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EZCodes: A diagnostic terminology as the foundational step of quality for the
dental profession
Kalenderian-Groenewegen, E.
Publication date 2013
Document Version Final published version
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Citation for published version (APA):
Kalenderian-Groenewegen, E. (2013). EZCodes: A diagnostic terminology as the foundational step of quality for the dental profession.
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EZCodes: a diagnostic terminology as the foundational step of
quality for the dental profession
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EZCodes: a diagnostic terminology as the foundational step of
quality for the dental profession
ACADEMISCH PROEFSCHRIFT
Ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus
Prof. dr. D.C. van den Boom
ten overstaan van een door het college voor promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel
op 2 oktober 2013, te 10 uur
door
Elisabeth Kalenderian-Groenewegen Geboren te Amersfoort
Promotiecommissie
Promotor : Prof. dr. A.J. Feilzer Co-promoter : Prof. dr. R.B. Donoff
Overige leden : Prof. dr. G.J.M.G. van der Heijden Prof. dr. F.R. Rozema
Prof. dr. G.H.W. Verrips Prof. dr. D. Wismeyer Prof. dr. J.M. White
To Annemieke The shortness of life cannot dissuade us from its pleasures, nor console us for its pains.
This thesis is prepared in cooperation between the Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine and the Department of Dental Materials Science at the Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam.
___________________________________________________________________________
Chapter 1 Introduction 9
Chapter 2 Standardized Dental Diagnostic Codes Are a Fundamental Public
Health Tool 27
Chapter 3 The Development of a Dental Diagnostic Terminology 53
Chapter 4 Evaluating a Dental Diagnostic Terminology in an Electronic
Health Record 71
Chapter 5 Assessing the Use of a Standardized Dental Diagnostic
Terminology in an Electronic Health Record 91
Chapter 6 Treatment Planning in Dentistry Using an Electronic Health
Record: Implications for Undergraduate Education 107
Chapter 7 The Value of the EZCodes Dental Diagnostic Terminology –
Use Case 127
Chapter 8 General Discussion 141
Summary 167
Samenvatting 177
Biosketch 189
C
HAPTER
1
Introduction
EZCodes: a diagnostic terminology as the foundational step of
quality for the dental profession
Introduction
Fundamental requirements for a proper indication of oral care
As in medicine, dental treatment should be based on the complex integration of a multitude of factors including the patient’s chief complaint, medical and dental history (anamnesis), findings discovered during intra- and extra-oral examination, the patient’s preferences, and social context, among others.1 In modern society, the patient should be able to expect dental treatment proposals that are based on the best available evidence. When taking this view, even preventive measures, such as tooth brushing instructions, must be seen as “treatment” and ought to be evidence based. In reality, however, patients are often advised to undergo preventive treatments where the evidence for actual oral health improvement is uncertain at best.
Evidence-based research is frequently performed in controlled environments, such as academic clinics, because field research lacks the ability for proper registration of all variables required for treatment evaluation.2 As a result, controlled environments are often not representative of the “field” or are not easily generalizable to the practicing dentist in the private or community clinic setting. Attempts should be undertaken to standardize documentation of dental treatment by the non-academic dentist in such a way that structured epidemiologic and clinical evaluations are possible. Currently, dental treatment documentation is reasonably well established in many countries throughout the world. This is because rather often, dental providers cannot generate income without adequate documentation in place. However, to enhance evidence-based research in oral care, documentation of treatment alone is insufficient. At a minimum, it has to be combined with the dental diagnosis that formed the basis for the indication of treatment. For example, when one wants to study the longevity of a Class IV restoration of the upper frontal incisor, it is of interest to differentiate between the diagnoses “fracture due to trauma from being hit by a hockey stick” and “severe caries”. It is not unreasonable to expect that a diagnosis of trauma may influence the longevity of the restoration differently than a diagnosis of disease.
The diagnostic terminology must be clear and indisputable, allowing for a straightforward, consistent collection of dental diagnostic information. When dental providers enter terms validly and efficiently, information gained will enhance teaching and digital evaluation, research and outcomes analyses, and ensure quality improvement.
Existing diagnostic systems for medicine and dentistry
The development of a standardized diagnostic terminology does not have as long of a history as that of the medical lexicon in general. Where modern medicine can trace its roots back to Hippocrates and Galen, whose writings include anatomic, pathologic, and therapeutic terms that remain still in use today,3 the development of diagnostic terminologies started a mere 250 years ago. After attempts by Sauvage, Cullen, and Farr, Bertillon created the first generally adopted set of standardized medical diagnoses in 1893. His “Bertillon Classification of Causes of Death” formed the basis for the current ICD diagnostic terminology used world-wide.4 The history of the development of ICD is documented in Figure 1.1.
Figure 1.1: History of ICD
While the International Classification of Diseases (ICD)5 is undoubtedly the international standard diagnostic classification used in the medical clinic, epidemiological studies, health management and economics, it does not have adequate coverage of oral and dental diagnoses.6, 7 The U.S. developed ICD-CM (Clinical Modification), which has more information and detail than ICD. The current ICD-10-CM version contains 68,000 terms; ICD 10 has far less terms. Both terminologies’ oral health chapters lack sufficient detail for prudent documentation of dental diagnoses.
