The role of electronic records in the integration of oral health and primary care services in community health centers

BACKGROUND: Medical-Dental integration involves the provision of fluoride varnish application, caries risk assessment, anticipatory guidance, and provision of dental referrals by pediatricians during well-child visits. Integration has been recommended as a means to increase access to quality dental care for patients from racial and ethnic minority groups who are at an increased risk of developing oral health problems. METHODS: Guided by the RE-AIM framework (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance), this case study explored the barriers and facilitators for the incorporation of a medical-dental integration program at two community health centers in Massachusetts. Specifically, this study explored the degree to which electronic records were instrumental in the provision and documentation of oral health preventive services during pediatric primary care at the study sites. Data sources included analysis of records from 2014–2015 (before integration) to those from 2016-2018 (post integration), interviews with staff, clinicians, and administrators and direct observations of the workflow at dental and pediatric medicine departments in the study sites. A General Estimating Equation Analysis was conducted to estimate the odds of application of oral health preventive measures before and after electronic dental and medical electronic records were integrated at one of the sites. FINDINGS: During the years post-record integration, children were 40.3 times more likely to receive dental screenings, 2.7 times more likely to receive fluoride varnish during well child visits and 1.6 times more likely to receive fluoride in the dental department within six months of their well child visits compared to the period prior to integration. Respondents identified the complexity, ease of use and accessibility of tools within the electronic medical records as significant factors in success of integration efforts. CONCLUSIONS: Community health centers interested in successfully implementing a medical-dental integration model should invest in sufficient workflow and training resources for the transition to the new records system, develop a simplified protocol for the application of dental preventive services, design accessible electronic tools for documentation of services, and establish accurate reporting systems for both internal program monitoring and external surveillance purposes

Innovations that Address Socioeconomic, Cultural, and Geographic Barriers to Preventive Oral Health Care

This report focuses on nine oral health innovations that integrate service delivery and workforce models in order to reduce or eliminate socioeconomic, geographic, and cultural barriers to care. Two additional reports in this series describe the remaining programs that provide care in non-dental settings and care to young children. Although the programs are diverse in their approaches as well as in the specific characteristics of the communities they serve, a common factor among them is the implementation of multiple strategies to increase the number of children from low-income families who access preventive care, and also to engage families and communities in investing in and prioritizing oral health. For low-income children and their families, the barriers that must be addressed to increase access to preventive oral health care are numerous. For example, even children covered by public insurance programs face a shortage of dentists that accept Medicaid and who specialize in pediatric dentistry.(Guay, 2004).The effects of poverty intersect with other barriers such as living in remote geographic areas and community-wide history of poor access to dental care in populations such as recent immigrants . Overcoming these barriers requires creative strategies that address transportation barriers; establish welcoming environments for oral health care; and are linguistically and culturally relevant. Each of these nine programs is based on such strategies, including:-Expanding the dental workforce through training new types of providers or adding new providers to their workforce to increase reach and community presence;-Implementing new strategies to increase the cost-effectiveness of care so that more oral health care services are available and accessible;-Providing training and technical assistance that increase opportunities for and competence in delivering oral health education and care to children;-Developing creative service delivery models that address transportation and cultural barriers as well as the fear and stigma associated with dental care that may arise in communities with historically poor access.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies for overcoming barriers to access that have potential for rigorous evaluation that could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

Strategic Shift to a Diagnostic Model of Care in a Multi-Site Group Dental Practice.

BackgroundDocumenting standardized dental diagnostic terms represents an emerging change for how dentistry is practiced. We focused on a mid-sized dental group practice as it shifted to a policy of documenting patients' diagnoses using standardized terms in the electronic health record.MethodsKotter's change framework was translated into interview questions posed to the senior leadership in a mid-size dental group practice. In addition, quantitative content analyses were conducted on the written policies and forms before and after the implementation of standardized diagnosis documentation to assess the extent to which the forms and policies reflected the shift. Three reviewers analyzed the data individually and reached consensuses where needed.ResultsKotter's guiding change framework explained the steps taken to 97 percent utilization rate of the Electronic Health Record and Dental Diagnostic Code. Of the 96 documents included in the forms and policy analysis, 31 documents were officially updated but only two added a diagnostic element.ConclusionChange strategies established in the business literature hold utility for dental practices seeking diagnosis-centered care.Practical implicationsA practice that shifts to a diagnosis-driven care philosophy would be best served by ensuring that the change process follows a leadership framework that is calibrated to the organization's culture

