Assessing the completeness of periodontal disease documentation in the EHR: a first step in measuring the quality of care

Abstract

Background Our objective was to measure the proportion of patients for which comprehensive periodontal charting, periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to assess how well four dental institutions documented periodontal disease-related information. An automated database script was developed and implemented in the EHR at each institution. The measure was validated by comparing the findings from the measure with a manual review of charts. Results The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution 2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value < 0.0001). The largest gaps in documentation were related to periodontal diagnoses and capturing oral homecare compliance. A random sample of 1224 charts were manually reviewed and showed excellent validity when compared with the data generated from the EHR-based measure (Sensitivity, Specificity, PPV, and NPV > 80%). Conclusion Our results demonstrate the feasibility of developing automated data extraction scripts using structured data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness within and across different dental institutions.

Gingivitis diagnoses using 2017 classification versus pre-2017 criteria: a retrospective study using electronic dental record data

“…Similarly, our study illustrates strength of using EDR data to study the effect of new case de nitions that may be di cult to pursue through prospective studies [29]. Despite the promising potential of using EDR data for research, is important to quality of the before its intended since the EDR data not collected for research, but for patient care [30,31]. In this study, determined the accuracy of the clinician-recorded diagnoses by comparing with This study required processing approximately 12 million observations at the rate of at least 600 periodontal charting observations per patient using computational approaches.…”

Comparing the effectiveness of competition as a method of reminding primary oral health care dentists to record diagnoses with two alternative methods used to enhance the recording of diagnoses in primary health care

“…Fortunately, the situation is changing. Nevertheless, the diagnoses may still be poorly recorded by dentists [ 22 , 23 ]. Thus, actions should be taken to prompt dentists to enhance the recording of dental diagnoses.…”

“…Maintaining appropriate patient documentation files, including recording diagnoses, is an essential component of medical practice, as well as of oral health settings. However, the recording of diagnoses in visits to primary health care clinicians may still be at an unsatisfactory level in primary health care [ 22 , 23 , 25 ]. The need of specific methods to ensure the recording of diagnoses may, of course, be indicative of a weakness in education and supervision.…”

Developing Automated Computer Algorithms to Phenotype Periodontal Disease Diagnoses in Electronic Dental Records

“…Only few dental studies have evaluated the quality of EDR data. 5 6 8 12 20 21 22 23 For example, Patel et al compared the self-reported cardiovascular disease (CVD) information with dental patients' medical records. They found low to no agreement and concluded that self-reported CVD information in the EDR may not be reliable research sources compared with electronic medical records.…”

“…Mullins et al have assessed the completeness of PD documentation in the EHR and found the feasibility of developing automated data extraction script using only structured data. 23 Despite this effort, as per our best knowledge, no study has attempted to improve the completeness of PD diagnoses by utilizing different sections of the EHR such as periodontal charting, clinical notes, and diagnoses reported by the clinicians.…”