diagnosis and treatment, and enhance patient communication and perception. Barriers included insufficient operational reliability, program limitations, a steep learning curve, cost, and infection control issues.

CONCLUSION

Clinical computing is being increasingly adopted in general dentistry. However, future research must address usefulness and ease of use, workflow support, infection control, integration, and implementation issues.

Continuing dental education requirements for relicensure in the United States

BACKGROUND

Mandatory continuing education (CE) is an almost universal requirement for relicensure of dentists in the United States. In recent years, computer-based methods have become more widely adopted as a vehicle for earning CE credits. To obtain a comprehensive overview of CE requirements in the United States, the authors conducted a survey on how computer-based CE methods are regulated.

METHODS

The authors reviewed the dental statutes of 50 states and the District of Columbia regarding the license renewal period, required number of CE hours, limitations on clinical and nonclinical subjects, on-site versus independent-study courses, and other requirements regarding CE.

RESULTS

The authors found that 45 states and the District of Columbia mandate CE for relicensure at this time. Most dentists were required to complete approximately 20 hours per year. Ten states specified a minimum number of clinical hours, 17 states limited nonclinical hours, and seven states placed constraints on both clinical and nonclinical CE. Sixty-five percent of states limited the number of CE credits that could be accumulated through independent study. Specific requirements for computer-based methods of earning CE credits were absent in general.

CONCLUSIONS

State licensing boards across the United States have implemented comprehensive requirements for CE. Few, if any, provisions addressed computer-based methods of earning CE credits.

PRACTICE IMPLICATIONS

Given the increasing adoption of computer-based methods of earning CE credits, state dental boards and accrediting agencies may want to consider steps to improve the quality of computer-based methods of earning CE credits.

Comparative case study of two biomedical research collaboratories

Background

Working together efficiently and effectively presents a significant challenge in large-scale, complex, interdisciplinary research projects. Collaboratories are a nascent method to help meet this challenge. However, formal collaboratories in biomedical research centers are the exception rather than the rule.

Objective

The main purpose of this paper is to compare and describe two collaboratories that used off-the-shelf tools and relatively modest resources to support the scientific activity of two biomedical research centers. The two centers were the Great Lakes Regional Center for AIDS Research (HIV/AIDS Center) and the New York University Oral Cancer Research for Adolescent and Adult Health Promotion Center (Oral Cancer Center).

Methods

In each collaboratory, we used semistructured interviews, surveys, and contextual inquiry to assess user needs and define the technology requirements. We evaluated and selected commercial software applications by comparing their feature sets with requirements and then pilot-testing the applications. Local and remote support staff cooperated in the implementation and end user training for the collaborative tools. Collaboratory staff evaluated each implementation by analyzing utilization data, administering user surveys, and functioning as participant observers.

Results

The HIV/AIDS Center primarily required real-time interaction for developing projects and attracting new participants to the center; the Oral Cancer Center, on the other hand, mainly needed tools to support distributed and asynchronous work in small research groups. The HIV/AIDS Center’s collaboratory included a center-wide website that also served as the launch point for collaboratory applications, such as NetMeeting, Timbuktu Conference, PlaceWare Auditorium, and iVisit. The collaboratory of the Oral Cancer Center used Groove and Genesys Web conferencing. The HIV/AIDS Center was successful in attracting new scientists to HIV/AIDS research, and members used the collaboratory for developing and implementing new research studies. The Oral Cancer Center successfully supported highly distributed and asynchronous research, and the collaboratory facilitated real-time interaction for analyzing data and preparing publications.

Conclusions

The two collaboratory implementations demonstrated the feasibility of supporting biomedical research centers using off-the-shelf commercial tools, but they also identified several barriers to successful collaboration. These barriers included computing platform incompatibilities, network infrastructure complexity, variable availability of local versus remote IT support, low computer and collaborative software literacy, and insufficient maturity of available collaborative software. Factors enabling collaboratory use included collaboration incentives through funding mechanism, a collaborative versus competitive relationship of researchers, leadership by example, and tools well matched to tasks and technical progress. Integrating electronic collaborative tools into routine scientific practice can be successful but requires further research on the technical, social, and behavioral factors influencing the adoption and use of collaboratories.

