Dental EHR-infused Persona Ontologies to Enrich Dental Dialogue Interaction of Agents.

The quality of patient-provider communication can predict the healthcare outcomes in patients, and therefore, training dental providers to handle the communication effort with patients is crucial. In our previous work, we developed an ontology model that can standardize and represent patient-provider communication, which can later be integrated in conversational agents as tools for dental communication training. In this study, we embark on enriching our previous model with an ontology of patient personas to portray and express types of dental patient archetypes. The Ontology of Patient Personas that we developed was rooted in terminologies from an OBO Foundry ontology and dental electronic health record data elements. We discuss how this ontology aims to enhance the aforementioned dialogue ontology and future direction in executing our model in software agents to train dental students.

Assessing the benefit of a personalized EHR-generated informed consent in a dental school setting.

Informed consents are routinely used as an important source of information to help patients make appropriate clinical decisions. However, current standard consent forms may not accomplish their intended purpose due to the variety of patient literacy and experiences and, in the dental school setting, the developing competence of students. The purpose of this pilot study was to test the efficacy of a personalized informed consent generated through an electronic health record (EHR) at one dental school and its role in patient decision making. In the study, a set of informed consents, or SmartConsents, were developed for specific diagnoses and procedures, enhanced with graphics, and delivered through the school's EHR. Fifty patients were recruited in the school's Urgent Care Clinic and divided evenly into two groups: one (control) receiving the standard consent, with the second receiving a SmartConsent. Following treatment, patients were assessed based on demographics, decisional conflict, satisfaction, health literacy, and knowledge. Overall, there were no significant differences in main effects between SmartConsent and standard informed consents for decisional conflict and satisfaction, although significant differences were identified during secondary analysis of satisfaction, gender, and ethnicity. The study also demonstrated the potential for consents to aid the student provider in better communicating with patients.

Use of virtual patients in dental education: a survey of U.S. and Canadian dental schools.

The use of virtual patients in dental education is gaining acceptance as an adjunctive method to live patient interactions for training dental students. The objective of this study was to determine the extent to which virtual patients are being utilized in dental education by conducting a survey that was sent to sixty-seven dental schools in the United States and Canada. A total of thirty dental schools responded to the web-based survey. Sixty-three percent of the responding dental schools use virtual patients for preclinical or clinical exercises. Of this group, 31.3 percent have used virtual patients in their curricula for more than ten years, and approximately one-third of those who do use virtual patients expose their students to more than ten virtual patient experiences over the entirety of their programs. Of the schools that responded, 90.5 percent rated the use of virtual patients in dental education as important or very important. An additional question addressed the utilization of interactive elements for the virtual patient. Use of virtual patients can provide an excellent method for learning and honing patient interviewing skills, medical history taking, recordkeeping, and patient treatment planning. Through the use of virtual patient interactive audio/video elements, the student can experience interaction with his or her virtual patients during a more realistic simulation encounter.

Ethics and the electronic health record in dental school clinics.

Electronic health records (EHRs) are a major development in the practice of dentistry, and dental schools and dental curricula have benefitted from this technology. Patient data entry, storage, retrieval, transmission, and archiving have been streamlined, and the potential for teledentistry and improvement in epidemiological research is beginning to be realized. However, maintaining patient health information in an electronic form has also changed the environment in dental education, setting up potential ethical dilemmas for students and faculty members. The purpose of this article is to explore some of the ethical issues related to EHRs, the advantages and concerns related to the use of computers in the dental operatory, the impact of the EHR on the doctor-patient relationship, the introduction of web-based EHRs, the link between technology and ethics, and potential solutions for the management of ethical concerns related to EHRs in dental schools.

Assessing the delivery of comprehensive care at a dental school.

