Systematically assessing the quality of dental electronic health record data for an investigation into oral health care disparities.

OBJECTIVES: This work describes the process by which the quality of electronic health care data for a public health study was determined. The objectives were to adapt, develop, and implement data quality assessments (DQAs) based on the National Institutes of Health Pragmatic Trials Collaboratory (NIHPTC) data quality framework within the three domains of completeness, accuracy, and consistency, for an investigation into oral health care disparities of a preventive care program. METHODS: Electronic health record data for eligible children in a dental accountable care organization of 30 offices, in Oregon, were extracted iteratively from January 1, 2014, through March 31, 2022. Baseline eligibility criteria included: children ages 0-18 with a baseline examination, Oregon home address, and either Medicaid or commercial dental benefits at least once between 2014 and 2108. Using the NIHPTC framework as a guide, DQAs were conducted throughout data element identification, extraction, staging, profiling, review, and documentation. RESULTS: The data set included 91,487 subjects, 11 data tables comprising 75 data variables (columns), with a total of 6,861,525 data elements. Data completeness was 97.2%, the accuracy of EHR data elements in extracts was 100%, and consistency between offices was strong; 29 of 30 offices within 2 standard deviations of the mean (s = 94%). CONCLUSIONS: The NIHPTC framework proved to be a useful approach, to identify, document, and characterize the dataset. The concepts of completeness, accuracy, and consistency were adapted by the multidisciplinary research team and the overall quality of the data are demonstrated to be of high quality.

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.

Dental Students' Clinical Experience Across Three Successive Curricula at One U.S. Dental School.

As dental schools continue to seek the most effective ways to provide clinical education for students, it is important to track the effects innovations have on students' clinical experience to allow for quantitative comparisons of various curricula. The aim of this study was to compare the impact of three successive clinical curricula on students' experience at one U.S. dental school. The three were a discipline-based curriculum (DBC), a comprehensive care curriculum (CCC), and a procedural requirement curriculum plus externships (PRCE). Students' clinic experience data from 1992 to 2013 were analyzed for total experience and in five discipline areas. Clinic experience metrics analyzed were patient visits (PVs), relative value units (RVUs), and equivalent amounts (EQAs). A minimum experience threshold (MET) and a high experience threshold (HET) were set at one standard deviation above and below the mean for the DBC years. Students below the MET were designated as low achievers; students above the HET were designated as high achievers. The results showed significant differences among the three curricula in almost all areas of comparison: total PVs, total EQAs, total RVUs, RVUs by discipline, and number of high and low achievers in total clinical experience and by discipline. The comprehensive care approach to clinical education did not negatively impact students' clinical experience and in many cases enhanced it. The addition of externships also enhanced student total clinical experience although more study is needed to determine their effectiveness. The insights provided by this study suggest that the methodology used including the metrics of PVs, EQAs, and RVUs may be helpful for other dental schools in assessing students' clinical experience.

Six common misconceptions about the standard of care in dentistry.

As a legal concept, standard of care refers to the set of practices that are accepted as appropriate based on the body of common case law decisions. This is contrasted with a concept of ethical standard of care, which is defined as the conscientious application of up-to-date knowledge, competent skill, and reasoned judgment in the best interest of the patient, honoring the autonomy of the patient. The article probes six areas where the understanding of standard of care is ambiguous.

Different labs.

In this case a young dentist has signed onto a managed care plan that has several attractive features. Eventually, however, he notices that he makes little or no net revenue for some of the work that he does. A colleague recommends that he use different labs for different patients, with labs matched to each patient's dental plan and coverage. Offshore labs are used for managed care patients. Three knowledgeable experts comment on the case, two with many years of private practice experience, two who are dental educators holding master's degrees in philosophy and bioethics.

Writing off the copayment.

Three dentists who have been involved in teaching ethics comment on a case where an associate discovers that the 40% of collections she was expecting as compensation is being reduced because of the practice in the office of routinely writing off patient copays. The commentators note legal requirements and professional codes, but generally seek alternatives that do not require that patients pay the amount agreed by insurance contracts.

Caries risk assessment in practice for age 6 through adult.

The aim of this article is to present a practical caries risk assessment procedure and form for patients who are age 6 through adult. The content of the form and the procedures have been validated by outcomes research after several years of experience using the factors and indicators that are included.

Clinical protocols for caries management by risk assessment.

This article seeks to provide a practical, everyday clinical guide for managing dental caries based upon risk group assessment. It is based upon the best evidence at this time and can be used in planning effective caries management for any patient. In addition to a comprehensive restorative treatment plan, each patient should have a comprehensive caries management treatment plan. Some sample treatment plans are included.

Products--old, new, and emerging.

The paradigm shift in understanding the etiology, prevention, and treatment of dental caries requires an understanding of the dental products that are currently available to assist the clinician in prudent recommendations for patient interventions. The purpose of this review is to present the evidence base for current products and those that have recently appeared on the market.

Why our ethics curricula do work.

The purpose of this article is to respond to Dr. Charles Bertolami's article "Why Our Ethics Curricula Don't Work" in the April 2004 issue of the Journal of Dental Education. This article analyzes the arguments put forth by Bertolami and challenges his assumptions and conclusions. Several examples are given of the ways in which our current ethics curricula do, in fact, work.

Restoration and enhancement: is cosmetic dentistry ethical?

The ethical ground for restoration (returning a patient to healthy form and function) differs from enhancement (using medical means to improve appearance). Physicians and dentists who argue that enhancements improve self-esteem must reconcile this claim with the fact that they are not licensed to practice psychology. The extreme views are that doctors either should provide cosmetic services as requested by patients or they should not. The middle position is that doctors must retain their fiduciary position of trust based on professional judgment and advocating for patients' health interests. Patient health always outweighs patients' cosmetic desires.

My way or the highway: do dental patients really have autonomy?

Ethical dilemmas arise when it is not possible to simultaneously optimize conflicting values, each of which independently is worthy. This paper analyzes three cases where patients' autonomy is in conflict with dentists' professional judgments about their own practice patterns and what is in the best interests of patients' oral health. The hierarchy of values proposed by Ozar and Sokol is a valuable aid in addressing such dilemmas, but the dentist must still engage in a detailed analysis of the situation.

Is it ethical to involve patients in state board examinations?

It is argued that the state becomes an ethical agent when it requires that candidates for licensure perform dentistry on patients. As an ethical agent, the state is required to give full information, obtain true voluntary cooperation of patients, not expose patients to increased risk, and provide oversight while unlicensed dentists are practicing and follow-up care where untoward outcomes occur. The possibility of unsuccessful outcomes is known in advance, and there is no evidence showing that known exposure of individual patients to risk is compensated by decreased risk to patients generally.