Background

Quality improvement requires using quality measures that can be implemented in a valid manner. Using guidelines set forth by the Meaningful Use portion of the Health Information Technology for Economic and Clinical Health Act, the authors assessed the feasibility and performance of an automated electronic Meaningful Use dental clinical quality measure to determine the percentage of children who received fluoride varnish.

Methods

The authors defined how to implement the automated measure queries in a dental electronic health record. Within records identified through automated query, the authors manually reviewed a subsample to assess the performance of the query.

Results

The automated query results revealed that 71.0% of patients had fluoride varnish compared with the manual chart review results that indicated 77.6% of patients had fluoride varnish. The automated quality measure performance results indicated 90.5% sensitivity, 90.8% specificity, 96.9% positive predictive value, and 75.2% negative predictive value.

Conclusions

The authors' findings support the feasibility of using automated dental quality measure queries in the context of sufficient structured data. Information noted only in free text rather than in structured data would require using natural language processing approaches to effectively query electronic health records.

Practical implications

To participate in self-directed quality improvement, dental clinicians must embrace the accountability era. Commitment to quality will require enhanced documentation to support near-term automated calculation of quality measures.

OBJECTIVES:The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling. METHODS:We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts. RESULTS:Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice. CONCLUSIONS:We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Process-of-care quality measure research can be used to identify gaps in the delivery of dental services to pregnant patients. The aim of this study was to evaluate the types of dental services that pregnant patients received in four dental clinics over five years as documented in the electronic health record (EHR). To accomplish this objective, the authors modified and validated a previously published claims-based dental quality measure for EHR use. After the electronic dental quality measure specifications were defined, the number of pregnant patients was calculated at three academic dental institutions and one large accountable care organization, and the types of dental care services they received over a five-year period (2013-17) were determined. Calibrated reviewers at each institution independently reviewed a sub-sample of patient charts to validate the information obtained from EHR queries, and the concordance between manual chart reviews and EHR query reports was analyzed. Of the 335,078 women aged 15-44 years who received care at the four clinics for the five reporting years, 3.9% (n=13,026) were pregnant. Among these pregnant patients, 48.9% (n=6,366) received a periodic dental examination; 30.0% (n=3,909) received a comprehensive dental exam; and 21.5% (n=2,799) received additional dental services, irrespective of comprehensive or periodic oral evaluations. Overall, the mean proportion of pregnant patients seeking care in these academic dental and group practice clinics was low, but 78.9% of them received either a periodic or comprehensive oral evaluation. Given the importance of oral health care during pregnancy, these findings suggest a need for curriculum development to incorporate prenatal oral health education in the training of dental students.

BACKGROUND: Longitudinal patient level data available in the electronic health record (EHR) allows for the development, implementation, and validations of dental quality measures (eMeasures). OBJECTIVE: We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year. METHODS: Both eMeasures define the numerator and denominator beginning at the patient level, populations specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments. RESULTS: EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%). CONCLUSION: Patient-level data available in the EHRs can be used to implement process-of-care dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.

BACKGROUND: Our 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. RESULTS: The 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%). CONCLUSION: Our 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.

Background

Patients with diabetes are at increased risk of developing oral complications, and annual dental examinations are an endorsed preventive strategy. The authors evaluated the feasibility and validity of implementing an automated electronic health record (EHR)-based dental quality measure to determine whether patients with diabetes received such evaluations.

Methods

The authors selected a Dental Quality Alliance measure developed for claims data and adapted the specifications for EHRs. Automated queries identified patients with diabetes across 4 dental institutions, and the authors manually reviewed a subsample of charts to evaluate query performance. After assessing the initial EHR measure, the authors defined and tested a revised EHR measure to capture better the oral care received by patients with diabetes.

Results

In the initial and revised measures, the authors used EHR automated queries to identify 12,960 and 13,221 patients with diabetes, respectively, in the reporting year. Variations in the measure scores across sites were greater with the initial measure (range, 36.4-71.3%) than with the revised measure (range, 78.8-88.1%). The automated query performed well (93% or higher) for sensitivity, specificity, and positive and negative predictive values for both measures.

Conclusions

The results suggest that an automated EHR-based query can be used successfully to measure the quality of oral health care delivered to patients with diabetes. The authors also found that using the rich data available in EHRs may help estimate the quality of care better than can relying on claims data.

Practical implications

Detailed clinical patient-level data in dental EHRs may be useful to dentists in evaluating the quality of dental care provided to patients with diabetes.

Background

Although sealants are highly effective in preventing caries in children, placement rates continue to be low. The authors' goals were to implement and assess the performance of 2 existing sealant quality measures against a manual audit of charts at 4 dental institutions and to identify measurement gaps that may be filled by using data from electronic health records.

Methods

The authors evaluated the performance of 2 quality measures designed for claims-based data: the Dental Quality Alliance (DQA) sealant measure, which includes patients at risk of developing elevated caries, and the Oregon Health Authority (OHA) sealant measure (irrespective of caries risk). The authors adapted and validated these measures at 4 sites: 3 dental schools and 1 large dental accountable care organization.

Results

The overall modified DQA and modified OHA measure scores in the 6- through 9-year-old age group were 37.0% and 31.6% and in the 10- through 14-year-old age group were 15.8% and 6.6%, respectively. Results from the manual review of charts showed that 67.6% of children who did not receive sealants did not have any teeth to seal because their molars had not yet erupted, had been extracted, had been sealed previously, or had existing caries or restorations.

Conclusions

Both the DQA and OHA measures, which rely mainly on Current Dental Terminology procedure codes, led to underestimation of the care delivered from a practice perspective. Future sealant quality measures should exclude patients whose teeth cannot be sealed.

Practical implications

This study's results support the suitability of using electronic health record data for assessing the quality of oral health care, particularly for measuring sealant placement in children.

BACKGROUND: Although sealants are an established and recommended caries-preventive treatment, many children still fail to receive them. In addition, research has shown that existing measures underestimate care by overlooking the sealable potential of teeth before evaluating care. To address this, the authors designed and evaluated 3 novel dental electronic health record-based clinical quality measures that evaluate sealant care only after assessing the sealable potential of teeth. METHODS: Measure I recorded the proportion of patients with sealable teeth who received sealants. Measure II recorded the proportion of patients who had at least 1 of their sealable teeth sealed. Measure III recorded the proportion of patients who received sealant on all of their sealable teeth. RESULTS: On average, 48.1% of 6- through 9-year-old children received 1 or more sealants compared with 32.4% of 10- through 14-year-olds (measure I). The average measure score decreased for patients who received sealants for at least 1 of their sealable teeth (measure II) (43.2% for 6- through 9-year-olds and 28.4% for 10- through 14-year-olds). Fewer children received sealants on all eligible teeth (measure III) (35.5% of 6- through 9-year-olds and 21% of 10- through 14-year-olds received sealant on all eligible teeth). Among the 48.5% who were at elevated caries risk, the sealant rates were higher across all 3 measures. CONCLUSIONS: A valid and actionable practice-based sealant electronic measure that evaluates sealant treatment among the eligible population, both at the patient level and the tooth level, has been developed. PRACTICAL IMPLICATIONS: The measure developed in this work provides practices with patient-centered and actionable sealant quality measures that aim to improve oral health outcomes.