The Systematized Nomenclature Of Medicine (SNOMED) was developed in 1965 by the College of American Pathologists as SNOP (Systematized Nomenclature of Pathology), and later extended into other medical fields. The current version SNOMED Clinical Terms (SNOMED CT) is a controlled medical terminology for use in the EHR. As a reference terminology, it has comprehensive coverage of diseases, clinical findings, etiologies, procedures, and outcomes and contains more than 311,000 unique terms organized into hierarchies.8 SNODENT, a Systematized Nomenclature for Dentistry, was devised by the American Dental Association (ADA) in the early 1990’s. SNODENT is composed of diagnoses, signs, symptoms, and complaints9 and
currently includes over 7700 terms. In 1998, the ADA entered into an agreement to incorporate SNODENT Version I into SNOMED. In 2012, SNODENT Version II was incorporated into the SNOMED CT. Until its recent inclusion into SNOMED CT, SNODENT was only available by license and was maintained by the ADA. As a result, SNODENT has never been implemented in the dental profession. The sheer size of oral health terms makes effective integration into a dental electronic health record (EHR) difficult and actual utilization improbable.
Clinical terminologies as well as classifications capture detailed data in the EHR. Where clinical terminologies are the input format, classification systems are the output format. Though they are designed for different purposes, they should be considered complementary. ICD is considered a classification or “output” system. As a result, the primary documentation of clinical care is not its intended use. Indeed, it is mainly used in the U.S. for external reporting (billing, quality control) requirements. In contrast, SNOMED-CT is a clinical terminology, and as an “input” system, it is designed for the primary documentation of clinical care.
It is reasonable to assume that the “one size fits all” principle will not work when trying to utilize one terminology or classification to fulfill all required administrative needs of a healthcare organization. For example, with nearly 7700 dental terms and 311,000 medical terms, SNOMED-CT is designed to identify data at the point of care. Whereas ICD, with around 100 oral health terms and 68,000 medical terms, (ICD CM has around 320 oral health terms) has the ability to aggregate data and is more suitable for claims processing. Additionally, which terminology or classification system shall be used is determined, in part, by regulatory requirements.10
Rationale for the development of a dental diagnostic terminology
Until now, a commonly accepted standardized diagnostic terminology did not exist for oral diagnoses. However, the dental provider has never documented diagnoses, whether in electronic or paper format, in a structured way. In contrast, medicine has used standardized terminologies for over a century, and specifically, ICD is a requirement of the American billing process. More recently, the U.S. Office of the National Coordinator (ONC) is requiring the use of SNOMED CT11 terms for populating the problem list in the EHR for those providers who want to participate in its “Meaningful Use incentive program”.12, 13
There are a multitude of benefits for documenting diagnoses in a standardized and consistent way as our colleagues in medicine have been doing “since the bubonic plaque”14 (or rather one of its later local outbreaks: the Great Plaque of London in
1665), or to be precise, since 1763.9 They include documentation of the types and frequency of diseases encountered by the care provider and thus, the ability to track disorders treated for internal quality control. This enhances communication with patients and between care providers, especially when care is shared between health care providers, enables outcomes tracking, and facilitates data sharing across sites.15 It allows epidemiologists to evaluate disease patterns, treatment patterns, and disease outcomes. From a research point of view, it will allow health services researches to study risk-adjusted, cross sectional, and temporal variations in access to health care, health care quality, costs of care, and treatment effectiveness.16 In the academic setting, a standardized dental diagnostic terminology will allow both students and faculty to hone their formal diagnostic skills, emphasizing the link between diagnosis and treatment and thus enhancing patient care.17 Lastly, the standardization of documenting diagnoses will allow for the true measuring of outcomes, defined as the condition of a patient at the end of therapy or a disease process,18 and as such, forms the foundation of the development of clinical guidelines or recommendations to inform evidence-based dentistry (EBD).19
Figure 1.2 is a graphical representation of the relations between diagnostic codes and applications.
Figure 1.2: Relationship between diagnostic codes and applications
Financial
The United States is expected to spend approximately 19% of its Gross Domestic Product (GDP) on health care in 2014.20 In 2011, per capita healthcare spending rose by 4.6%.21 According to the Kellogg Foundation’s 2011 report titled,
healthcare system spends significantly more money per capita…than other developed nations” while trailing other developed nations in several health indicators,22 ranking 39th in infant mortality, 43rd in adult female mortality, 42nd in adult male mortality, and 36th in overall life expectancy. Meanwhile, the mortality rate for American males 15-60 years of age is worse than in Sweden or Australia,23 countries that are similarly to the U.S with respect to population wealth (GDP/capita). Additionally, in the U.S., where health insurance is predominantly employer-sponsored, increased unemployment levels, and the subsequent loss of employer-provided insurance, have served to decrease access to healthcare. Meanwhile, as a result of reductions in dental insurance benefits, Americans are increasingly paying for oral healthcare out-of-pocket or foregoing needed dental procedures, to the point where “dental care is among the largest out-of-pocket health expenditures in the U.S., second only to prescription drugs”.22
These sobering facts demand not only adjustments in healthcare spending, becoming more efficient, or making incremental changes, but also true innovation.24 In response to spiraling healthcare costs in the United States and resultant negative public health impacts, the “Triple Aim” was developed by the Institute for Healthcare Improvement (IHI) in an effort to create an improved model of healthcare delivery. Its three conceptual dimensions are:
(1) improving the patient experience of care; (2) improving the health of populations, and (3) reducing the per capita cost of healthcare.
In Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better
Health and Lower Costs, Bisognano and colleagues described how healthcare
innovators have found a way to achieve “measurable progress on the challenges of quality and costs”.25
The seven innovators present implemented solutions that produced documented results in improving patient care while controlling costs. The Triple Aim model is in part an effective model to apply to dentistry in an effort to start addressing quality and cost issues. However, it might have been better if the architects of the Triple Aim had included oral health directly into some of their approaches instead of perpetuating the siloed structure of dentistry and medicine.
