s
EZCodes: A diagnostic terminology as the foundational step of quality for the
dental profession
Kalenderian-Groenewegen, E.
Publication date 2013
Link to publication
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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CHAPTER 7
The Value of Using the EZCodes Diagnostic Terminology in an
Electronic Health Record
E. Kalenderian1, R. Ramoni2, A. AbdulRahiman1, O. Tokede1, Dat Q. Phan4, J. M. White3, R. Vaderhobli3, M. F. Walji4
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
Abstract
Secondary data analysis allows for in depth epidemiologic and public health research, thereby allowing for effective quality control and clinical outcomes measurement. Four dental schools using the same EHR, contributed data to a dental data repository based on the Informatics for Integrating Biology and the Bedside (i2b2) data warehousing platform. Users were able to query across the full repository without being able to identify a specific institution. The EZCodes Dental Diagnostic Terminology was used to document diagnoses in a standardized fashion. A use case, describing adherence to current practice guidelines for generalized chronic moderate periodontitis, was developed to establish the value of documenting a standardized diagnosis in the EHR. The results show that less than half of the patients undergoing scaling and root planing for their disease received appropriate follow up care. The availability of a structured diagnosis in the form of the EZCodes terminology in an EHR allows for meaningful secondary electronic data analysis and for the first time linking of diagnosis to treatment. This allowed for outcome measurement with clinical care as well as educational implications. We conclude that documenting a diagnosis in the EHR by using the EZCodes dental diagnostic terminology is relevant and is value added.
Key words: Diagnosis, Terminology, Dentistry, EHR, Periodontitis, Practice Guidelines, Outcome Measures, Epidemiology
Background
Secondary Data Analysis
“Secondary data analysis is defined as the analysis of data that was collected by someone else for another primary purpose”.1
In this case the data was collected during routine clinical care of the patient and stored in the patient’s clinical EHR. Using secondary data can provide for large sample sizes, relevant measures, and longitudinal data for relatively low cost and minimal time. Secondary data analysis allows for in depth epidemiologic and public health research. It can also provide ammunition for true quality control and clinical outcomes measurement. However, in that case the presence of a documented diagnosis is a prerequisite. Of course the drawback of using secondary data is that the study population and measures collected are not always exactly the way one might have preferred to collect the data. However, optimal secondary data analysis is accomplished through the development of a good research question that should have implications for patient care or public policy.1
Data Repository
The data repository in which the secondary data is housed is based on the Informatics for Integrating Biology and the Bedside (i2b2) data warehousing platform.2 Four academic institutions (UCSF, HSDM, UT Houston, Tufts) are currently contributing data to this data repository. This centralized repository contains a limited dataset in which data are de-identified with the exception of dates (e.g., date of birth, visit dates) and zip codes. An advantage of i2b2 is the availability of a web-based client that allows end users from each of the four institutions to securely access, explore, and query the repository.
All four dental schools use the same EHR, AxiUm (Exan, Vancouver, Canada). The data repository houses over 1 million unique patients, with different schools adding data at different times. See Table 7.1.
Table 7.1: Institutions participating in the data repository Institution Start date
axiUm EHR
Look back date for data in DR
Dx terminology start date
HSDM April 2009 April 2009 April 2009
UCSF July 2005 July 2005 July 2005
UT Houston August 2006 August 2006 August 2011
Tufts June 2004 June 2004 --
Not all data points in the EHR are always entered for every patient. For
that meaningful epidemiologic and public health research through secondary data analysis is fully dependent on proper data entry on the front end. See Table 7.2.
Table 7.2: Demographics of patients in the data repository
School of dentistry
School 1 School 2 School 3 School 4
Demographics N=15,219 N=34,126 N=34,318 N=13,927 Mean age (SD) 48 (17.0) 47 (17.8) 50 (23.2) 45 (17.5) Sex (%) Male 42.4 46.1 45.3 39.2 Female 55.7 53.9 53.3 55.9 Others/don’t know 1.9 0.0 1.4 4.9 Prevalence of periodontitis was significant among the patient population of all four schools, see Table 7.3. Periodontitis was calculated using data recorded in the periodontal chart according to CDC/AAP case definition:3
Mild periodontitis was defined as ≥ 2 interproximal sites with ≥ 3 mm clinical attachment loss (CAL), and ≥ 2 interproximal sites with ≥ 4 mm pocket depth (PD) (not on the same tooth) or 1 site with ≥ 5 mm.
