Research opportunities at the interface of dental and medical informatics

Titus Schleyer, DMD, PhD

(with help from Mei Song, PhD) University of Washington School of Dentistry - Department of Oral Medicine & School of Medicine Biomedical and Health Informatics

August 2, 2011
MacDonald Lake, Glacier Park Titus Schleyer 2001

Center for Dental Informatics University of Pittsburgh School of Dental Medicine

Todays talk
is intended to be more of a discussion than a talk. is not just about medical and dental informatics. may create some (healthy) tension . hopefully will make you rethink some prior beliefs.
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Topics
how informatics (and healthcare) are organized the One patient how health records are organized suggestions for integrative research
standards information presentation and usability decision support for distributed care

discussion and outlook

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How informatics (and healthcare) are organized

Basic Research

Medical Informatics Methods, Techniques, and Theories

Applied Research

Bioinformatics

Imaging Informatics

Clinical Informatics

Public Health Informatics

Molecular and Cellular Processes

Center for Dental Informatics University of Pittsburgh School of Dental Medicine

Tissues and Organs

Individuals (Patients)

Populations and Society

Shortliffe EH, Johnson SB. Medical informatics training and research at Columbia University. IMIA Yearbook 2002;173-180.

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Basic Research
Basic Research

Basic Research Basic Research

Medical Informatics Methods, Techniques, and Methods, Dental InformaticsTheories Techniques, and Theories Nursing Informatics Methods, Techniques, and Methods, Other Informatics Theories Techniques, and Theories

Applied Research Applied Research Applied Research Applied Research

Bioinformatics Bioinformatics
Molecular and Bioinformatics Cellular Molecular and Processes Bioinformatics Cellular Molecular and Processes Cellular Molecular and Processes Cellular Processes

Imaging Informatics Imaging Informatics Imaging Tissues and Informatics Organs Imaging Tissues and Informatics
Organs Tissues and Organs Tissues and Organs

Clinical Informatics Clinical Informatics Clinical Individuals Informatics (Patients) Clinical Individuals Informatics (Patients)
Individuals (Patients) Individuals (Patients)

Public Health Informatics Public Health Informatics Public Health Populations Informatics and Society Public Health Populations Informatics and Society
Populations and Society Populations and Society

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The One patient

healthy dentition

early childhood caries (ECC)

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Early childhood caries: The actors

O: ON: GD: P: PN: PD: PDN: Obstetrician Obstetric Nurse General Dentist Pediatrician Pediatric Nurse Pediatric Dentist Pediatric Dental Hygienist
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Recommended early dental interventions

Childs Age Prenatal/Perinatal HC professional(s) Clinical maternal dental hygiene limit salivary contact mothers oral health (e.g. pregnancyassociated gingivitis) mother: nutrition, oral hygiene childs sugar intake schedule dental exam at 6 months age mother: optimal fluoride levels caries-risk assessment disabilities and caries risk window of infectivity: 7 months to 36 months eruption of deciduous teeth caries/oral hygiene assessment mother: nutrition, oral hygiene early childhood caries particularly prevalent 12 to 18 months possible restorative interventions child may start on fluoride toothpaste oral hygiene instruction for child pediatric care vital if no dental care O, ON, GD

Neonatal

ON

6 months

P, PN, PD, PDH

7 months

P, PN, PD, PDH

1 year

P and/or PD

18 months

PD

2 years

P, PN, PD, PDH

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Some other examples of intersecting interests

diabetes, cardiovascular disease and periodontal disease prenatal care, periodontal disease and low birth weight post-radiation and bisphosphonate-caused osteonecrosis oral cancer screening, tobacco and alcohol oral hygiene and respiratory infections kidney disease and periodontal disease and many more
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A timely book

http://www.springer.com/public+health/book/978-1-4471-2184-8
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How health records are organized

Margate, New Jersey T. Schleyer 1999

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Electronic records: Medicine

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Electronic records: Dentistry

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One integrated model: Veterans Administration

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Advantages
eliminate dual entry of clinical information into separate medical and dental systems integrate dental progress note creation with CPRS transactional recording of data in a computable format bidirectional information exchange allowing for improved clinical decision support
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Suggestions for integrative research

Natchez Trace, Mississippi T. Schleyer 2001

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Standards

Grand Tetons, Wyoming T. Schleyer 2001

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Order from chaos the Dental Information Model (DIM)

Acharya A, Mital DP, Schleyer TK. Electronic dental records information model. International Journal of Medical Engineering and Informatics 2009;1(4):418-34.