One of the most effective ways to improve effectiveness of care is to increase the degree to which dental and medical providers collaborate with respect to overall care for their shared patients. This is a significant paradigm shift for both parties since currently the relationship is most often limited to one of referring for expert treatment (“cure”). However, only when the dental provider begins to function as a “health care ambassador” (i.e. monitoring blood pressure), or the medical provider as a “dental
advocate”, supplying advice and preventive care (i.e. supplying fluoride treatment for children), will the patient truly benefit through ongoing managed care, instead of episodic expert “cure”. Dentistry brings well-documented value to the Triple Aim - a partnership with the medical physician for providing screening, preventive maintenance care and actively participating as a member of the Proactive Practice Team. The dentist thereby becomes a partner in the detection of systemic diseases, as a number of systemic diseases can be first diagnosed orally. Examples include immunosuppressive diseases (i.e. pemphigus vulgaris), chronic illnesses (i.e. diabetes), and infectious diseases (i.e. HIV/AIDS, the first AIDS patient was diagnosed in San Francisco General Hospital as Karposi Sarcoma of the palate.26) The models developed by Bellin Health25 and others can be adapted to include oral health providers. Use of a dental diagnostic terminology will hold the key to moving from “cure” to care”, as well as improving the capacity for oral public health research connecting medical and dental care. This in turn will promote collaborative efforts, and enable oral health data collection that fosters capacity for medical-dental partnerships.
Since a number of chronic diseases have oral manifestations, dentist-physician collaboration can increase early diagnosis for patients with chronic illnesses and thus prevent expensive treatment of complications later on. For example, uncontrolled diabetes will negatively influence the periodontal status of the patient, and, conversely, improving periodontal health will positively influence the diabetic status of the patient.27 One such example of dentist-physician collaboration is seen in twenty schools that are part of the Consortium for Oral Health Research and Informatics (COHRI).28 These schools are participating in efforts to engage their patients in simple primary care screening efforts as participants of the Meaningful Use Incentive Program,29 a part of the HITECH Act of 2009 that provides payment incentives for utilizing EHRs. These efforts include blood pressure measurement, tobacco use and cessation screening, asthma acerbations screening, and assuring pneumonia and influenza vaccinations. In addition to augmenting medical management of chronically ill patients, these quality measures also represent a budding partnership with the patient at the center and the medical and oral health physicians as partners and collaborators, connected to each other and the patient. The core of this effort is the ability for the provider to document a medical, as well as an oral health, diagnosis in a structured and consistent way.
Quality
Documenting diagnoses in a standardized way has to be at the foundation of any quality effort to reach the Triple Aim of better care, better health, at lower cost.25 Expanding the Institute of Health Improvement’s simple triad illustrates the foundational role of a dental diagnostic terminology to affecting quality in oral health (see Figure 1.3). The problem for dentistry, however, is that while ICD is undoubtedly the international standard diagnostic classification used in the medical arena, it does not have adequate coverage of oral and dental diagnoses. Conversely, SNOMED, and the majority of the oral health terms imbedded in it as SNODENT, offers such an overwhelming number of terms that it effectively becomes unmanageable chair-site. However, as mentioned earlier, the ability to capture information about oral health diagnoses in a standardized way is essential for quality of care, epidemiological health tracking, and research and cost-effectiveness reasons. Entering a diagnosis in a structured field in an EHR not only reinforces the link between diagnosis and treatment, but also allows for efficient outcomes assessment and continuous quality monitoring through data mining. Hence, the need for the development of a dental diagnostic terminology, intended to reap the benefits of being positioned as an interface terminology, becomes quite evident.30
Research
Martin et al., nicely outline the central issues regarding the use of dental diagnosis in dentistry and dental research when they mention that “(…) currently dentistry has a disconnect between procedure codes (…) and diagnostic codes….”.31 As a result, there are serious challenges to combining data across disparate sites and comparing results across studies. As Pitts noted, “Many apparently similar terms are used interchangeably in the literature, but are taken by different groups of researchers and clinicians to mean very different things”.32 Clearly, the dental profession’s ability to conduct research is limited by the lack of clear definitions and standardized nomenclature to describe diagnoses.
One of the stated goals of the Centers for Disease Control’s (CDC) Healthy
People 2020 is to “prevent and control oral and craniofacial diseases, conditions, and
injuries, and improve access to preventive services and dental care”.33 Toward these goals, in September 2011, the National Priorities Partnership (NPP), formed by the nonprofit National Quality Forum (NQF), recommended including three oral health measures delineated by Healthy People 2020 as measurable objectives. These oral health measures are:
(1) the proportion of young children aged 3-5 years with dental caries experience in their primary teeth;
(2) the proportion of adults with untreated dental decay, and
(3) the proportion of children, adolescents, and adults who used the oral healthcare system in the past year.34
In order to effectively measure these objectives, a standardized dental diagnostic terminology that is practical and easy to use chair-site will be necessary.
Evidence-Based Dentistry (EBD)
The periodontal community is leading the dental profession by starting the debate about the absence of a “gold standard…which contains all the information needed to form a diagnosis”.31 With the ongoing implementation of EHRs in the dental setting, it is important that, once the diagnosis is made, it is captured electronically, along with the procedure performed, using a dental diagnostic terminology. Nevertheless, as Meyers’ argument underscores, “dentists do not have a set of diagnostic terms or clinical pathways to attain dental health for their patients based on the best available evidence and accurate risk assessment”.35
Evidence-based dentistry (EBD) is the coming together of three equally important concepts:
(1) the best available, clinically relevant, scientific evidence relating to the patient’s oral and medical condition and history;
(2) a dentist’s clinical expertise, and
(3) the patient’s treatment needs and preferences.