Should dentistry be part of the National Health Information Infrastructure?

BACKGROUND

The National Health Information Infrastructure, or NHII, proposes to improve the effectiveness, efficiency and overall quality of health in the United States by establishing a national, electronic information network for health care. To date, dentistry's integration into this network has not been discussed widely.

METHODS

The author reviews the NHII and its goals and structure through published reports and background literature. The author evaluates the advantages and disadvantages of the NHII regarding their implications for the dental care system.

RESULTS

The NHII proposes to implement computer-based patient records, or CPRs, for most Americans by 2014, connect personal health information with other clinical and public health information, and enable different types of care providers to access CPRs. Advantages of the NHII include transparency of health information across health care providers, potentially increased involvement of patients in their care, better clinical decision making through connecting patient-specific information with the best clinical evidence, increased efficiency, enhanced bioterrorism defense and potential cost savings. Challenges in the implementation of the NHII in dentistry include limited use of CPRs, required investments in information technology, limited availability and adoption of standards, and perceived threats to privacy and confidentiality.

CONCLUSIONS

The implementation of the NHII is making rapid strides. Dentistry should become an active participant in the NHII and work to ensure that the needs of dental patients and the profession are met. Practice Implications. The NHII has far-reaching implications on dental practice by making it easier to access relevant patient information and by helping to improve clinical decision making.

Why integration is key for dental office technology

BACKGROUND

Information technology, or IT, devices and applications for dental practice have multiplied tremendously during the last two decades. While many of these innovations can bring significant benefits to clinical practice, integrating them into a smooth working environment is a significant challenge.

METHODS

The author reviewed the level of integration of different IT-related products for dental practice and analyzed the consequences for work flow and ergonomics. He identified practical examples for different levels of integration among dental technology products.

RESULTS

The integration of hardware devices and software applications in the dental care environment leaves much to be desired. Practitioners are engaged in a constant struggle to keep their "technology parks" working smoothly. Four levels of integration exist: hardware-hardware, hardware-software, software-software and task-oriented information integration. While there are many examples for the successful integration of hardware devices, products tend to be less integrated in other areas. Task-oriented information integration is a vision that, in general, has not been realized.

CONCLUSIONS

Integration is crucial to the efficient and effective functioning of the dental office. However, practitioners cannot do much when industry does not integrate its products sufficiently. The industry, therefore, should adopt user-centered design principles, and its designers should work together to improve the integration of products from different vendors.

Dental informatics: an emerging biomedical informatics discipline

Biomedical informatics is a maturing discipline. During the last forty years, it has developed into a research discipline of significant scale and scope. One of its subdisciplines, dental informatics, is beginning to emerge as its own entity. While there is a growing cadre of trained dental informaticians, dental faculty and administrators in general are not very familiar with dental informatics as an area of scientific inquiry. Many confuse informatics with information technology (IT), are unaware of its scientific methods and principles, and cannot relate dental informatics to biomedical informatics as a whole. This article delineates informatics from information technology and explains the types of scientific questions that dental and other informaticians typically explore. Scientific investigation in informatics centers primarily on model formulation, system development, system implementation, and the study of effects. Informatics draws its scientific methods mainly from information science, computer science, cognitive science, and telecommunications. Dental informatics shares many types of research questions and methods with its parent discipline, biomedical informatics. However, there are indications that certain research questions in dental informatics require novel solutions that have not yet been developed in other informatics fields.

