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A Qualitative Investigation of the Content of Dental Paper-based and Computer-based Patient Record Formats

Schleyer, T and Spallek, H and Hernández, P (2007) A Qualitative Investigation of the Content of Dental Paper-based and Computer-based Patient Record Formats. Journal of the American Medical Informatics Association, 14 (4). 515 - 526. ISSN 1067-5027

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Abstract

Objective: Approximately 25% of all general dentists practicing in the United States use a computer in the dental operatory. Only 1.8% maintain completely electronic records. Anecdotal evidence suggests that dental computer-based patient records (CPR) do not represent clinical information with the same degree of completeness and fidelity as paper records. The objective of this study was to develop a basic content model for clinical information in paper-based records and examine its degree of coverage by CPRs. Design: We compiled a baseline dental record (BDR) from a purposive sample of 10 paper record formats (two from dental schools and four each from dental practices and commercial sources). We extracted all clinical data fields, removed duplicates, and organized the resulting collection in categories/subcategories. We then mapped the fields in four market-leading dental CPRs to the BDR. Measurements: We calculated frequency counts of BDR categories and data fields for all paper-based and computer-based record formats, and cross-mapped information coverage at both the category and the data field level. Results: The BDR had 20 categories and 363 data fields. On average, paper records and CPRs contained 14 categories, and 210 and 174 fields, respectively. Only 72, or 20%, of the BDR fields occurred in five or more paper records. Categories related to diagnosis were missing from most paper-based and computer-based record formats. The CPRs rarely used the category names and groupings of data fields common in paper formats. Conclusion: Existing paper records exhibit limited agreement on what information dental records should contain. The CPRs only cover this information partially, and may thus impede the adoption of electronic patient records. © 2007 J Am Med Inform Assoc.


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Details

Item Type: Article
Status: Published
Creators/Authors:
CreatorsEmailPitt UsernameORCID
Schleyer, Ttitus@pitt.eduTITUS0000-0003-1829-971X
Spallek, Hhspallek@pitt.eduHSPALLEK
Hernández, P
Centers: Other Centers, Institutes, or Units > Center for Dental Informatics
Date: 1 July 2007
Date Type: Publication
Journal or Publication Title: Journal of the American Medical Informatics Association
Volume: 14
Number: 4
Page Range: 515 - 526
DOI or Unique Handle: 10.1197/jamia.m2335
Schools and Programs: School of Dental Medicine > Dental Science
Refereed: Yes
ISSN: 1067-5027
MeSH Headings: Dental Records; Forms and Records Control; Humans; Medical Records Systems, Computerized; User-Computer Interface
Other ID: NLM PMC2244908
PubMed Central ID: PMC2244908
PubMed ID: 17460133
Date Deposited: 13 Sep 2012 14:31
Last Modified: 05 Feb 2019 07:55
URI: http://d-scholarship.pitt.edu/id/eprint/14103

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