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© 2003 SAGE Publications Using Information Technology and Community-based Research to Improve the Dental Health-care SystemPresented at "Dental Informatics & Dental Research: Making the Connection", a conference held in, Bethesda, MD, USA, June 12–13, 2003, sponsored by the University of Pittsburgh Center for Dental Informatics and supported in part by award 1R13DE014611-01 from the National Institute of Dental and Craniofacial Research/National Library of Medicine.
UCLA School of Dentistry, Box 951668, Los Angeles, CA 90095-1668; kathya{at}dent.ucla.edu
It is commonly acknowledged that the United States’ health-care system produces some of the finest care in the world for some people but fails to meet the needs of others. The Institute of Medicine (IOM) issued six aims for a redesigned health-care system, that it be: safe, effective, patient-centered, timely, efficient, and equitable. The purpose of this paper is to use an ongoing community-based study to illustrate current problems in the provision of oral health services that could be addressed through information technology. Appropriate use of information technology can assist dental schools and clinics in community-based clinical outcomes research needed to assemble the evidence base for improving oral health care. This conference serves as an important steppingstone to establish a means for information technology to improve the community’s oral health.
Key Words: Health-care quality • public health dentistry • dental health surveys • health-care evaluation mechanisms
It is commonly acknowledged that the United States’ health-care system produces some of the finest patient care in the world—for some people. Much speculation has arisen regarding the reasons that the health-care system fails to meet the needs of all Americans. The Institute of Medicine (IOM) completed a review of the health-care system and, in the second of its reports, details problems and a roadmap for change. Among the problems found were that the system is poorly organized; medical records are incomplete; there is an unacceptable number of medical errors; the system is fragmented and unfriendly to many patients; and it lacks control over ensuring that care is completed, and is unable to improve or maintain a community’s health with the limited health-care dollars spent (Committee on Quality Health Care in America, IOM, 2001). The IOM defined quality as "the degree to which health-care services for individuals and populations increases the likelihood of desired outcomes and are consistent with professional knowledge" (Committee on Quality Health Care in America, IOM, 2001). This simple statement issues a three-fold mandate to health-care providers. Health-care professionals should offer evidence-based services that will improve health for patients. Conversely, health-care professionals should not offer services that are destined to make patients worse. And finally, health-care professionals should not waste resources by offering services that are not effective or are inefficient. Numerous underlying reasons for inadequate quality of care were noted in the IOM report: a growing complexity of science and technology, an increase in chronic conditions among patients as the population ages, and finally, the topic of this paper, constraints on our use of information technology. The report concluded with a message entreating health-care leaders to redesign the systems of care, "including the use of information technology to support clinical and administrative processes" (Committee on Quality Health Care in America, IOM, 2001). Although this discussion took place about the medical care system at large, it is clear that the issues noted—a growing emphasis on the need for better information to manage chronic diseases, a statement that chronic disease management be ongoing, collaborative, and multidisciplinary, and that communication between and among providers is imperative for high-quality care—are arguably also true for dental care. Six aims for a redesigned 21st century health-care system were proffered, that a health-care system be: safe, effective, patient-centered, timely, efficient, and equitable (Committee on Quality Health Care in America, IOM, 2001). Woven into their recommendations to achieve these goals are specific suggestions on increased use of information technology. The purpose of this paper is to use an ongoing community-based clinical research study to illustrate current problems in the provision of oral health services that could be addressed through information technology for the ultimate improvement of community health.
The research setting is the King-Drew Medical Center (KDMC) in South Central Los Angeles, where a clinical research study is under way to improve our understanding of patient preferences for surgical or non-surgical treatment for a mandibular fracture. While in many cases, a fracture can be treated either surgically or non-surgically, costs can differ by a factor of 10, depending on the treatment selected; patients can experience a wide range of post-treatment complications, depending in part on the treatment modality; and a range of providers is used during the treatment phase. Thus, this case study is ideal for illustrating examples of problems associated with the six goals of the health-care system’s redesign: safe, effective, patient-centered, timely, efficient, and equitable oral health care. Information for this first phase of a two-part study was collected through multiple focus groups in which former patients of King Drew Medical Center who either had third molars extracted under general anesthesia or a mandibular fracture treated described their problem, the type of treatment, and the care sequence process. Briefly, all participants signed a consent document to participate in the focus groups and a second consent to allow for video- and audiotaping of the focus group discussion. We recruited people 18 years of age or older who were African-American or Latino and had recently received treatment at King Drew Medical Center. Interviews were conducted by the dentists, assisted by a bilingual project manager. Focus groups were organized by subject characteristics (gender, race/ethnicity and treatment type [third molar removal or fracture], and ethnic status). Comparisons of thematic differences by gender, treatment type, and race/ethnicity were made during the analysis. Using an open-ended interview style, we asked people about the type of informed consent risk and benefit information presented by the doctor, post-operative instructions and any information remembered, and types of post-operative difficulties and their severity. Additional information about the study has been published previously (Atchison et al., 2003; Black et al., 2003). In total, 34 men and women, African-American and Hispanic individuals, participated in a focus group and shared their health-care experiences.
