eHealth Records to Improve Dental Care for Patients with Chronic Illnesses (Minnesota)

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eHealth Records to Improve Dental Care for Patients with Chronic Illnesses - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Technology (IT) (R18)
  • Grant Number: 
    R18 HS 017270
  • Project Period: 
    September 2007 - September 2011
  • AHRQ Funding Amount: 
    $996,737
  • PDF Version: 
    (PDF, 211.85 KB)

Summary: An electronic dental record (EDR) integrated with an electronic medical record (EMR) and personal health record (PHR) provides a unique opportunity to improve the dental care of patients with chronic conditions by alerting them to special care requirements and alerting dentists at the point-of-care. Furthermore, the integration of an EMR, PHR, and EDR into an integrated electronic health record (EHR) system improves health information exchange, communication, and cost effectiveness of care, particularly for patients with chronic illnesses. This project involved a randomized clinical trial to evaluate the effectiveness of simple reminders in an integrated EHR to improve the quality and safety of dental care for patients with chronic illnesses.

This project involved a randomized clinical trial to evaluate the effectiveness of simple reminders in an integrated EHR to improve the quality and safety of dental care for patients with chronic illnesses. The study involved 102 dentists from 15 dental clinics within HealthPartners, a large integrated health system in Minnesota that consists of a dental group, a medical group, a hospital system, a health plan, and a dental plan. The patients in the study population had special dental care needs as a result of four chronic conditions: diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disease, and xerostomia (dry mouth) caused by medications or related conditions. The interventions were designed to address how and to whom special dental care needs are communicated. The impact of two clinical decision support (CDS) approaches was compared with a usual-care control group. Dental providers were randomly assigned to one of the intervention groups or the control group. The interventions were: 1) a reminder to the patient delivered by a PHR e-mail or, if e-mail was not available, over the phone by the dental clinic staff or by postal mail; or 2) a point-of-care reminder to the dentist through the EDR.

This study demonstrated that utilization of clinical guidelines for medically compromised patients can be improved with CDS using electronic dental records with provider and patient activation strategies. The clinical implication is that, as our population ages, dentists must adapt care for medically compromised patients to maintain their safety and quality of services.

Specific Aims:

  • Determine the effectiveness of integrated EMR-based interventions toward changing dentist and patient behavior. (Achieved)
  • Determine the impact of an integrated EMR-based intervention upon the use of emergency and or restorative dental care. (Achieved)
  • Produce and distribute a generalizable, replicable model of evidence-based care recommendations for implementing an integrated health information technology system for diabetes and other chronic illness management within dental care practices throughout the United States. (Achieved)

2011 Activities: The focus of activity was on completing data analysis and writing up the study findings and a final report. The third manuscript to result from this project, Electronic Health Records Improve the Use of Clinical Care Guidelines for Medically Complex Patients, was published as the cover story in the October 2011 issue of the Journal of the American Dental Association. Two additional manuscripts, "eHealth Records Improve Quality of Care for Medically Complex Patients" and "The Impact of eHealth Records on Adverse Events in Medically Complex Patients," were submitted to journals for consideration. Two grant applications were also submitted to the Agency for Healthcare Quality as an extension of this grant.

Due to challenges with data collection, particularly in accessing data from the EDR earlier in the project, a 12-month no-cost extension was necessary to complete the project, which ended in September 2011. As last self-reported in the AHRQ Research Reporting System, project progress was on track and project budget spending was on target.

Impact and Findings: Participants in both the provider and patient activation groups increased use of the system during the first 6 months to access the guidelines for all patients. They also improved the accuracy of documenting medical history and use of preventive care as recommended in the guidelines. The intervention did not have an impact on patient complications (which were relatively low) between groups. Provider activation was more effective in promoting access to the guidelines than was patient activation. However, providers did not sustain their high level of use of the system.