Developing high-quality educational software

The development of effective educational software requires a systematic process executed by a skilled development team. This article describes the core skills required of the development team members for the six phases of successful educational software development. During analysis, the foundation of product development is laid including defining the audience and program goals, determining hardware and software constraints, identifying content resources, and developing management tools. The design phase creates the specifications that describe the user interface, the sequence of events, and the details of the content to be displayed. During development, the pieces of the educational program are assembled. Graphics and other media are created, video and audio scripts written and recorded, the program code created, and support documentation produced. Extensive testing by the development team (alpha testing) and with students (beta testing) is conducted. Carefully planned implementation is most likely to result in a flawless delivery of the educational software and maintenance ensures up-to-date content and software. Due to the importance of the sixth phase, evaluation, we have written a companion article on it that follows this one. The development of a CD-ROM product is described including the development team, a detailed description of the development phases, and the lessons learned from the project.

Evaluation of educational software

Evaluation is an important component of developing educational software. Ideally, such evaluation quantifies and qualifies the effects of a new educational intervention on the learning process and outcomes. Conducting meaningful and rigorous educational evaluation is difficult, however. Challenges include defining and measuring educational outcomes, accounting for media effects, coping with practical problems in designing studies, and asking the right research questions. Practical considerations that make the design of evaluation studies difficult include confounding, potentially small effect sizes, contamination effects, and ethics. Two distinct approaches to evaluation are objectivist and subjectivist. These two complement each other in describing the whole range of effects a new educational program can have. Objectivist demonstration studies should be preceded by measurement studies that assess the reliability and validity of the evaluation instrument(s) used. Many evaluation studies compare the performance of learners who are exposed to either the new program or a more traditional approach. However, this method is problematic because test or exam performance is often a weak indicator of competence and may fail to capture important nuances in outcomes. Subjectivist studies are more qualitative in nature and may provide insights complementary to those gained with objectivist studies. Several published examples are used in this article to illustrate different evaluation methods. Readers are encouraged to contemplate a wide range of evaluation study designs and explore increasingly complex questions when evaluating educational software.

The technologically well-equipped dental office

BACKGROUND

Information technology, or IT, applications for dental practice continue to develop rapidly. More than 85 percent of all dentists use computers in their offices, and the number of clinical uses for the computer is on the rise. This article discusses the state of the art of several technologies, provides an integrative view of a technologically well-equipped office and offers several guidelines for technology purchasing decisions.

CONCLUSIONS

Most administrative applications are relatively mature and are required for the smooth functioning of today's dental offices. Clinical applications--such as dental and medical health histories, charting, digital imaging, diagnostic and treatment applications, and decision support--vary in their degree of maturity. Most Internet applications-such as Internet-based scheduling and e-mail communication with patients--still are an optional adjunct for dental practices.

PRACTICE IMPLICATIONS

Practitioners should develop a comprehensive plan for implementing or updating the IT infrastructure in their offices. Issues to be considered in technology purchasing decisions include usability, integration, work flow support, cost-benefit analysis and compliance with standards.

Dental concepts in the Unified Medical Language System

OBJECTIVE

Currently, no comprehensive, controlled vocabulary for dentistry is available. The objective of this study was to determine how well the Unified Medical Language System, the largest repository of concepts and terms in biomedicine, represents dental concepts.

METHOD AND MATERIALS

The dental subset of concepts was extracted from Unified Medical Language System using the software program APEX (APplication for the EXtraction of domain-specific concepts). The relationships contained in the Unified Medical Language System Metathesaurus were used to locate the concepts related to 12 seed terms. The Encyclopédie Médico-Chirurgicale (513 dental terms) and the Diagnostic Codes developed by Leake et al (124 terms) were compared to the dental subset. Terms were classified as exact match, related term, or no match. The resultant matching characteristics were compared to those determined by the National Library of Medicine/Agency for Health Care Policy and Research Large Scale Vocabulary Test.

RESULTS

The dental subset of Unified Medical Language System contained 948 concepts. The Encyclopédie Médico-Chirurgicale and the Diagnostic Codes exhibited similar matching characteristics for exact match (61.6% and 58.9%, respectively) and related term (38.0% and 32.2%, respectively). For no match, the matching frequencies were significantly different (P < .001).

CONCLUSION

The Unified Medical Language System may be a comprehensive source of terms suitable for various representation requirements in dentistry.