A safe health-care system avoids injury to patients from care that is intended to help them. A primary component of safety includes the availability of the patient’s medical history and treatment information to all treating providers. For example, within busy hospitals with multiple clinics and numerous providers, knowledge about patient history must be open and accessible to all providers who must review and integrate that information into the treatment process. One African-American woman at KDMC noted that she was allergic to codeine and during the process of getting her pain medication had to repeatedly remind providers of her allergy because repeated prescriptions were made for codeine. While bright stickers, formerly used on the outside of physical charts, offered critical information about the patient’s health status, they also offered many opportunities for mistakes and are now discouraged due to the Health Insurance Portability and Accountability Act. Technology, in the form of a flashing alert in an electronic patient record, can draw the provider’s attention to information that a patient has a medication allergy. Further, according to the IOM, safety is improved when the patient’s chart is readable by all providers, from emergency room to operating room and to the outpatient clinic. Again, drawing on the same example, a common electronic chart, with flashing alert, would notify all providers of the patient’s allergy and prevent a medication error. Similarly, the prescribing doctor can contact the pharmacy electronically to alert them of the patient’s need for a non-formulary drug or liquid version of antibiotics and pain medication. Better yet are the computerized systems that can help providers prevent medication errors. Medication errors are estimated to have resulted in over 7000 deaths annually (Van Cott, 1994). Several studies have tested the impact of computerized prescribing and pharmaceutical decision-support software in reducing adverse events for hospitalized patients (Tierney et al., 1993; Bates et al., 1998; Magnus et al., 2002; Ahearn and Kerr, 2003). Results indicate that simple technology, including a computerized prescribing or decision support system, such as computerized drug interaction alert systems, can reduce errors with legibility (transcription), drug-drug interaction checking, drug-laboratory checking, and allergy checking. Prescription safety also requires that standards of quality be consistent across all days and times of days. KDMC patients told of treatment delays because of problems finding operating room (OR) time to treat the fracture. Using information technology, one could electronically record and prioritize incoming patients and their treatment needs to achieve a better scheduling of OR time so that patients with fractures are not waiting for two days. A safe health-care system also necessitates that patients and caregivers be informed about the condition and possible treatment and associated risks and benefits. Information technology could be used to prepare engaging, informative education programs in multiple languages to inform patients about the risks and benefits associated with treatment needed. An effective health-care system provides services based on scientific knowledge to all who could benefit and refrains from providing services to those not likely to benefit (Committee on Quality Health Care in America, IOM, 2001). The IOM notes the importance of appropriate communication and anticipating patient needs, via appropriate recall systems. One fracture patient in the KDMC study missed the obligatory one-month recall visit for removal of the interarch wires and discussed how he still had arch wires on some seven months later. A computer-driven recall system could be used within an electronic record to remind clinicians repeatedly that patients have failed appointments and are in need of a follow-up message. Electronic prompts and reminder systems have been tested in improving care in diabetes (Nuckolls, 2003) and epilepsy (Thapar et al., 2002). The essence of patient-centered care is to provide care that is respectful of and responsive to the individual patient’s preferences, needs, and values (Committee on Quality Health Care in America, IOM, 2001). Stewart et al.(2000) showed that integrating patient-centered clinical care improved outcomes, such as improved health status and reduced diagnostic tests, on headache management. According to the IOM, "Care must be based on a ‘continuous healing relationship’ where the patient can receive care when he needs it and in many forms, including electronic health education, communications with the health-care provider, and laboratory results." Telephone case management, one form of technology for delivering care, was shown to be equally successful in providing education and case management and patient satisfaction to women with upper respiratory infection (Barry et al., 2001). Patient-centered care also requires coordination and integration of treatment, appropriate information, education, and communication among providers and between providers and the patient, physical and emotional support, and culturally competent care. While some KDMC focus group participants mentioned satisfaction with culturally appropriate discussions with clinicians of the same ethnic group, others described situations