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

BMC Oral Health

Aram Kim¹  Joel M. White²  Elizabeth Mertz²  Alfa Yansane²  Elsbeth Kalenderian³  Krishna Kumar Kookal⁴  Suhasini Bangar⁴  Ana Neumann⁴  Shwetha V. Kumar⁴  Todd R. Johnson⁴  Gregory W. Olson⁴  Muhammad F. Walji⁴  Emily Sedlock⁴  Joanna Mullins⁵  Ryan Brandon⁵  Kristen Simmons⁵ 

[1] Harvard School of Dental Medicine, Boston, MA, USA;San Francisco – School of Dentistry, University of California, San Francisco, CA, USA;San Francisco – School of Dentistry, University of California, San Francisco, CA, USA;Harvard School of Dental Medicine, Boston, MA, USA;School of Dentistry, University of Pretoria, Pretoria, South Africa;School of Dentistry, University of Texas Health Science Center At Houston, 7500 Cambridge, SOD 4184, 77054, Houston, TX, USA;Willamette Dental Group, Portland, OR, USA;

关键词: Quality;    Dental quality measures (DQMs);    Value;    EHR;    Periodontal disease;    Periodontal risk assessment;   

DOI  :  10.1186/s12903-021-01633-w

来源: Springer

【 摘 要 】

BackgroundOur 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.ResultsThe 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%).ConclusionOur 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.

【 授权许可】

CC BY