Systematic reviews of published papers are considered the preferred method for assembling the best available scientific evidence. As such, the results from systematic reviews may be used for decision making about research and the provision of health care. A systematic review includes:
A stated clinical question, preferably in “PICO” format that identifies: Population (the individuals or groups for whom an answer is sought)
Intervention (the treatment or clinical condition of interest, i.e. patient type, disease)
Comparison (an alternative treatment or control group for comparison to intervention)
Outcome (the measure(s) used to assess the effects of the intervention)
Example: In persons with adult periodontitis, how does scaling and root planing combined with local antimicrobial therapy affect bleeding and pocket depths compared to scaling and root planing alone?36
Clearly, without a well-defined diagnosis that is documented in a standardized way throughout the literature, it will be difficult to “identify and evaluate all of the evidence with which to answer a specific, narrowly focused clinical question”.37 As such, one might argue that a number of the current EBD recommendations have a low level of certainty of net benefit. As described in the ADA Clinical Recommendation Handbook, “The ‘level of certainty’ is the probability that the Expert Panel’s assessment of the net benefit of an intervention is correct. For example, a low level of certainty may result from a lack of evidence; from studies of inappropriate design; from studies of appropriate design, which are of poor quality or have meager or no applicability; from too small and/or too few studies; and from inconsistent results between studies”.37
When reviewing the American Dental Association Council on Scientific Affairs’ EBD recommendations, it is clear that standardized documentation of diagnosis is paramount in the development of such guidelines:
(1) Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.38 The guideline reviews how “a multitude of indirect evidence was included in this guideline that investigates particular components of this complex mechanism”. It states, “Multiple high strength studies link oral procedures to bacteremia, a surrogate measure of risk for orthopaedic implant infection”. One might argue that without knowing the diagnosis and thus why a procedure was performed, it is difficult to understand the surrogate link between procedure and bacteremia. Extraction of an abscessed tooth occurs in a quite different oral environment than removal of four pre-molars for orthodontic reasons.
(2) Nonfluoride caries-preventive agents.39 Several studies recorded dental caries according to the World Health Organization (WHO) definitions, which include four caries stages, however, not all four stages were always included in the statistical analysis.40 This may have impacted understanding the preventive impact of xylitol on the formation of white lesions.
(3) Dietary Fluoride Supplements.41 The panel concluded, “Owing to known increases in exposure to fluoride from multiple sources and the increased prevalence of enamel fluorosis, the panel recommended fluoride supplement use for children at high risk of developing caries”. The guidelines also note that “the panel did not identify studies that supported its use specifically in populations at high or low risk of developing caries” and that “the clinician should conduct a caries risk assessment to determine the appropriateness of prescribing dietary fluoride supplements. There is no exact definition of high risk of developing caries; rather, it can be a continuum”. However, a standardized diagnostic terminology that not only includes terms for the various forms of caries, but also includes terms for “High, Moderate and Low Caries Risk” should significantly help with the risk benefit analysis of preventing caries versus promoting the incidence of fluorosis.
(4) Evidence-Based Clinical Recommendations for the Use of Pit-and-Fissure Sealants.42 The report states that “in clinical care settings, diagnosis of caries implies not only determining whether caries is present (that is, detection) but also determining if the disease is arrested or active and, if active, progressing rapidly or slowly”. Additionally, the report states, “Pit-and-fissure sealants are underused, particularly among those at high risk of experiencing caries”. Only when the patient’s level of caries risk assessment, as well as level of disease, is documented in a consistent, standardized way, can we make conclusions regarding the true effectiveness of the intervention.
(5) Professionally applied topical fluoride.43 The guidelines state, “The panel encourages dentists to employ caries risk assessment strategies in their practices”. In order to assess effectiveness of this intervention for a single patient or an entire population, standardized documentation of caries risk level will be necessary.
(6) Evidence-Based Clinical Recommendations Regarding Fluoride Intake From Reconstituted Infant Formula and Enamel Fluorosis.44 This report states evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. For ongoing assessment and monitoring of fluorosis among infants, documenting the various stages of fluorosis in a standardized way will be paramount.
(7) Evidence-Based Clinical Recommendations Regarding Screening for Oral Squamous Cell Carcinomas.45 The guidelines state, “When a clinician observes a persistent or progressive lesion, he or she may consider prompt referral to a dental or medical provider with advanced training and experience in diagnosis of oral mucosal disease before performing tissue biopsy”. This will require consistent documentation of a diagnosis in an easily retrievable manner. The preference would be an electronic format, since these are easiest to retrieve. Thus, the use of a diagnostic terminology will be essential.
Research project of this thesis
The study described in this thesis aims to develop a validated dental diagnostic terminology (called ‘EZCodes’) to enhance a proper registration of diagnostic findings for, amongst others, research in EBD. Basic principles for terminology development will be applied. Moreover, the notion to position the terminology as an interface terminology, interfacing with existing diagnostic and payment systems will be explored.
Chapter 2 discusses the public health impact of the use of a standardized dental diagnostic terminology. It provides an overview of how standards are developed and accepted worldwide. As an interface terminology, the EZCodes terminology is positioned to play a prominent role in this important, but yet underexplored arena.
In Chapter 3, the iterative process to develop a dental diagnostic terminology adhering to principles of terminology development is described. Additionally, a first attempt was made to build an interface terminology consisting of categories and subcategories. This resulted in 1158 terms that are mappable to:
(1) ICD for Medicaid billing purposes;
(2) SNOMED, its reference terminology, for Meaningful Use purposes, and (3) the treatment terminology CDT,46 for general dental billing purposes.
In essence, the EZCodes are the center of serving or informing four crucial entities of the dental profession (see Figure 1.4).
Figure 1.4: Relationship between diagnostic codes and applications
Chapter 4 describes the validation process of the diagnostic terminology through a retrospective analysis of the use of Z codes (a subset of the EZCodes) as they relate to procedure codes. The study showed successful development, implementation, and utilization of diagnostic codes and terms in an EHR with low elective utilization but high validity.