A key mission of a dental school is to train students to be competent dentists through the delivery of comprehensive care to patients. Comprehensive care is defined as a seamless and integrated dental treatment that addresses all patients' dental needs. Identification of a health care problem is the essential first step in quality improvement to medical education curriculum and its outcomes. It is critical for students to receive adequate clinical experience and for patients to receive needed treatment. This study assessed the degree to which comprehensive care was delivered from the patient and student perspective, and to determine why patients discontinue their course of treatment. We conducted a retrospective analysis of electronic health record (EHR) data in one group practice at the University of Texas School of Dentistry at Houston. Semistructured interviews of patients, students and faculty were also conducted. The results showed that 29% of assessed and admitted patients received comprehensive care. A large proportion of dropouts occurred after the third or fourth visit. It took on average 9.8 visits and 210 days for patients to complete their planned treatments. Dental students had a patient family of 25-29 patients, delivered 75% of their care in their fourth year, and predominantly provided restorative treatments compared with other dental disciplines. Interview transcripts were analyzed to determine strengths, weaknesses, and opportunities relating to the provision of comprehensive care. Patients perceived that they received cost effective and high quality care. Students and faculty provided suggestions for streamlining care. Findings from both the retrospective analysis of EHR data and semi-structured interviews revealed several areas for improvement. One solution that was subsequently piloted was to combine the separate assessment and treatment planning appointments into a single all-day session to reduce patient dropouts. During the pilot period over the summer session, 84 patients were scheduled in the combined assessment and treatment planning session. Of this population, 69% percent were accepted and deemed suitable for undergraduate care. And 83% among those accepted received a treatment plan on the first appointment. In the future we expect to integrate more formal evidence-based exercises and reassess the impact of these changes in improving educational and clinical care outcomes. In addition we expect to adopt evidence-based solutions and reassess the impact of these changes in improving educational and clinical care outcomes.

Assessing the content, presentation, and readability of dental informed consents.

Informed consents are important aids in helping patients make optimal decisions. Little knowledge exists about the quality of dental informed consents. Fifty-two informed consents used throughout the University of Texas Health Science Center at Houston Dental Branch were evaluated based on the quality of their content, readability, and presentation. Content quality was judged on four basic elements: description of procedure, risk, benefits, and alternatives. Of the clinical consents, 26 percent of forms contained all four of the basic content elements, 48 percent contained three of four elements, 16 percent contained two of four elements, and 10 percent contained one of four elements. Presentation quality was judged on twelve criteria items. The average clinical consent included seven out of twelve presentation items, and the average nonclinical consent included eight out of twelve items. Readability was judged using three standard instruments for rating readability: Flesch Reading Ease, Flesch-Kincaid Grade-Level, and Simple Measure of Gobbledygook (SMOG) grading. Average Flesch-Kincaid Grade-Level was 12.7 (range, 7.4 to 19.1), significantly higher than the recommended ninth grade level (p<.001). The results suggest that many existing dental informed consents may be improved by 1) increasing the comprehensiveness of the content, 2) improving the design and layout, and 3) reducing the readability levels for patient comprehension.

Innovation in dental education in Texas: The University of Texas Dental Branch at Houston.

Innovation has been an integral part of The University of Texas Dental Branch at Houston and its approach to educating dentists since the school's origin in 1905. Its history is rich with examples, such as a modular, self-directed curriculum and a general practice-based patient care delivery system. Moving into the 21st century, the school has embraced new models for patient care and research upon which to build innovative programs for teaching and learning. Combined with a technological explosion across the world and in education, UTDB has been a leader on many fronts, such as electronic patient records, clinical simulation and research in informatics. As the school looks ahead to a new building by 2012, additional advances and innovations are planned to follow. This article takes a look at the past, present, and future contributions by UTDB to innovation in dental education.

Factors influencing implementation and outcomes of a dental electronic patient record system.

Implementation of clinical information systems is often difficult and costly. Little is known about how to implement electronic patient records in a complex dental school environment. The purpose of this study is to report how such a system was implemented at the University of Texas Health Science Center at Houston Dental Branch and to provide insights that may be useful for other institutions. To identify success factors and barriers, we reviewed project documents, interviewed key individuals on the implementation team, and surveyed end users before and after implementation. Eight critical issues were identified after extensive interviews with the project team. Surveys of students, faculty, and staff before and after implementation indicated that users had mixed feelings about the system in terms of efficiency and time required compared with paper charts. After using the system, many users felt that the electronic patient record improved patient care and that they would recommend such a system to dentists starting a new practice. By sharing lessons learned and knowledge about the science of implementation, we hope to reduce failures and costs for dental schools embarking on large-scale information technology implementations.