Moderate periodontitis was defined as ≥ 2 interproximal sites with ≥ 4 mm CAL (not on the same tooth) or 2 or more interproximal sites with PD ≥ 5 mm, also not on the same tooth.
Severe periodontitis was defined as the presence of ≥ 2 interproximal sites with ≥ 6 mm CAL (not on the same tooth) and ≥ 1 interproximal site(s) with ≥ 5 mm PD. Total periodontitis was the sum of mild, moderate and severe periodontitis.
Table 7.3: Prevalence of periodontitis in Dental Data Repository database between
January 1, 2010 and December 31, 2011
School of dentistry
School 1 School 2 School 3 School 4
Oral health status N=15,219 N=34,126 N=34,318 N=13,927
Periodontitis
(%)
N= 913 N=2,671 N=4,918 N=5,913
Chronic Periodontitis
The American Academy of Periodontology (AAP) defines chronic periodontitis as “the inflammation of the gingiva extending into the adjacent attachment apparatus. Chronic periodontitis with slight to moderate destruction is characterized by a loss of up to one-third of the supporting periodontal tissues”. Treatment is centered on altering or eliminating the microbial etiology and contributing risk factors for the disease. Initial therapy consists of a number of steps:
Management of contributing systemic risk factors;
Instruction, reinforcement, and evaluation of the patient’s plaque control; Supra- and subgingival scaling and root planing;
Antimicrobial agents or devices may be used;
Local factors contributing to chronic periodontitis should be eliminated, or controlled;
Evaluation of the initial therapy’s outcomes;
Periodontal maintenance should be scheduled at appropriate intervals.
If the results of initial therapy do not resolve the periodontal condition, periodontal surgery should be considered.4 More recent publications reiterate the need for subgingival debridement in conjunction with supragingival plaque control,5 as well as the clinical benefits that antibiotics provide in conjunction with scaling and root planing.6
Methods
The institutional datasets were mapped to a combined terminology to allow users to query across the full repository without being able to identify a specific institution. The EZCodes Dental Diagnostic Terminology was used to map the diagnoses.7 All four institutions used the Universal Tooth Numbering System to refer to each tooth.8 Additionally, periodontal data had a great degree of consistency amongst the sites. The data for each site is modeled so that a user familiar with the AxiUm EHR can easily navigate through the i2b2 representation.
A use case, describing adherence to current practice guidelines for generalized chronic moderate periodontitis was developed to establish the value of documenting a standardized diagnosis in the EHR.
Research question:
Are patients in the data repository with a documented diagnosis of ‘Generalized Chronic Moderate Periodontitis’ being treated according to the current AAP
guidelines, specifically according to guidelines #3, 6, and 7--that is, do they receive periodontal prophylactic treatment only, periodontal maintenance treatment only, Scaling and Root Planing (SR/P) only, or SR/P with a follow up periodontal maintenance treatment and/or periodontal prophylaxis for their disease?
The diagnostic terms (EZCodes) and treatment procedures (CDT codes) used for the database search are shown in Table 7.4. The search criteria are shown in Table 7.5.
Table 7.4: Diagnostic and treatment concepts used for periodontitis use case
Terminology Concept ID#
EZCodes Generalized Chronic Moderate Periodontitis 785649
CDT Periodontal prophylaxis adult treatment D1110
CDT Periodontal maintenance treatment D4910
CDT Periodontal Scaling and Root Planing, four or more teeth per quadrant
D4341
CDT Periodontal Scaling and Root Planing, one to three teeth per quadrant
Table 7.5: Search criteria for periodontitis use case EZCodes ID 785649 AND CDT D1110 OR -- EXCLUDE CDT D4910 CDT D4341 CDT D4342 EZCodes ID 785649 AND CDT D4910 OR -- EXCLUDE CDT D4341 CDT D4342 CDT D1110 EZCodes ID 785649 AND CDT D4910 CDT D1110 OR -- EXCLUDE CDT D4341 CDT D4342 EZCodes ID 785649 AND CDT D4341 OR CDT D4342 EXCLUDE CDT D1110 CDT D4910 EZCodes ID 785649 AND CDT D4341 CDT D4342 OR -- EXCLUDE CDT D1110 CDT D4910 EZCodes ID 785649 AND CDT D4341 CDT D1110 OR CDT D4342 EXCLUDE CDT D4910 EZCodes ID 785649 AND CDT D4341 CDT D4910 OR CDT D4342 EXCLUDE CDT 1110 EZCodes ID 785649 AND -- OR -- EXCLUDE CDT D4341 CDT D4342 CDT D4910 CDT D1110 Results
The data shows that 13% of patients with a documented diagnosis of ‘Generalized Chronic Moderate Periodontitis’ received periodontal prophylaxis treatment only, step 6 of the initial therapy as recommended by the American Academy of Periodontology (AAP). 4% received periodontal maintenance treatment only, step 7 of the initial therapy as recommended by the AAP. (See Table 7.6.) 30% of the patients received periodontal maintenance treatment in combination with other guideline treatment and 36% received prophylaxis treatment in combination with other guideline treatment. (See tables 7.7 and 7.8) Scaling and root planing is part of the recommended therapy for this disease and 63% of the patients in our data repository received this treatment. However, of these 2206 patients, only 514 (23%) received a periodontal maintenance treatment, and 328 (15%) received a periodontal maintenance as well as prophylaxis treatment. Thus, less than half of the patients undergoing
scaling and root planing for their disease received appropriate follow up care. (See table 7.9.)