Chapter 5 describes the assessment of the EZCodes terminology in two dental schools. After one year of non-compulsory use, utilization was low; however, validity was high.
Chapter 6 explores the role of the EZCodes in treatment planning in the EHR. The study underscores the impact of technology on the fundamental skills of diagnosis and treatment planning within the modern educational setting.
Chapter 7 describes a short use case that demonstrates the value of documenting a diagnosis in a standardized way. Four U.S. dental schools have pooled de-identified, clinical EHR data in a first-ever dental data repository. With one million unique patients, many who have diagnostic as well as treatment codes documented in their EHR, it was possible to answer research questions focused solely on the value of entering a diagnostic term.
In Chapter 8 the general discussion integrates the results of the studies, explores steps towards future research, demonstrates the value of the EZCodes terminology and provides a call to action for further integrating of the EZCodes diagnostic terminology into the curriculum of today’s dental students.
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41. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a
report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2010;141(12):1480-9.
42. Beauchamp J, Caufield PW, Crall JJ, et al. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2008;139(3):257-68.
43. American Dental Association Council on Scientific A. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc 2006;137(8):1151-9.
44. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2011;142(1):79-87.
45. Rethman MP, Carpenter W, Cohen EE, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 2010;141(5):509-20.
46. American Dental Association. CDT 2013 Dental Procedure Codes. Chicago, Ill.: ADA; 2013.
C
HAPTER
2
Standardized Dental Diagnostic Codes Are a Fundamental
Public Health Tool
E. Kalenderian*1, R. Ramoni*2, A. AbdulRahiman1, O. Tokede1, J.M. White3, M.F. Walji4, A.J. Feilzer5
1 Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA
2 Center for Biomedical Informatics, Harvard Medical School, Boston, MA, USA 3
Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California, San Francisco, CA, USA
4
Department of Diagnostic and Biomedical Sciences, University of Texas Health Science Center School of Dentistry at Houston, Houston, TX, USA
5 Academic Centre for Dentistry Amsterdam (ACTA) University of Amsterdam and VU University, Amsterdam, The Netherlands
Abstract
Public health efforts in medicine have long benefited from the International Classification of Disease (ICD), which was adopted in 1900 as an international standard for describing diagnosis. ICD underpins core public health activities – including the analysis of the general health situation of population groups, monitoring the incidence and prevalence of diseases, classifying diseases, enabling storage and retrieval of diagnostic information for epidemiological and quality purposes, and resource allocation decision making by countries. Dental public health and quality improvement activities have not enjoyed the same benefits of ICD as medicine has due to the limited representation of oral health diagnoses in ICD. The advent of electronic health records (EHRs) has served as a catalyst to fill this knowledge representation gap in dentistry, and standardized dental diagnostic terminologies are in their early days of broader adoption. Within the clinical setting, dental practitioners are key stakeholders in the consistent documentation of oral health diagnoses: documentation of ICD diagnoses in medicine is nearly ubiquitous in part because medical billing required documentation of diagnosis. In the dental setting, where documentation of diagnosis is not currently a requirement for billing, practitioners perceive both motivations for and barriers against the adoption and use of this foundational population health tool.
Introduction
In medicine, the International Classification of Diseases (ICD)1 underpins core public health and health services research activities – including the analysis of the general health situation of population groups, monitoring the incidence and prevalence of diseases, classifying diseases, enabling storage and retrieval of diagnostic information for epidemiological and quality purposes, and resource allocation decision making by countries.5 Israel said it well: “A major purpose for gathering descriptive
statistics is to allow comparisons of data over time and among different places. In the case of public health it has been particularly important to make such comparisons utilizing diagnostic information. Without a standard measuring tool which remains fixed for periods of time and which is applied uniformly from place to place, meaningful comparative analyses of diagnostic information would not be possible.”2
In dental public health, diagnostic terms are an underutilized but powerful tool. Diagnostic terms would allow epidemiologists to consistently evaluate disease patterns, treatment patterns, and disease outcomes; health services researchers could use the terms to study risk-adjusted, cross-sectional, and temporal variations in access to healthcare, healthcare quality, costs of care, disparities, and treatment effectiveness.3 Further, being able to capture information about diagnoses in a standardized way is essential to compare outcomes of varying treatments of the same diagnosis (evidence-based care); to compare the trajectory of a patient with a given diagnosis relative to the population with the same diagnosis; to enhance communication with the patient; to better tailor care to diagnosis; to more efficiently audit the appropriateness of a treatment for a given diagnosis; to determine the cost-effectiveness of treatments for a given diagnosis; and to report, compile, and compare data consistently. One of the reasons that dental public health has not been able to take advantage of standardized dental diagnostic terms is that ICD has not had sufficiently broad coverage of specific oral health diagnoses.4 In the absence of terms describing specific diagnoses, one must often resort to selecting catch-all terms to capture those diagnoses ‘not otherwise specified.’ Recognizing the importance of specific diagnostic terms to clinical care and public health, the EZCodes dental diagnostic terminology was created in 2009 and since then has undergone two revisions. Today, 15 dental academic centers in the United States and Europe; as well as Willamette Dental Group, a set of 54 practices in the Pacific Northwest of the United States, are benefiting from this shared diagnostic terminology.
For an explanation of the definitions used throughout this paper, please see Box 1.
