Learning how to be a Chief Information Officer (CIO) in dentistry: A new online course

Just in time for the holidays, I decided to write what will be my last blog post for the year. In late January/early February, we plan to release an online continuing dental education course on information technology in dentistry. It essentially teaches you how to be the “Chief Information Officer” in a dental care delivery setting.

The course is formally titled Introduction to Health Information Technology in Dentistry and the product of two years of work by the Center for Dental Informatics. Here are the short stats:

  • designed as a full-semester, 3-credit graduate course
  • 15 sessions, each of which takes about 3 hours to complete
  • expected to award about 50-60 continuing dental education credits
  • priced at prevailing rates

So, why are we offering this course? Successfully implementing and using health information technology (HIT) requires more than just knowledge about technology. It is, essentially, a complex, socio-technical challenge. Therefore, the course delivers solid technical knowledge about informatics, as well as leadership and management skills. The course is not designed to make participants into experts in everything “technology.” Rather, it delivers a strong technology- and management-focused package to help them succeed at implementing electronic dental records (EDR) and other technologies.

The course has two main objectives. It will participants:

  1. use information systems for managing dental data and supporting clinical decision making in the context of the dental care and office workflow; and
  2. plan, evaluate technology for, administer and manage information technology implementations in dentistry.

Our premise for the course is that participants are not simply interested in becoming consumers of a fully implemented information system, but intend to acquire a deeper background for the “why” and “how” of HIT implementation in dentistry. By doing so, they will become “educated consumers” of HIT and will be able to optimize how HIT contributes to achieving their goals. Successful completion of the course will make participants competent to lead and/or substantially contribute to applying HIT to dentistry successfully in a variety of clinical care settings.

The course modules include (subject to finalization): Course introduction and overview; Dental care workflow and analysis; Overview of electronic dental records; Dental data and their representation; Controlled vocabularies, terminologies and ontologies; User-centered design methods for EDRs; Practical information design; Supporting clinical decision making with computers; Failures in Health Information Technology (HIT); Planning and implementing IT in dental practice; Requirements analysis and technology evaluation; Managing HR for IT; Introduction to hardware and software; Privacy, confidentiality and security; and a Course review session.

So, who is the course targeted at? Three main audiences:

  1. Dentists: Dental personnel will benefit from the course through a comprehensive overview of health information technology use and implementation in dental practice. A key focus of the course is how information technology can help improve patient care and support the clinical activities of the dental team. As leaders of the dental team, dentists will gain a particular understanding of how the office workflow relates to requirements for IT systems, and how to best plan and select products for, as well as manage, implementation.
  2. Dental auxiliary personnel: Auxiliary personnel often play a key role in the success of HIT systems because they are the most frequent users. Dental hygienists and assistants will mostly benefit from an understanding of system functions and usability in light of the daily use of IT applications.
  3. Non-dentists, such as information technology support personnel and consultants: Non-dental personnel will gain a basic understanding of how dental offices work and how IT can be used to support its operations.

Did this description get you mildly interested? If so, check out our marketing video:

Last but not least, you probably want to know who is teaching the course:

  • Titus Schleyer, DMD, PhD, Assoc. Professor and Director, Center for Dental Informatics
  • Thankam P. Thyvalikakath, DMD, PhD, Assistant Professor, Center for Dental Informatics
  • Heiko Spallek, DMD, PhD, MSBA, Associate Professor, Dental Public Health, Center for Dental Informatics
  • Richard A. Oldham, DDS, Graduate Student, Department of Biomedical Informatics
  • Corey Stein, BSc, Graduate Student, Department of Biomedical Informatics

There are a limited number of slots available in the course. If you’re interested, please e-mail me at schleyer@regenstrief.org.

With my best wishes for Happy Holidays!


P.S. This course is not an in-depth tutorial on the functions of particular practice management or EDR systems. Rather, it uses practical examples from these systems to highlight important theoretical concepts relevant to health information technology in dentistry.

– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics


Does dentistry really need more than one diagnostic vocabulary?

In case you had to guess, the answer is “no.” Recently, DrBicuspid.com ran a story about the EZCode system and SNODENT titled “Diagnostic dental codes: Are we there yet?” Unfortunately, the answer to that question is also “no.”