Table 7.6: All treatments received for documented diagnosis of Generalized Chronic
Moderate Periodontitis
Treatments Received # Patients %
Prophylaxis Adult (D1110) only 460* 13%
Periodontal maintenance (D4910) only 138* 4% Prophy Adult D1110 and Perio maintenance D4910 only 88* 3% 1-3 or >4 teeth /quadrant Scaling & Root Planing (SR/P
D4341 or 4342) only
985*
28%
1-3 and >4 teeth /quadrant SR/P (D4341 and 4342) only 59 2% 1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and only
Prophy Adult (D1110)
379*
11%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and only Perio maintenance (4910)
514*
15%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and Prophy Adult (D1110) and Perio maintenance (4910)
328*
9%
No SR/P, Adult Prophylaxis or Periodontal Maintenance 627 18% Total patients with one or more of the four treatments* 2892 82% Total patients with SR/P and/or Perio Maintenance Tx 2432 69%
Total patients with Diagnosis 3519
Table 7.7: Number of patients who received Periodontal Maintenance related
treatments for documented diagnosis of Generalized Chronic Moderate Periodontitis
Periodontal Maintenance Treatments # Patients %
Periodontal maintenance (D4910) only 138 4% 1-3 or >4 teeth /quadrant SR/P (D4341 or
4342) and only Perio maintenance (4910)
514
15%
Prophylaxis Adult D1110 and Perio maintenance D4910 only
88
3%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and Prophylaxis Adult (D1110) and Perio maintenance (4910)
328
9%
Total patients receiving periodontal maintenance treatment
1068 30%
Total patients with Diagnosis 3519
Table 7.8: Number of patients who received periodontal Prophylaxis Adult treatment
for documented diagnosis of Generalized Chronic Moderate Periodontitis
Prophylaxis Treatments # Patients %
Prophylaxis Adult (D1110) only 460 13% Prophylaxis Adult D1110 and Periodontal
maintenance D4910 only
88
3%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and only Prophylaxis Adult (D1110)
379
11%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and Prophylaxis Adult (D1110) and Periodontal maintenance (4910)
328
9%
Total patients receiving prophylaxis treatment 1255 36% Total patients with Diagnosis 3519
Table 7.9: Number of patients who received Scaling and Root Planing treatment for
documented diagnosis of Generalized Chronic Moderate Periodontitis
Scaling and Root Planing Treatments # Patients %
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) only
985
28%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and only Prophylaxis Adult (D1110)
379
11%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and only Perio maintenance (4910)
514
15%
1-3 or >4 teeth /quadrant SR/P (D4341 or 4342) and Prophylaxis Adult (D1110) and Periodontal maintenance (4910)
328
9%
Total patients with 1-3 or >4 teeth /quadrant Scaling & Root planing (D4341 or 4342)
2206 63%
Total patients with Diagnosis 3519
Discussion
As this use case shows, many of the patients did not receive treatment according to current guidelines for generalized chronic moderate periodontitis. Many factors influence disease beyond the documentation of a diagnosis. We do not know why patients may have refused or did not receive recommended treatment. Proper follow-up is a critical phase of clinical dentistry as well as an excellent patient management and risk management technique. Good follow-up procedures enhance both patient care and patient satisfaction by identifying clinical problems early and addressing patient concerns and complaints quickly. The initial investment the patient makes toward scaling and root planing is lost to the patient if adequate maintenance and follow up appointments are not kept. However, studies have shown that compliance with recall visits is not optimum among patients requiring periodontal maintenance treatment.9-11 However, these data are an important tool for the dental schools as part of the armamentarium for curriculum development, student feedback, patient education, continuous quality improvement and clinical care.