History of Standardized Diagnostic Terminologies
While standardized diagnostic terminologies are now an integral part of medical care, their development and acceptance had many false starts, beginning 250 years ago. In 1763, François Bossier de Lacroix (aka Sauvages) published Nosologia
methodica the first published classification system of diseases,5 inspired by the classification of plants. Twenty-two years later, the charismatic William Cullen (1710-1790) published his own classification of disease under the title Synopsis nosologiae
methodicae: Cullen’s classification was the most broadly used in the early 1800s. In
1837, William Farr (1807-1883), the first medical statistician in the General Register Office for England and Wales, found that Cullen’s classification did not meet his needs because it had not kept up with advances in the understanding of disease and it fragmented diagnoses into too many categories to be useful from a statistical point of view. In the first Annual Report of the Registrar General,6 Farr outlined the principles that should underpin a statistical classification of disease and advocated for the adoption of a uniform classification:
“The advantages of a uniform statistical nomenclature, however imperfect, are so obvious, that it is surprising no attention has been paid to its enforcement in Bills of Mortality. Each disease has, in many instances, been denoted by three or four terms, and each term has been applied to as many different diseases: vague, inconvenient names have been employed, or complications have been registered instead of primary diseases. The nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences, and should be settled without delay.”
In 1853, Farr and Marc d’Espine, of Geneva, were called upon by the first International Statistical Congress to create an internationally applicable uniform classification of causes of death. Alas, this classification and its subsequent revisions were never universally accepted. The first generally adopted set of standardized diagnoses was the Bertillon Classification of Causes of Death, created in 1893 by Jacques Bertillon under the auspices of the International Statistical Institute, the successor to the Congress. In 1898, the American Public Health Association (APHA) recommended the adoption of the Bertillon Classification by registrars of Canada, Mexico, and the United States of America. The APHA also recommended the implementation of a revision process every decade. Consequently, the first
international conference to revise the International Classification of Diseases (ICD) or International List of Causes of Death, as it was then called, convened in 1900. In 1948, the World Health Organization (WHO) took responsibility for the now renamed International Classification of Diseases, Injuries, and Causes of Death with the sixth edition.
Development of a Standard
Standards are greatly beneficial for human societies, which is perfectly represented by the International System (SI) or metric system of weights and measures. Allowing every country or state to develop its own system would result in enormous redundancy and loss in productivity.
There are four primary paths for standards development:
(1) Consortium (Ad hoc): A group of interested people and organizations agree on an informal standard specification, which is accepted as a standard through this mutual agreement.
(2) De facto: One stakeholder controls a large enough market share to make its product the standard.
(3) Government mandate (de jure standard): A government agency, such as the National Institute for Standards and Technology (NIST) develops a standard and legislates its use. A de jure standard can be enacted by law or regulation, i.e. the Health and Insurance Portability and Accountability Act (HIPAA) of 1996 mandated how medical information is shared. As a result the Accredited Standards Committee X12, accredited by the American National Standards Institute (ANSI) developed Form 5010 for the electronic transaction of dental claims for Medicaid patients.7
(4) Consensus: A set of volunteer stakeholder representatives participate in an open process to create a standard. Most health-care standards are produced by this method. An example is the Health Level 7 (HL7) standard for the interchange of clinical data.8 Sometimes specific organizations are formed to create standards, i.e. American Society for Testing Material (ASTM).9
On its path to maturity, a standard will generally go through several versions. The first attempts at implementation are often challenging as stakeholders may have different interpretations of the standard and as areas not addressed by the standard are identified. As the standard evolves to address early challenges, there must be attention paid to backward compatibility. During the course of maturation, an implementation guide may be produced to help new adopters benefit from the experience of early adopters. As illustrated in the History of Standardized Diagnostic Terminologies
section, early acceptance and adoption rate are critical to the success of a standard. Accredited standards bodies, governments, other major stakeholders, and the marketplace may influence this process. In the case of a standardized dental diagnostic terminology, these parties would include payors (insurance companies), government agencies, academic institutions, dental electronic health record vendors, professional organizations (responsible for the oversight of the profession), dental providers and care team members, and informed patients (consumers). After the early stage, the maintenance and promulgation of the standard are essential to ensure widespread availability and continued value. It is also important to have agreement among stakeholders about how rules will be enforced in order to assure adherence to the standard (conformance).
In some cases, standards are developed by organizations that required the standard to execute their principal functions; in others, coalitions are formed for the purpose of developing a particular standard. In addition, there are standards organizations whose sole purpose is to develop and promote standards.10 In the US, the American National Standards Institute (ANSI) administers the only government-recognized system for establishing American National Standards. ANSI does not create standards; instead, it guides standards developers and users to reach consensus. ANSI also represents U.S. interests in international standardization, serving as the U.S. voting representative on the International Standards Organization (ISO). The ISO was established as a membership organization to provide a focal point for all international standards with one member for each country. Its Vienna agreement describes how disagreements between different standards should be handled.11
With the development of the European Union, the European Committee for Standardization (Comité Européen de Normalisation, CEN) was developed as the major provider of European Standards and technical specifications. Just as ISO, CEN is a membership organization and counts thirty-three countries as its members. CEN signed the Vienna agreement with ISO in 1991.
ISO and CEN follow a strict workflow, which can take years, in order to arrive at an international standard.12 Adding new items to an existing standard or adopting a standard from another organization may fall under the “Fast-track procedure” in which “a document with a certain degree of maturity is available at the start of a standardization project.” In this case the document can be submitted directly for approval as a Draft International Standard (DIS) or final DIS (FDIS, if developed by an international standardizing body recognized by the ISO Council), skipping many stages of standard development.13 ISO approval of standards is important since a number of countries have laws that require the use of ISO standards if they exist.
Table 2.1: Standards Development Process
Development Methods9
De facto method: A group of interested people and organizations agree on an informal standard specification through mutual agreement. These "marketplace" standards often are developed more quickly than standards developed in a more formal process.
Consortia (Ad-hoc) method: Companies agree to work together to solve a specific market need. Membership often requires a substantial financial contribution.
Government-mandate (de jure) method: A government agency creates a standard and legislates its use.