where health education had not occurred, including absences in post-operative instructions on diet, cleaning of arch wires, and contacting of providers after hours. A common electronic record would facilitate communication between providers. Further, some patients might even choose to be contacted by clinicians via e-mail or telephone, facilitating real-time service to the patient. Mold and co-workers (1998) reported that between 80% and 90% of people seeing physicians in the Oklahoma Physicians Research/Resource Network currently have e-mail or plan to get it within six months and want to communicate with their physician via e-mail. Timely care reduces waits and potentially harmful delays, for both those who receive and those who give care. Examples abound of aspects of care where technology could improve the timeliness of treatment. Inclusion of priority guidelines within scheduling of OR or clinic time could improve the patient flow to those most in need of an immediate appointment. Several former patients mentioned that they were discharged before their consultation with a dietician at KDMC. E-mailing of lab results or consults, compared with sending information via ‘snail-mail’, could cut days from time spent waiting for information. Tracking of laboratory prosthesis cases so that patients are immediately informed when cases are ready could increase the speed with which patients are fitted with their prostheses. Efficient patient care avoids the waste of equipment, supplies, space, people, ideas, and energy. Efficient treatment is provided when the most economical treatment—in terms of time, money, and providers—is rendered that meets the needs of the patient and clinician. Treatment cost for a mandibular fracture at KDMC can exceed $20,000 if treated surgically, including provider and 3–7 days of hospitalization. Non-surgical treatment, conversely, is provided in an outpatient clinic with no associated hospital days, bringing totals closer to $2,000. Information technology can be used to provide clinical guidelines suggesting which patients might be effectively treated non-surgically. A computerized reminder system was tested to increase a provider’s use of ordering preventive services, such as pneumococcal and influenza vaccination (Dexter et al., 2001). Integrated electronic systems can also be used to ensure efficient inventory management, confirmation of patient appointments to decrease the number of failed appointments, and improved communication between caregivers or between patients and caregivers. Providing care that does not vary in quality because of the patient’s personal characteristics—such as gender, ethnicity, geographic location, and socio-economic status—is an example of equitable treatment. Telemedicine/teledentistry has also been experimented with to improve access to care for patients in rural or difficult-to-reach locations, thus improving timely care (Chang et al., 2003; Robinson et al., 2003). Additionally, information technology is essential for collecting and storing the types of data needed to perform ongoing clinical outcomes and epidemiological research. Differential rates of surgery vs. non-surgical treatment, or variations in complication rates for people with different patient characteristics would provide the profession with valuable information on whether or not oral surgery is equitable.
Dental schools and clinics must engage in community-based clinical outcomes research to assemble the data needed to improve the evidence base for oral health care. Through a combination of quality assurance, development of case reports, program evaluation, outcomes research, and epidemiological research, a stronger evidence base will be obtained. Various forms of technology are being developed that can facilitate the collection and merging of data necessary for continuous quality improvement. Many are not yet in use in dental practice, or are only in their infancy. Although the IOM recommendations for a revised health-care system do not specifically mention oral health, they are equally appropriate to serve as guides for improving the oral health-care system. Additionally, these recommendations are timely ones as the profession moves to integrate information technology more fully. The use of integrated technology for scheduling, communications, efficient managing of operations, and electronic patient records is in order to achieve a system where care is based on a "continuous healing relationship". The ultimate system should assist the health-care provider to anticipate the patient’s future needs. It should facilitate improved use of evidence in clinical decision-making. A properly established electronic patient record provides an efficient means of accumulating data on an ongoing basis for programmatic review that will ensure high-quality dental care. This conference will serve as an important steppingstone on which to build guides that apply to dentistry that establish a means for information technology to improve the community’s oral health.
The study used for examples was supported by the National Institute of Dental and Craniofacial Research, study #1RO1DE13839.
Publication supported by Software of Excellence (Auckland, NZ)
Advances in Dental Research, Vol. 17, No. 1,
86-88 (2003)
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Abstract
Introduction