States' Roles in Shaping High Performance Health Systems

Analyzes results from the State Health Policies Aimed at Promoting Excellent Systems survey and a review of current research on efforts to improve state healthcare systems, with a focus on coverage; quality, safety, and value; and infrastructure

Advancing cognitive engineering methods to support user interface design for electronic health records

Background Despite many decades of research on the effective development of clinical systems in medicine, the adoption of health information technology to improve patient care continues to be slow, especially in ambulatory settings. This applies to dentistry as well, a primary care discipline with approximately 137,000 practitioners in the United States. A critical reason for slow adoption is the poor usability of clinical systems, which makes it difficult for providers to navigate through the information and obtain an integrated view of patient data. Objective In this study, we documented the cognitive processes and information management strategies used by dentists during a typical patient examination. The results will inform the design of a novel electronic dental record interface. Methods We conducted a cognitive task analysis (CTA) study to observe ten general dentists (five general dentists and five general dental faculty members, each with more than two years of clinical experience) examining three simulated patient cases using a think-aloud protocol. Results Dentists first reviewed the patient’s demographics, chief complaint, medical history and dental history to determine the general status of the patient. Subsequently, they proceeded to examine the patient’s intraoral status using radiographs, intraoral images, hard tissue and periodontal tissue information. The results also identified dentists’ patterns of navigation through patient’s information and additional information needs during a typical clinician-patient encounter. Conclusion This study reinforced the significance of applying cognitive engineering methods to inform the design of a clinical system. Second, applying CTA to a scenario closely simulating an actual patient encounter helped with capturing participants’ knowledge states and decision-making when diagnosing and treating a patient. The resultant knowledge of dentists’ patterns of information retrieval and review will significantly contribute to designing flexible and task-appropriate information presentation in electronic dental records

Use of Internet for General and Dental Health along Acculturation Features in a Sample of Mexican Americans

The objectives of this study were to explore self-reported Internet and electronic platforms used to search for and store medical and dental information among people of Mexican origin. A sample of adults self-identified as European American (250) and as Mexican American (255), residing in Central Indiana, answered a one-time survey that included technology use questions and measured acculturation via the Psychological-Behavioral Acculturation Scale. Overall use of information technologies was estimated through an Information and Communication Technology score. Overall, participants with higher scores searched online for general and oral health information at higher rates than those with lower scores. Younger Mexican Americans and those with higher use scores were more likely to search online for general health information, as were those more psychologically and behaviorally acculturated. Interestingly, Mexican Americans were more likely than European Americans to search online for dental health information. All participants demonstrated high interest in accessing and storing their own health information especially on paper format; storage in other places, such as personal computers, smartphones, or USB flash drives, was less endorsed. Most participants would allow spouses access to their health records; however, there were significant differences between both population groups regarding access given to physicians, dentists and other family members, with Mexican Americans reporting more restrictions. Our findings provide initial information on differential use pattern of electronic health resources among Mexican Americans and suggest that new information technologies reach population groups traditionally underserved; such features may help address disparities in general and dental health

NEOREG : design and implementation of an online neonatal registration system to access, follow and analyse data of newborns with congenital cytomegalovirus infection

Today's registration of newborns with congenital cytomegalovirus (cCMV) infection is still performed on paper-based forms in Flanders, Belgium. This process has a large administrative impact. It is imortant that all screening tests are registered to have a complete idea of the impact of cCMV. Although these registrations are usable in computerised data analysis, these data are not available in a format to perform electronic processing. An online Neonatal Registry (NEOREG) System was designed and developed to access, follow and analyse the data of newborns remotely. It allows patients' diagnostic registration and treatment follow-up through a web interface and uses document forms in Portable Document Format (PDF), which incorporate all the elements from the existing forms. Forms are automatically processed to structured EHRs. Modules are included to perform statistical analysis. The design was driven by extendibility, security and usability requirements. The website load time, throughput and execution time of data analysis were evaluated in detail. The NEOREG system is able to replace the existing paper-based CMV records

Why Not the Best? Results From the National Scorecard on U.S. Health System Performance, 2011

Assesses the U.S. healthcare system's average performance in 2007-09 as measured by forty-two indicators of health outcomes, quality, access, efficiency, and equity compared with the 2006 and 2008 scorecards and with domestic and international benchmarks

The Public and the Health Care Delivery System

Analyzes survey results on Americans' views on the adoption of electronic medical records (EMR) and its effects on the quality of care, effectiveness, costs, and patient privacy; the efficiency of the system; the impact of rising costs; and other issues