Medical Providers’ Dental Information Needs: A Baseline Survey

Abstract

Articulation of medical and dental practices has been strongly called for based on the many oral-systemic connections. With the rapid development and adoption of electronic health records, the feasibility of integrating medical and dental patient data should be strongly considered. The objective of this study was to develop an initial understanding of the medical providers’ core dental information needs and opinion of integrated medical-dental electronic health record (iEHR) environment in their workflow. This was achieved by administering a 13 question survey to a group of 1,197 medical care providers employed by Marshfield Clinic in Wisconsin, United States. The survey received a response rate of 35%. The responses were analyzed based on provider ‘Role’ and ‘Specialty’. The majority of the respondents felt the need for patient’s dental information to coordinate or provide effective medical care. An integrated electronic health record environment could facilitate this holistic patient care approach.

Introduction

The ‘Great Divide’ between dentistry and medicine is a well known fact of the healthcare delivery system. However, it is often said that mouth is the mirror of overall health and there has been many studies linking the oral and systemic connections [1, 2].

The Institute of Medicine (IOM) of the National Academy of Sciences released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 [3]. The IOM report called for a strong cohesion between medicine and dentistry, it states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care” [3]. An article by Baum “Will dentistry be left behind at the healthcare station?” [4] indicates that economic prosperity of dental practices and the financial constraints on dental education is keeping dentistry isolated from utilizing biological approaches to managing oral health.

Although the healthcare team consists of various specialists trained in different area of expertise, there is often a lack of bi-directional information flow between the dentists and the medical care providers. Many factors contribute to this lack of effective communication and sharing of patient information between the different groups of care providers in delivering a holistic approach to patient care. Some of the contributing factors could be security issues, lack of infrastructure, and the business model of the practices to list a few. A recent study by Schleyer et al. [5] found that although 55% of the respondents to a survey answered ‘yes’ when asked whether they would allow other providers to access information about their patients, many qualified their response by indicating that they would require a level of security in place. The need for dentistry to be part of National Health Information Infrastructure has also been discussed in literature [6]. Only 32% of the physicians are in solo or 2-physician practices [7], on the contrary almost 73% of all dentists in U.S. are in solo practices [8] representing the different business model of the practices. However, with the advanced technological development and widespread adoption of electronic health records, some of the larger healthcare organizations are in a unique position to explore the feasibility of providing a holistic care approach to their patients through a medical-dental integrated electronic health record (iEHR) environment. The objective of this study was to develop an initial understanding of the medical care providers’ core dental information needs and opinion of medical-dental integrated electronic health record (iEHR) environment in their workflow.

Background

Founded in 1916, Marshfield Clinic is one of the largest comprehensive medical systems in the United States. This 777-physician, 6519-employee multi-specialty group practice provides patient care, research and medical education across 52 Wisconsin locations. The Marshfield Clinic center works closely with St. Joseph's Hospital a 524-bed acute facility and maintains a joint EHR.

Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. FHC has been providing on-site dental services since the fall of 2002. Currently, FHC operates seven dental sites with two additional sites under construction that will be operational in the fall of 2011.

Marshfield Clinic made a significant commitment to internal development of its information systems over the past 40 years. Physicians have collaborated with affiliated hospitals, clinics and an in-house development staff of over 300 IT professionals to develop systems. CattailsMD™ is the first internally developed EHR to be certified by the Certification Commission for Health-care Information Technology (CCHIT). Marshfield Clinic is currently developing a robust medical-dental integrated electronic health record (iEHR) environment. The beta version of the dental module, Cattails Dental has been implemented and successfully rolled out in all of the seven dental centers. The survey discussed in the manuscript is one of the many studies conducted at the Marshfield Clinic as part of the iEHR environment design and development.

Methods

The research group developed the survey instrument and pilot-tested to identify any issues. Minor changes were carried out to the survey instrument as a result of the pilottest. The development of the survey was also informed by a literature review that helped identify certain aspects of the survey instrument. The survey consisted of 13 questions with both structured and open-ended questions. Figure 1 illustrates the final survey instrument used in this study to measure the medical care providers’ core dental information needs and opinion of medical-dental integrated electronic health record (iEHR) environment.

Figure 1.

Survey instrument used in the study

The final survey and the research protocol were submitted to the Marshfield Clinic Institutional Review Board, which classified the study as exempt under section 45 CFR 46.101(b) and waived requirement for an authorization (FWA00000873).

A list of all the medical providers was extracted from the Marshfield Clinic data warehouse that included Physicians, Surgeons, Residents, Registered Nurses, Nurse Practitioners, Certified Nurses and Licensed Practical Nurses. The list identified 1,197 providers from all Marshfield Clinic locations and St. Joseph’s Hospital who were eligible to participate in the survey.