Consensus method: Industry professionals from both the public and private sectors work in an open process to create a standard. The voluntary process requires full cooperation by all parties and depends upon data gathering and compromises among a diverse range of stakeholders.
Phases of Standard Maturation35
Identification stage: Awareness that a standard is needed for some domain and that there is technology that can support such a standard.
Conceptualization stage: The characteristics of a standard are defined, e.g., scope, purpose, format.
Discussion stage: An outline of content, critical issues, and timeline are created. The author states that basic concepts are usually heated topics of discussion.
Writing of a draft standard: Written by a small group of vendors. An open policy is followed with an open balloting process.
Comments and recommendations invited.
Critical Success Factors
Backward compatibility: allows the use of previous versions of the standard. Early implementation
Acceptance
Rate of Implementation
Conformance: compliance with the standard and usually includes specific agreements among users of the standard, who affirm that specific rules will be followed.
Certification: a neutral body certifies that a vendor’s product complies and conforms to the standard.
Current Representation of Oral Health Conditions in Standardized Diagnostic Terminologies
Diseases of the oral cavity were codified in the early revisions of ICD. However, ICD codes for oral diseases were not sufficiently subdivided and were difficult to use due to the scattered arrangement of codes throughout the ICD volume. Consequently, the ICD-DA, or the Application of the International Classification of Diseases to Dentistry and Stomatology was added at the time of the Eighth revision of the ICD in 1965. Despite these efforts, ICD’s coverage of oral and dental diagnoses remains insufficient.13-15 E.g. ICD does not distinguish between primary and recurrent caries, the two stages of enamel caries or three levels of dentinal caries. ICD does also not include diagnoses that encompass the need for tooth restoration or tooth replacement, such as a biologically unacceptable restoration.16 In the U.S. the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) developed the ICD-10 Clinical Modification (ICD-10-CM) for classifying diagnoses, medical coding and reporting for billing purposes. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO), which replaces ICD-9. There are approximately 68,000 ICD–10–CM codes.17 There is more information and detail within these codes than its American predecessor ICD–9–CM. As such, the oral health component of ICD-10-CM is a bit more granular that ICD 10.
SNOMED was developed in 1965 by the College of American Pathologists (CAP) as SNOP (Systematized Nomenclature of Pathology), and later extended into other medical fields. In 1999, through collaboration with the National Health Service (NHS) SNOMED Clinical Terms (SNOMED CT) was developed. SNOMED CT is a comprehensive, multilingual clinical healthcare terminology for use in the EHR. Developed as a reference terminology, it contains more than 311,000 unique terms organized into hierarchies. In 2007 the International Health Terminology Standards Development Organization (IHTSDO) acquired SNOMED CT (and the rights to all older versions). IHTSDO, a healthcare standard development organization (SDO), is similarly to ISO and CEN a membership organization, and has eighteen countries participating as members as of 2012.18 SNODENT, a Systematized Nomenclature for Dentistry, was devised by the American Dental Association (ADA) in the early 1990’s (DIOC 2009). In 1998, the ADA entered into an agreement with CAP, licensing them to incorporating SNODENT into SNOMED. In 2012, SNODENT was incorporated into the SNOMED CT medical code set, thanks to a licensing agreement with IHTSDO. SNODENT is composed of diagnoses, signs, symptoms and complaints and
currently includes over 7700 terms. Up until its inclusion into SNOMED CT, SNODENT was only available by license and was maintained by the ADA’s Advisory Committee on Dental Electronic Nomenclature, Indexing and Classification (ACODENIC), a group comprised of representatives from each recognized dental specialty. As a result SNODENT has not yet been implemented in the dental profession.
Table 2.2: Selected Diagnostic Terminologies Relevant to Oral Health
Terminology Focus
International Classification of Diseases (ICD)
First published in 1893 and revised at 10-year intervals. The coding system consists of a core classification of three digit codes that are the minimum required to report mortality statistics to the WHO. A fourth digit provides an additional level of detail. ICD-9-CM is compatible with ICD-9 and provides extra levels of detail in many places by adding fourth-digit and fifth-digit codes. Most of the diagnoses in the United States are coded in ICD-9-CM allowing
compliance with international treaty (by conversion to ICD-9) and supporting billing requirements.
Systemized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT)
In 1996, SNOMED changed from a multi-axial structure to a more logic-based structure called Reference Terminology.36, 37
In 1999, the College of American Pathologists and the NHS merged their products into SNOMED-CT38 containing terms for 344,000 concepts. Despite the broad coverage of SNOMED-CT, it continues to allow users to create new ad hoc terms through post coordination of existing terms. SNODENT Since the early 1990s, the American Dental Association
(ADA) has led the creation of SNODENT, the Systematized Nomenclature for Dentistry. SNODENT is composed of diagnoses, signs, symptoms and complaints, and currently includes over 7,700 terms. However, SNODENT is not available for use by the general practitioner or any dental schools. In June 2012 The ADA signed a licensing agreement with the International Health Terminology Standards Development Organization (IHTSDO) to allow for the integration of SNODENT into the SNOMED CT medical code set.
The EZCodes Dental Diagnostic Terminology
To meet the need for a comprehensive yet concise set of dental diagnostic terms, a happy medium between ICD sparseness and SNOMED enormousness, an academic workgroup came together in 2009 to create and implement the EZCodes dental diagnostic terminology. This work was funded by a National Institutes of Health grant R01 DE021051. The team is made up of dental clinicians/faculty, epidemiologists, informaticians and cognitive scientists from academic institutions in the US and Europe led by the Harvard School of Dental Medicine (Boston, Massachusetts). The workgroup charge and guiding principles in the creation and revision of the EZCodes dental diagnostic terminology have been published.4 Briefly they are based on the belief that diagnosis should precede treatment, that diagnoses should be documented consistently and in a standardized way, and that structured documentation of a diagnosis in an electronic health record should be easy and error free.