SmartConsent: a computerized informed consent for dental patients.

Communicating personalized information to patients about the risks, benefits and other critical information about dental disease and treatment is often difficult for providers. In this research we developed a novel informed consent prototype that can accurately translate and communicate information to patients in a standardized and effective manner based on their diagnosis and prescribed treatment. In future work, we aim to integrate SmartConsent into the institutional electronic patient record (EPR) and determine its effectiveness in a randomized controlled study.

Use of electronic forms within an electronic patient record to create an institutional clinical data repository.

The transition to an electronic patient record (EPR) and a paperless, filmless patient care environment provided new opportunities for clinical data collection, storage and retrieval. Electronic patient care forms were developed using accepted information science principles, such as controlled vocabularies, and agreed upon levels of term specificity. Electronic forms in concert with information science principles enabled The University of Texas Dental Branch at Houston (UTDB) to streamline patient care and to create a robust, well-organized and functional institutional repository of clinical data.

A persuasive toothbrush to enhance oral hygiene adherence.

In this research we propose that a real-time wireless monitoring and reminder system can assist patients in maintaining optimal oral health. We provide a conceptual framework that incorporates both the behavioral and technical aspects of the proposed system. Further we present preliminary results of a feasibility experiment of modifying an inexpensive electric toothbrush by attaching an accelerometer and determining the ability to track motion and time by wirelessly transmitting data via Bluetooth technology.

Economic outcomes of a dental electronic patient record.

The implementation of an electronic patient record (EPR) in many sectors of health care has been suggested to have positive relationships with both quality of care and improved pedagogy, although evaluation of actual results has been somewhat disillusioning. Evidence-based dentistry clearly suggests the need for tools and systems to improve care, and an EPR is a critical tool that has been widely proposed in recent years. In dental schools, EPR systems are increasingly being adopted, despite obstacles such as high costs, time constraints necessary for process workflow change, and overall project complexity. The increasing movement towards cost-effectiveness analyses in health and medicine suggests that the EPR should generally cover expenses, or produce total benefits greater than its combined costs, to ensure that resources are being utilized efficiently. To test the underlying economics of an EPR, we utilized a pre-post research design with a probability-based economic simulation model to analyze changes in performance and costs in one dental school. Our findings suggest that the economics are positive, but only when student fees are treated as an incremental revenue source. In addition, other performance indicators appeared to have significant changes, although most were not comprehensively measured pre-implementation, making it difficult to truly understand the performance differential-such pre-measurement of expected benefits is a key lesson learned. This article also provides recommendations for dental clinics and universities that are about to embark on this endeavor.

Combination of aspirin and clopidogrel for the prevention of thrombosis: implications for the dental practitioner.

The use of aspirin and clopidogrel as effective antiplatelet therapy in preventing secondary thromboembolic events is well-established. However, there is controversy among dentists and physicians regarding the appropriate dental management of patients receiving dual antiplatelet therapy due to the lack of clinical studies about hemorrhagic risk in these patients. Indications for modifying dual antiplatelet therapy--whether it is done by altering doses, switching to monotherapy, or discontinuing it completely--occur infrequently, as most patients can be treated in a dental office setting. In all cases, patients must be managed jointly by the dentist and physician, taking into account the patient's medical and dental history. This article reviews the current use of aspirin and clopidogrel as combination therapy, examining their effect on platelet function, the associated hemorrhagic risk during dental procedures for patients using this therapy, and how oral health care providers can manage these patients safely and effectively.

Assessing user perceptions of an electronic patient record (EPR) before implementation.

As part of a comprehensive strategy to implement an electronic patient record (EPR), faculty, residents, students and support staff, were surveyed to assess their attitudes and awareness towards an EPR before implementation. Results of the survey suggested a high degree of awareness and optimistic outlook by many users about the potential of the EPR to improve efficiency and patient care.