The survey was administered through an online survey tool, Survey Monkey (Portland, OR). The survey was administered between January 14^th, 2010 and February 15^th, 2010. Two reminders were sent, the first on January 25^th and the second on February 6^th. The providers had an option to be entered into a drawing for an iPod on completing the survey to encourage participation.

The survey respondents were grouped based on the ‘Role’ and ‘Specialty’. Groups based on ‘Role’: Group 1 - Physician, Surgeon, Anesthesiologist, Medical Director, Department Chair, Resident and Nurse Practitioner, Group 2 - Certified Nurse, Nurse Midwives, Licensed Practical Nurses and Registered Nurse and Group 3 - Managers and Others. Groups based on ‘Specialty’: 1. Surgery; 2. Cardiology; 3. Emergency Medicine; 4. Primary Care; 5. Oncology; 6. Pediatrics; 7. Neurology; 8. Women’s Health/Obstetrics-Gynecology; 9. Other Specialties. Questions Q5 to Q10 which were ‘structured’ in their format and were analyzed based on the ‘Role’ and ‘Specialty’. P values were derived by performing the Chi-square test. Questions Q11 to Q13 were open-ended and the collected data were coded, analyzed and identified under appropriate major themes. As all the questions in the survey were not mandatory, any missing data from the providers’ response to a particular question were handled by not including that respondent for the analysis of the respective question.

Results

The survey was initially emailed to 1221 provider email addresses within the system. There were 24 emails that were undeliverable and those providers email addresses were removed from the original list. Of the original 1,197 eligible providers, 417 completed the survey, which yielded a response rate of 34.84%. The provider’s response to Questions Q5, Q7 and Q8 were statistically significant when analyzed based on the ‘Role’ (P-value < 0.05). On the other hand, when analyzed based on ‘Specialty’, Questions Q5, Q7, Q8 and Q9 were statistically significant (P-value < 0.05). Granular details regarding the responses to individual questions could not be presented in the manuscript due to the space limitation. However, Figure 2 illustrates the overall medical provider’s dental data needs based on the different dental categories.

Figure 2.

Medical provider’s dental information needs based on the different dental information categories

After analyzing the responses to Q13, it was determined that most of the comments fell under Q11 and Q12 and were included under the respective category for analysis. The data collected from the responses to Q11, which represented the respondents’ mentioned advantages of a medical-dental iEHR environment were coded and identified under the following themes: a. access to reliable dental information and history, b. better communication with the dentist, c. holistic care and better continuity of patient care, d. better coordination of patient care, e. easy and faster access to dental information and f. reduce narcotic abuse. Similarly, the data collected to Q12, which represented the respondents’ mentioned disadvantages of a medical-dental iEHR environment were coded and identified under the following themes: a. information overload, b. cost issues, c. privacy concern, d. system slowness and e. coping with dental jargon.

Discussion

There is no data from previous literature regarding medical providers’ opinions on an integrated electronic health record environment. The survey results present a baseline measure by different medical specialties and major roles. Considering the busy nature of the medical providers and the historic disconnect between how medicine and dentistry has been practiced, the response rate of 35% was encouraging. However, there is further scope for extensive investigation into the articulation of medical and dental iEHR. It would also be interesting to explore how a similar survey would perform on a state, national or an international level.

The majority of the respondents felt the need for patient’s dental information to coordinate or provide effective medical care, especially Cardiologists, Emergency medicine physicians, Primary care physicians, Oncologists, Pediatricians and Neurologists. Since there are well-established connections between oral health and these specialties, this reflected the expected outcome. However, only about half of Surgeons and Obstetricians-Gynecologists who responded to the survey expressed the need for patient’s dental information for coordinating or providing effective medical care. Based on the medical providers’ response, there seems to be a strong need for inter-communication between the physicians and dentists regarding their patients’ health information. About 55% of the respondents requested a consult monthly or less and 10% weekly from the general dentist or dental specialist. The need for patients’ oral health status, dental treatment plan, dental problem list and dental diagnosis was of importance for the majority of the survey respondents. Although dentists rarely document diagnostic codes, this calls for an urgent need for documenting diagnosis in their patient records and could be supported by standardized dental diagnostic codes.

It is evident from this baseline study that the medical providers have recognized the need for patient’s dental information to provide comprehensive care. Hence, an iEHR environment could facilitate this holistic approach. There is scope for further investigation into specific dental information required for each of the identified specialties. Also a quantitative analysis of the advantages vs. disadvantages of an iEHR environment can further be conducted to explore the feasibility of such an environment.