Since 2009, the EZCodes terminology has undergone 2 major revisions and has been adopted by 15 academic dental institutions in the U.S. and Europe, one hospital-based academic dental clinic and one large group practice with 54 clinics in three states, with additional institutions in line to begin using it in the near future. The EZCodes dental diagnostic terms have been validated16 and mapped to SNOMED, ICD 9, ICD 10 and ICD 10-CM, as well as the American and Dutch treatment coding classifications (CDT19 and UPT,20 respectively). These mappings were performed to assist in the administrative functions associated with payment and to keep pace with the American requirements for EHR functionality.21 The EZCodes’ usability, utilization, relevance and implications for dental education have been reported earlier.22-25 The EZCodes have already been a boon to health services research, as the standardization of diagnosis has enabled the pooling of clinical data across four dental institutions representing over one million patient visits in the United States.
The EZCodes were built upon existing best practices. EZCodes has incorporated the description and sub-classification of periodontal terms following the American Academy of Periodontology format.26 This format tackles the biggest challenges of previous classification attempts27-29 unique to the classification of periodontal disease such as the lack of sufficient knowledge to separate truly different diseases (disease heterogeneity) from differences in the presentation/severity of the same disease (phenotypic variation). It also adopted the recommendations of the American Board of Endodontics30 to classify diagnosis in two dimensions – symptomaticity and reversibility – both of which have implications for the clinical
management of patient presentation. The EZCodes terminology includes the American Academy of Pediatric Dentistry’s caries risk assessment procedure for assessing caries risk. This is especially important in informing a clinician whether or not to institute specific interventions. Following the principles of the International Caries Detection and Assessment System (ICDAS), the EZCodes dental diagnostic terminology follows best practices in caries diagnoses, which require an indication of the extent of decay. Lastly, the 2012 version of the EZCodes terminology contains terms relating to removable prosthodontics – an important sub-discipline in dentistry. These terms were the fifth most commonly utilized23 and are not available in ICD 10-CM, although analogous terms are available in ICD10-CM for complications/failures of cardiac and joint prostheses.
With 1355 terms, the EZCodes dental diagnostic terminology is developed as an interface terminology with SNOMED CT as its reference terminology. An interface terminology is a “bridge” which allows the user to describe the diagnosis using natural language, which is then mapped to the reference terminology using formal language. Once medical/dental information is captured with the interface terminology, it is mapped on the backend to ICD and SNOMED CT, the two relevant reference terminologies. In the context of an EHR, the usability of an interface refers to how easy it is for providers to interact with the terminology as represented in the EHR.31 Usability increases when the terminology is enhanced with attributes that improve the efficiency of selecting terms.32,33 These attributes include (1) presence of additional relevant medical/dental information (providing other more general facts about a concept, which is called assertional knowledge: e.g. when hovering over the diagnostic term “lichen planus”, a box will pop up that includes the following information: Oral lichen planus (OLP); reticular form (Wickham’s striae) – often bilateral and asymptomatic, bullous form, erosive forms (Atrophic LP & Ulcerative LP) – symptomatic, multiple areas of the mouth; affect middle age adults, female/male ratio is 3:2, rare in children.) (2) presence of adequate synonyms; (3) a balance between enough terms to pick from a list (pre-coordination) and the ability for the provider to create new terms by adding two or more terms together while using the electronic health record (post-coordination); and (4) mapping to terminologies having formal concept representations, such as ICD and SNOMED. The EZCodes terminology contains a fair quantity of these attributes with concrete steps to expand in this area over the next revisions. Specifically, the EZCodes include a full set of synonyms and descriptions for each term as part of the 2013 EZCodes terminology version.
Box 2.2 documents EZCodes terms that are currently not represented in ICD-10-CM and a suggested place they could be inserted. The list is longer for ICD 10, as that is a
less granular terminology. Although SNOMED CT is the reference terminology for the EZCodes, a number of EZCodes terms were developed that were not represented in SNOMED CT (mainly the removable partial denture terms as displayed in Box 2.2). We have successfully been able to submit those to IHTSDO for inclusion into SNOMED CT.
Barriers to the Adoption of a Standardized Diagnostic Terminology in Dentistry
In Fall 2012, three years after the implementation of the EZCodes, the researchers held a national conference to discuss the barriers against the broad adoption of standardized dental diagnostic terms. Participants included representatives from electronic health record vendors, insurance companies, government, dental professional organizations, dental academic centers and large dental group practices. Common concerns about implementing standardized dental diagnostic terms centered on cultural barriers, ease of use, return on investment, and technical issues, in particular:
Cultural inertia is a barrier to adoption. Moving to documenting diagnosis in standardized terms would represent a significant cultural change in a profession that tends to focus on procedures.
Fear of a loss of autonomy is a barrier to adoption. Some dentists may fear that the implementation of dental diagnostic terms will lead to more rigorous and inflexible oversight of the appropriateness of care, which may lead to the denial of insurance claims.
Fear of usability problems. If a standardized dental diagnostic terminology is difficult to use or disrupts the workflow, this will be a huge barrier to adoption. If terms are implemented in EHRs, users must be able to enter data with a minimum of effort.
Fear of adopting a terminology that would become outmoded. Given that dentistry has not, to date, widely agreed upon a single standardized diagnostic terminology, there is a hesitance to adopt a terminology that may not end up being broadly adopted.
Unclear utility. From the individual practitioner perspective, it may not be clear how using standardized diagnostic terms will improve their practice.
Not required for insurance reimbursement. Because they are not yet required for billing purposes, some dentists may not see the value in using standardized dental diagnostic terms.