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Order from chaos - an information model for general dentistry

extract data from ~100 de-identified patient records combine with results from previous studies validate information item list (~1,100 fields) through Delphi study construct information model

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What can you do with an information model?

Database User interface

Data interchange Forms

Information model Research

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National Health Information Infrastructure/ Health Information Exchange

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The DIM on the Web

http://www.dentalinformatics.org/projectdirectory/dim/

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Research suggestions
determine cross-discipline information needs map corresponding records and fields homogenize needed vocabularies/ ontologies implement and assess, build out from there
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Information presentation and usability

Logan Pass, Glacier National Park T. Schleyer 2001

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Usability of four dental computerbased patient records

Research questions:
Which usability problems are common in dental software? What is the rate of completed, incorrectly completed and incomplete user tasks?

Thyvalikakath T et al. Usability of four practice management systems, JADA

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Results

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User adverse events

70 60 50 40 30 20 10 0
ES PW DX SD

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Record a missing tooth correct path

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User paths

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Usability of dental computer-based patient records

Significant usability problems due to:
complex information design mismatch between system and user model difficulty in finding functionality

Participants had to exert cognitive effort that did not contribute to task completion.

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Research suggestions
elucidate common cognitive and decision making needs across clinical disciplines develop cross-discipline, modular user interface (UI) designs develop paradigms for information abstraction refine UI evaluation methodologies
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Sample project 1: Cognitive task analysis of dental examination

What cognitive processes do dentists engage in and what information do they use when they examine a patient and develop a treatment plan? Methods
think-aloud method with 3 standardized patient cases 5 dental faculty and 5 general dentists analyze the sessions to determine:
information that dentists requested sequence in which they reviewed information instances of concurrent review of information items

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Results
Average of patient data accessed in 10 high complexity cases
35 Average number of times each patient data accessed 30

25

20

15

10

0 0% Start of 10% 20% 100% Average session time in percentage (normalized) for a case of high complexityEnd of session
Social History Medical Consult Radiographs Oral Pathology Consult Medical History Dental History Hard Tissue Chart Treatment Plan Notes

30%

40%

50%

60%

70%

80%

90%

Patient Demographics Medications Intra-oral Images Periodontal Exam

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Results (cont.)
Average of patient data accessed in 10 low complexity cases
20 Average number of times each patient data accessed 18 16 14 12 10 8 6 4 2 0 0% Start 10% 20% 100% End of Average session time in percentage (normalized) for a case of low complexity sessio
Medical History Radiographs Treatment Plan Notes Dental History Hard Tissue Chart Extra-oral Images Periodontal Exam

30%

40%

50%

60%

70%

80%

90%

Patient Demographics Intra-oral Images Financial Informaton

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Visualization of information artifacts used over time

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Sample project 2: Cross-platform, modular UI design

Microsoft Common User Interface (MSCUI www.mscui.net) sample problem: pt. identifiers

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MSCUI: Designing for safety

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Sample design: Patient banner

(includes 26-page Design Guidance document)

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Decision support for distributed care

Yellowstone National Park, Wyoming T. Schleyer 2001

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We know that decision support works

Garg et al., 2005:
improved practitioner performance: 64% of studies improved patient outcomes: 13% of studies

Jaspers et al., 2011:

improved practitioner performance: 57% of studies improved patient outcomes: 30% of studies Evidence
Garg A. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes. JAMA Vol. 293, No. 10, p 1223-38 Jaspers M. et al. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. JAMIA 2011 18: 327-334

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Research suggestions
elucidate optimal interprofessional work and decision flow develop appropriate inferencing mechanisms that:
are provider role and patient-specific; adapt to short, intermediate and long-term outcomes; and are built on evolving best practices.

implement DSSs within a distributed systems context (databases, communication, user interface)
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Discussion: How do we meet these challenges?

By getting you involved!

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The Dental Informatics Online Community

established in 2007 > 1,000 members from 30 countries self-declared interest in DI emphasizes access to discipline resources:
member directory tutorials and white papers publication archive project directory

www.dentalinformatics.org
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http://ericwhitacre.com/the-virtual-choir
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1. What was the major insight/new knowledge you gained from this talk? 2. What kind of concrete idea(s), if any, did this talk spark?
Please take a minute to write down your thoughts. Hand in your card.

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Thank You for Your Attention!

Questions, comments?
Thanks to:

P. Hernandez

Please visit us at: http://di.dental.pitt.edu Twitter Facebook /titusschleyer Scribd

H. Spallek T. Thyvalikakath H. Torres-Urquidy J. Irwin

A. Acharya

and many others.

CDI 2008 Center for Dental Informatics University of Pittsburgh School of Dental Medicine

M. Song

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