Standardized dental diagnostic terminology

Kalenderian, Elsbeth; Ramoni, Rachel; Walji, Muhammad F.

doi:10.33582/2639-9210/1002

Cited by 9 publications

(11 citation statements)

References 12 publications

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“…1–4 However, these admirable goals for patient records may be thwarted by significant issues: a lack of universally accepted documentation standards, incomplete or inaccurate record-keeping practices, unfriendly EHR user interfaces, and a lack of easy and consistent access to patient records. Research consistently shows that these problems are pervasive, ongoing and occur in many patient care fields.…”

Section: Introductionmentioning

confidence: 99%

Clinical documentation of dental care in an era of electronic health record use

Tokede

Ramoni

Patton

et al. 2016

Journal of Evidence Based Dental Practice

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Background Although complete and accurate clinical records do not guarantee the provision of excellent dental care, they do provide an opportunity to evaluate the quality of care provided. However, a lack of universally accepted documentation standards, incomplete record-keeping practices, and unfriendly EHR user interfaces are factors that have allowed for persistent poor dental patient record keeping. Methods Using two different methods – a validated survey, and a two round Delphi process – involving two appropriately different sets of participants, we explored what a dental clinical record should contain, and the frequency of update of each clinical entry. Results For both the closed-ended survey questions and the open-ended Delphi process questions, respondents had a significant degree of agreement on the ‘clinical entry’ components of an adequate clinical record. There was however variance on how frequently each of those clinical entries should be updated. Summary Dental providers agree that complete and accurate record keeping is essential and that items such as histories, examination findings, diagnosis, radiographs, treatment plans, consents, and clinic notes should be documented. There, however, does not seem to be universal agreement how frequently such items should be recorded. Clinical Implications As the dental profession moves towards prevalent use of EHRs, the issue of standardization and interoperability becomes ever more pressing. Settling issues of standardization, including record documentation must begin with guideline-creating dental professional bodies who need to clearly define and disseminate what these standards should be, and; everyday dentists who will ultimately ensure that these standards are met and kept.

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Section: Introductionmentioning

confidence: 99%

Clinical documentation of dental care in an era of electronic health record use

Tokede

Ramoni

Patton

et al. 2016

Journal of Evidence Based Dental Practice

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“…In response to this need, our research group has established the DDS Dental Diagnostic System (formerly called EZCodes), which has been designed for use within EHRs in the dental setting. 19-22 The DDS is freely available and is currently installed at 16 academic institutions and several large dental group practices in the United States, Caribbean and Latin America, and Europe. The DDS has been designed to serve as a clinician-friendly interface to rich reference terminologies like, SNOMED, into which SNODENT 23 has been integrated.…”

Section: Discussionmentioning

confidence: 99%

Measuring up

Bhardwaj¹,

Ramoni²,

Kalenderian³

et al. 2016

The Journal of the American Dental Association

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Background Quality improvement requires quality measures that are validly implementable. In this work, we assessed the feasibility and performance of an automated electronic Meaningful Use dental clinical quality measure (percentage of children who received fluoride varnish). Methods We defined how to implement the automated measure queries in a dental electronic health record (EHR). Within records identified through automated query, we manually reviewed a subsample to assess the performance of the query. Results The automated query found 71.0% of patients to have had fluoride varnish compared to 77.6% found using the manual chart review. The automated quality measure performance was 90.5% sensitivity, 90.8% specificity, 96.9% positive predictive value, and 75.2% negative predictive value. Conclusions Our findings support the feasibility of automated dental quality measure queries in the context of sufficient structured data. Information noted only in the free text rather than in structured data would require natural language processing approaches to effectively query. Practical Implications To participate in self-directed quality improvement, dental clinicians must embrace the accountability era. Commitment to quality will require enhanced documentation in order to support near-term automated calculation of quality measures.

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“…This opened the door for the development of standardized quality improvement initiatives within dental practices (13). Coupled with recent efforts of development (14)(15)(16) and implementation (17)(18)(19)(20) of standardized dental diagnostic terminologies, it is now possible to evaluate longitudinal patient data collected for quality metrics research. MU Stage 2 includes several clinical quality care measures targeting tobacco cessation (21).…”

Section: Introductionmentioning

confidence: 99%

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

Neumann

Kumar

Bangar

et al. 2018

J Public Health Dent

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Objectives The purpose of this study was to adapt, test, and evaluate the implementation of a primary care “Preventive care and Screening” meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling. Methods We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts. Results Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice. Conclusions We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence‐based cessation strategies to improve oral health and general health outcomes.

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Standardized dental diagnostic terminology

Cited by 9 publications

References 12 publications

Clinical documentation of dental care in an era of electronic health record use

Clinical documentation of dental care in an era of electronic health record use

Measuring up

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

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