In general, the principal findings of the study include:

  1. The development and implementation of evidence-based guidelines improved safety and quality of dental care in patients with medical conditions.
  2. Reminder alerts to both dentists and patients increased utilization of care guidelines by 440 percent and 221 percent, respectively, from baseline, while the control group had no increase.
  3. Both provider and patient alerts had a generalizable, sustainable effect of increasing the providers reference care guidelines for all patients compared with usual care.
  4. Automated provider alerts in the EDR were more effective at encouraging the use of care guidelines than personalized alerts sent to patients.
  5. The CDS triggered a response by about 79 percent of all dental providers, leaving only 21 percent nonresponsive to the system.
  6. There was a clear trend toward increasing the frequency of correcting errors in medical history reconciliation by dental providers as triggered by the CDS.
  7. The CDS increased the use of preventive dental encounters from pre- to post-intervention periods per patient, as suggested by the guidelines.
  8. The CDS did not reduce the number of dental or medical complications per patient per year.

This study demonstrates that CDS that alerts providers through EDRs or alerts patients through PHRs can improve dental providers' review of clinical care guidelines for patients with medically complex conditions, improve medication reconciliation, and improve preventive care. However, dental providers' use of the CDS system declined after the first 6 months despite the continued use of alerts. This suggests that dentists and hygienists either did not feel the need to continue reviewing the clinical care guidelines or the alerts became less effective. Future research is needed to determine which additional CDS components will increase the percentage of dental providers who use it and to improve transferability and scalability of a system to more dental providers while maintaining high acceptability.

Target Population: Adults, Chronic Care*, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Other Conditions: Xerostomia

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Use: Implementation and Use

* This target population is one of AHRQ's priority populations.

eHealth Records to Improve Dental Care for Patients with Chronic Illnesses - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017270
  • Project Period: 
    September 2007 – September 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $996,737
  • PDF Version: 
    (PDF, 376.59 KB)


Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Xerostomia

Summary: This project is a group-randomized clinical trial with dentists on the use of simple reminders in an integrated electronic health record. The primary goal is to evaluate the effectiveness of an integrated electronic health record system that includes an electronic medical record (EMR), electronic dental record (EDR), and a personal health record (PHR) at improving the quality and safety of dental care for patients with chronic illnesses. The EMR used in this project is EPIC Hyperspace Spring 2007, developed by Epic Systems Corporation and certified by the Commission for Health Information Technology (CCHIT). The EDR, developed by General Systems Design Group, Inc., is not CCHIT certified, as a certification process for EDRs does not exist. The tethered PHR is EPIC MyChart? and is used in combination with HealthPartners’ Web-based patient portal.

The study compares two interventions against a usual care control. The interventions are designed to address how and to whom special dental care needs are communicated. The interventions are: 1) a reminder to the patient delivered primarily via a PHR e-mail or, if e-mail is not available, over the phone by the dental clinic staff and/or postal mail (Group A); or 2) a point-of-care reminder to the dentist through the EDR (Group B). The patients in the sample population have special dental care needs as a result of four chronic conditions: diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disease, and xerostomia (dry mouth) caused by medications or related conditions.

An EDR integrated with an EMR and PHR provides a unique opportunity to improve the dental care of patients with chronic conditions by alerting patients to their special care requirements and alerting dentists at the point of care. Furthermore, the integration of an EMR, PHR, and EDR into an integrated electronic health record system improves health information exchange, communication, and cost effectiveness of care, particularly for patients with chronic illnesses. This project demonstrates how leveraging an integrated electronic health record system can improve patient outcomes, increase awareness, and improve clinical decisionmaking by identifying problems that need remediation and providing immediate evidence-based recommendations.

Specific Aims:
  • Determine the effectiveness of integrated EMR-based interventions toward changing dentist and patient behavior. (Achieved)
  • Determine the impact of an integrated EMR-based intervention upon the use of emergency and/or restorative dental care. (Achieved)
  • Produce and distribute a generalizable, replicable model of evidence-based care recommendations for implementing an integrated health information technology system for diabetes and other chronic illness management within dental care practices throughout the United States. (Achieved)

2010 Activities: The primary focus of activity was on recruitment, data collection, and data analysis. In addition, a set of recommendations was developed on necessary action steps for dentists to meet the needs of patients. The outcome data on whether or not the guidelines were accessed was extracted and the impact of the intervention was analyzed. Outcomes were evaluated during the three phases of the study: a static period; the first 1 to 6 months of the activation period; and months 7 to 12 months of the activation period.