Documentation of clinical workflow: a key step in a plan to facilitate implementation of an Electronic Patient Record.

After a year of preparation, the UT Dental Branch implemented an Electronic Patient Record (EPR) and a Picture Archiving and Communication System (PACS) for digital imaging. Central to the preparatory process was documentation of existing clinic workflow as a set of detailed flowcharts, which eased cultural and logistical changes and had the immediate benefit of increasing system efficiencies.

Integrating electronic patient records into a multi-media clinic-based simulation center using a PC blade platform: a foundation for a new pedagogy in dentistry.

Simulation has been used for many years in dental education, but the educational context is typically a laboratory divorced from the clinical setting, which impairs the transfer of learning. Here we report on a true simulation clinic with multimedia communication from a central teaching station. Each of the 43 fully-functioning student operatories includes a thin-client networked computer with access to an Electronic Patient Record (EPR).

A human-centered design of a dental discharge summary (DDS) for patients.

Patients are often provided with sub-optimal information regarding their clinic visits. Patients sometimes forget post-discharge instructions provided verbally, and infrequently follow preventative advice to improve health. In this research we propose to develop and evaluate a dental discharge summary (DDS) for patients through a human-centered design process. Our long term goals are to automatically generate a personalized discharge summary after each clinic encounter to educate and motivate patients to maintain excellent oral health.

Creating a searchable digital dental radiograph repository for patient care, teaching and research using an online photo management and sharing application.

With the advent of digital dental radiographs, dentistry is amassing an unprecedented volume of images as electronic patient records (EPR) and dental PACS (picture archive and communication system) become more commonplace. While radiographic findings and diagnostic information are visually discerned from images, this information is not digitally associated with the images. This project will explore the formation of an online, searchable data repository of dental radiographs and associated meta information.

Scope of practice comparison: a tool for curriculum decision making.

The proportion of claims filed for specific dental procedures (ADA codes # 05110, 05120, 03320, 03330, 04260, 02150) between January 1, 2000 and June 30, 2004 by Texas general practitioners participating in a preferred provider network was compared to the proportion of these procedures performed by students graduating from the three Texas dental schools during the same period. Analysis of the data revealed that Texas dental students provide class two amalgam restorations in permanent teeth (02150) at approximately the same frequency as Texas general practitioners. Both groups provide periodontal osseous surgery (04260) at an extremely low frequency (<0.02% of total procedures). Bicuspid endodontic procedures (03320) were performed at a slightly higher frequency by students (0.43% of all procedures) than by general practitioners (0.36% of all procedures), and molar endodontic procedures (03330) were performed at a slightly higher frequency by general practitioners (0.65%) than by students (0.36%). Significant discrepancies between the groups were noted for the two complete denture procedures (05110, 05120). Students provided these procedures at frequencies fifteen times (05110) and twenty-five times (05120) greater than general practitioners. Dental schools should use data provided by scope of practice analyses to help determine an appropriate breadth and depth for their educational programs.

A model for clinical credentialing of dental school faculty.

Committed to the premise that the same standards of review for clinical practice may be applied to clinical teaching, The University of Texas Health Science Center Dental Branch at Houston began credentialing clinical faculty in 1997 as part of its quality assurance and risk management program, one of the first dental schools in the country to do so. Credentialing, modeled after health care institutions such as hospitals, is general and procedure-specific involving the review of qualifications such as licensure, training, education, experience, and performance of professional practitioners; measuring those qualifications against pre-established criteria; and granting of "clinical privileges" to clinical faculty to perform or supervise procedures for which they are deemed qualified, based on that review. The development process included the leadership of the Quality Assurance and Risk Management Committee who met with all interested parties, explained the rationale and justification for credentialing, and successfully gained the support of the clinical department chairs, clinical faculty, faculty senate, and the administration of the school in implementing the credentials process. Evaluation of this process indicates that it has been useful in providing a mechanism to address a variety of patient care and clinical education issues such as faculty competency, compliance, and accommodations through a peer review process.