A logical next step will be expansion of outcome measurement within the dental schools that are a member of the Consortium for Oral Health Research and Informatics (COHRI). COHRI’s membership comprises thirty dental schools, and one large dental practice group, consisting of 54 individual dental practices. Between these
million patient visits per year. As a member of COHRI, these dental schools also agree to share data. In order to facilitate sharing of data and specifically participating in the data repository, the COHRI schools are actively moving towards a standardized medical and dental history form as well as implementation of the EZCodes terminology. Fifteen of the COHRI schools have already implemented the EZCodes terminology and as such are an easy first focus for expansion of our outcome measurement research.
These data reflect patients in academic clinics only, and treatment provided may be a reflection of the student population and skills and therefore results may not be generalizable to the general private dental practice. As such another option may be expansion of this research into the dental practice based research network (PBRN). PBRNs can be an important tool for quality improvement in the general practitioner’s setting while also advancing research goals.12 As the challenge for many PBRNs has shifted to aligning networks with technology,13 the expansion of EHRs in the general practitioner’s clinic makes implementation of a structured diagnostic terminology a natural area for collaboration between universities and the recently reformatted national dental PBRN in the U.S.14 Hence we look forward to collaborating with the dental PBRN to include the EZCodes as an important part of future outcome measurement research.
Conclusion
The availability of a structured diagnosis in the form of the EZCodes terminology in an EHR allows for meaningful secondary data analysis and for the first time allows for the linking of diagnosis to treatment. This allows for exciting expansion of epidemiologic and dental public health research as well as quality control and clinical outcomes measurement. Indeed, we conclude that documenting a diagnosis in the EHR by using the EZCodes dental diagnostic terminology is relevant and is value added.
References
1. Smith AK, Ayanian JZ, Covinsky KE, et al. Conducting high-value secondary dataset analysis: an introductory guide and resources. J Gen Intern Med 2011;26(8):920-9.
2. Murphy SN, Weber G, Mendis M, et al. Serving the enterprise and beyond with informatics for integrating biology and the bedside (i2b2). J Am Med Inform Assoc 2010;17(2):124-30.
3. Eke PI, Page RC, Wei L, Thornton-Evans G, Genco RJ. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 2012;83(12):1449-54
4. American Academy of Periodontology. Parameters of Care. American Academy of Periodontology. J Periodontol 2000;71(5 Suppl):i-ii, 847-83.
5. Van der Weijden GA, Timmerman MF. A systematic review on the clinical efficacy of subgingival debridement in the treatment of chronic periodontitis. J Clin Periodontol 2002;29 Suppl 3:55-71; discussion 90-1.
6. Haffajee AD, Torresyap G, Socransky SS. Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results. J Clin Periodontol 2007;34(3):243-53.
7. Kalenderian E, Ramoni RL, White JM, et al. The development of a dental diagnostic terminology. J Dent Educ 2011;75(1):68-76.
8. Schwartz S, Stege D. Tooth numbering systems: a final choice. Ann Dent 1977;36(4):99-106.
9. Konig J, Plagmann HC, Langenfeld N, Kocher T. Retrospective comparison of clinical variables between compliant and non-compliant patients. J Clin Periodontol 2001;28(3):227-32.
10. Miyamoto T, Kumagai T, Jones JA, Van Dyke TE, Nunn ME. Compliance as a prognostic indicator: retrospective study of 505 patients treated and maintained for 15 years. J Periodontol 2006;77(2):223-32.
11. Lorentz TC, Cota LO, Cortelli JR, Vargas AM, Costa FO. Prospective study of complier individuals under periodontal maintenance therapy: analysis of clinical periodontal parameters, risk predictors and the progression of periodontitis. J Clin Periodontol 2009;36(1):58-67.
12. Mold JW, Peterson KA. Primary care practice-based research networks: working at the interface between research and quality improvement. Ann Fam Med 2005;3 Suppl 1:S12-20.
14. The Nation's Network. The National Dental Practice-Based Research Network 2013. "http://nationaldentalpbrn.org/". Accessed 5/14/2013.