The primary study outcomes are:

  1. Total Use: The overall frequency with which providers accessed the Web-based clinical guidelines.
  2. Targeted Use: The proportion of instances in which access to the Web-based clinical guidelines was done for targeted patients (i.e., those identified as having one of the four conditions of interest).
  3. Ongoing Use: The proportion of providers who accessed the Web-based clinical guidelines for all patients.

Preliminary findings were presented at several national meetings including the Agency for Healthcare Research and Quality Annual Health IT Grantee and Contractor Meeting in June. The findings are also being summarized for publication submission.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project has entered a no-cost extension period during which the findings will be reported and submitted for publication.

Preliminary Impact and Findings: The 18-month study period of the clinical decision support (CDS) alerts and personalized recommendations included 10,890 out of a total of 59,147 patients with one of the four chronic conditions, vastly surpassing an expected sample size of 2,600. The rate at which the providers accessed the clinical guidelines in response to the CDS alert was evaluated for 101 dental providers. The total use of care guidelines was found to have increased among both providers and patients. There was also a generalizable effect of increased use of guidelines by dentists for all patients (p

This project demonstrated that utilization of clinical guidelines for medically compromised patients can be improved with clinical decision support using e-dental records with provider and patient activation strategies. The clinical implication is that, as our population ages, dentists must be vigilant in adapting care for medically compromised patients to maintain safety and quality.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

Patients with chronic medical conditions have significant dental care implications including the increased risk of dental conditions such as periodontal disease and cavities, but also the risk of medical complications arising during or after dental treatment. Despite involvement with patients with chronic conditions, dentists lack robust training on these conditions. The result is a less than ideal ability to identify medical issues during dental care and to modify treatment accordingly.

The use of eDental Records (EDRs) is increasing, and presents an opportunity to utilize technology to improve the quality and safety of care by dentists. This project conducted a randomized clinical trial to evaluate the impact of two clinical decision support (CDS) interventions designed to improve the quality and safety of dental care in patients with medically complex conditions, with particular focus on diabetes mellitus, xerostomia, chronic obstructive pulmonary disease, and congestive heart failure.

The main objectives of this project were to:

  • Determine the effectiveness of integrated electronic medical record (EMR)-based interventions toward changing dentist and patient behavior.
  • Determine the impact of an integrated EMR-based intervention upon the use of emergency and/or restorative dental care.
  • Produce and distribute a generalizable, replicable model of evidence-based care recommendations for implementing an integrated health information technology system for diabetes and other chronic illness management within dental care practices throughout the United States.

Two CDS interventions were implemented, one into the EDR targeted to providers, the other into the patient’s personal health record (PHR) targeted to the patient. Fifteen dental practices, representing 102 dental care providers, were randomly assigned to one of the intervention arms or to the control group. The CDS was designed to promote the use of clinical care guidelines for complex medical conditions. Both interventions provided alerts about a patient’s chronic condition and provided links to personalized, condition specific, evidence-based guidelines. For patients without a PHR, notification came via email or the mail. Providers were given information about the implication of the condition during the dental visit and patients were encouraged to discuss their condition with their provider.

Data collected over a 2 year period showed that providers and patients increased their access to the guidelines by 440 percent and 221 percent respectively during the first 6 months. The accuracy of providers documenting medical history and the preventive care recommended in the guidelines increased. No impact on complications was found, although complications were relatively low. However, it is important to note that dental providers’ use of the CDS system declined after the first 6 months despite the continued use of alerts. Despite the decline, the project findings supported the use of CDS for dental patients to enhance decisionmaking and to improve the quality and safety of care for patients with medical conditions.

eHealth Records to Improve Dental Care for Patients with Chronic Illness - Final Report

Citation:
Fricton J. eHealth Records to Improve Dental Care for Patients with Chronic Illness - Final Report. (Prepared by HealthPartners Research Foundation under Grant No. R18 HS017270). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 734.27 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 

Dental Recommendations for Preventing Complications in Patients with Chronic Conditions

PDF: Dental Recommendations for Preventing Complications in Patients with Chronic Conditions (PDF, 115.17 KB)
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.