The emergence of not one, but two, dental diagnostic vocabularies is troubling. First we have essentially none, then suddenly two. This reminds me of a recent quote by Doug Fridsma, the Director of the Office of Standards and Interoperability in the Office of the National Coordinator for Health IT. At an AMIA 2012 Annual Symposium panel discussion, he remarked: “Standards are like toothbrushes. Everyone has one, but nobody wants to use someone else’s.” I appreciated the dental analogy, but duplicate standards are no laughing matter. Dentistry is currently wasting a huge opportunity to create a novel, forward-looking approach to representing dental diagnoses. Unfortunately, we seem to be stuck somewhere between the Stone Age and the 19th century.

To understand why, we need to look back a few years. The ADA started working on the first incarnation of SNODENT, its diagnostic vocabulary, sometime in the 90s. The project took a while and SNODENT was supposed to be released in January 2000 (see “SNODENT to provide inclusive means of transmitting dental information,” ADA News, 30:9; 5/3/1999 [unfortunately, not available online]). When the ADA News asked then ADA President Dr. Tim Rose: “Will you be using SNODENT in your office?” he confidently answered: “I sure will.” Fast-forward to 2012: Yes, we are still waiting for SNODENT, now going into its second incarnation. (Actually,can you be reincarnated when you have never been born? Sounds like a Zen koan.)

In part, the EZCodes diagnostic vocabulary, a project of Harvard University School of Dental Medicine‘s Dr. Elsbeth Kalenderian, emerged as a reaction to this “Waiting for Godot” scenario. Normally, few people would care about competing dental diagnostic vocabularies, were it not for two important factors. One is the HITECH Act. Sometime in the future, the Department of Health and Human Services will anoint one dental diagnostic vocabulary as “the” standard for interoperability of diagnostic information in dentistry. The second is that the ADA is realizing quite a bit of non-dues revenue from licensing the CDT. (According to a recent conversation with an ADA staffer, a CDT license is about $11/year per customer of an electronic practice management system and $1,000/year per institutional site license. With over 90% of all dentists using a computer in their office, you can do the math.) So, it stands to reason that licensing a diagnostic vocabulary similarly might generate another nice chunk of cash for the ADA every year. As a result, Harvard and the ADA have been at war over their respective diagnostic vocabularies for quite some time. (Of course, if you only have the slightest inkling about the organizational psychology of both entities, you know this had to end up in a mudwrestling match. But, that is another story.)

So, what about the comparative merits of SNODENT and EZCodes? The DrBiscuspid article provides some basic information: SNODENT has about 7,000 terms, EZCodes about 1,300. EZCodes was developed by a working group of the Consortium for Oral Health Research and Informatics, mainly by merging several existing dental diagnostic vocabularies. SNODENT was developed through a somewhat opaque process that, to my knowledge, was never really published. Both vocabularies are currently free for researchers after signing a licensing agreement.

So, how well do these codes work? According to the DrBicuspid article, the EZCodes are currently being piloted in 17 dental schools and institutions located in the U.S. and Europe. There is a 2011 paper on the evaluation of the Z Codes, a major component of the EZCodes. SNODENT is rumored to be evaluated in a few dental schools, but a search for “SNODENT” in PubMed today only turned up the same three papers that have been there since 2006. The only other reference to a comparison between the two vocabularies alleges that “the ADA sees EZCodes as an ‘interface terminology’ useful for capturing health problems but not as a replacement for SNODENT in storing information in EHRs.”

So, what should we make of all of this? I fear that neither effort at developing a dental diagnostic vocabulary will produce a very satisfying result in the long term, unless some radical changes are made. Even worse, the tug-of-war and duplicate work consumes precious resources that dentistry, as a profession, can ill afford to waste. Here are a few relevant observations:

  • The world is, in general, moving away from top-down, bureaucratic approaches to developing and implementing standards. Why? Because they don’t work. The healthcare landscape is littered with ailing, moribund or just plain dead standardization efforts that consumed a lot of time and energy, and are essentially not used in practice. The more promising approaches are smaller, nimbler and less bureaucratic, and engage the  communities who care about and use the product from the very beginning.
  • Dentistry has a very successful and broadly used coding system, the Current Dental Terminology (CDT). The CDT has about 710 codes. Clinicians know most of the ones they use frequently by heart. Clearly, knowing codes by heart gets harder the larger a code set is – difficult with 1,300 codes and fairly impossible with 7,000. However, that is not an unsolvable problem. The entry interface for the codes in the electronic patient record simply must be smart enough to make choosing the right code easy for the user. This is a significant, but solvable, human-computer interaction design challenge.
  • Speaking of design: One adage in the design community is “fail early, fail often.” Bringing something as complex as a new diagnostic vocabulary online rarely works with a big-bang approach. It makes much more sense to focus on smaller pieces of the puzzle, get the bugs out, and then move on to developing the next bigger increment. (One clue for this is hidden in the Z Codes evaluation paper cited above: Over a period of one year, UCSF used only 93 [63%] of 147 Z codes.) Unfortunately, developing a dental diagnostic vocabulary in an incremental, iterative approach would require a level of collaboration, shared vision and coordination between dentists, informaticians, vocabulary and terminology specialists, and the dental IT industry, that is unlikely to materialize.
  • Coming back to the statement above that “the ADA sees EZCodes as an ‘interface terminology’ useful for capturing health problems but not as a replacement for SNODENT in storing information in EHRs,” we need to clear up a misunderstanding.  Separating work on various aspects of a vocabulary makes no sense. As Kent Spackman states in an authoritative paper on terminologies, ideally, interface and other terminologies should be derived from a common reference terminology because this “may allow different terminological efforts to focus on separate parts of the problem and to cooperate in solving the overall problem.” Given what we are witnessing, wishful thinking indeed!
  • Unfortunately, both vocabulary development efforts decided to stick with outdated models of representing classifications and terminologies. Over the long term, those approaches will be about as efficient and effective as the horse and buggy are for transportation today. The formalism for representing “things” for the foreseeable future are “ontologies,” which even JADA discovered in a 2010 editorial. For a number of reasons, ontologies are way more powerful for representing diagnoses, treatments and other concepts in healthcare than traditional approaches. (One thing they do very elegantly is to combine the terminology, information and inferencing models described by A. Rector in The interface between information, terminology, and inference models.) So, at this point, ontologies are the way to go in architecting vocabularies. The good thing is that you can largely reuse the work spent on creating vocabularies when you build ontologies, so not all past effort is wasted.
  • Developing and maintaining large vocabularies requires a lot of time and money. Very few organizations have the wherewithal to support this process. Here, again, we can take a lesson from the ontology world. Many ontologies are developed in a completely open process by their community of users. While development still must be organized and regulated, costs and effort are spread over a much larger number of individuals, groups and institutions. This has two benefits: (1) everyone who needs the ontology uses it and (2) no one has to ask how much it costs. One example: the Gene Ontology, one of the most successful ontologies ever created.

So, what will the future hold for dental diagnostic vocabularies? Given the current path, most likely mediocrity, tension, conflict, widespread dissatisfaction and little benefit. Not a pretty picture.



– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics


P.S. In case you have not heard, an important pioneer of medical informatics, Dr. Homer Warner, passed away recently. Learn more about him in this obituary and video.

Henry Schein buys Exan Group … and what that means for the dental software industry

Some of you may have noticed the recent press release about Henry Schein acquiring a majority interest in the Exan Group. Exan develops and markets axiUm, the practice management and electronic dental record system in use at about 45 dental schools in the US. Henry Schein, on the other hand, owns Dentrix, with about 40% of the market the leader in the same product space, mainly in private practice. Henry Schein is no stranger to acquisitions, having grown its software and technology portfolio over the years essentially by buying other companies. Acquiring Dentrix in 1997 proved a particularly strategic move. Over the years, Dentrix has become one of the crown jewels in the Henry Schein holdings. Exan was started about 25 years ago and has business segments in dental schools, large group practices, private practice, and hygiene schools and programs. Over the past 15 years, it has grown into the dominant vendor of electronic dental record software (EDR) for dental schools.

I was not aware of this impending partnership, but it is nevertheless interesting to think about how it could affect the dental software industry, specifically the segment focused on dental schools:

  • With the purchase of Exan, Schein “owns” the dental school market overnight. While there are some other software offerings suitable for and in use in some dental schools, the barrier to entry in the dental school market has always been very high. Now, it is higher. The number of customers in the US is simply not large enough to realize superior returns, unless you are close to a monopoly position. From a business perspective, Exan is now even more entrenched in that market than before.
  • Exan’s enterprise product portfolio, including axiUm, complements Dentrix’s enterprise offerings quite well. Over the last decade or so, Dentrix has significantly strengthened its software offerings for large dental care settings. Having “a leg” in the dental school market rounds out Dentrix’s presence in that space (large group practices and the Indian Health Service being some other examples). Clearly, Schein sees potential for growth, both in the US as well as internationally.
  • In terms of product innovation, I am hoping that some of the more recent improvements in usability, software architecture and other aspects in Dentrix products carry over to the Exan product line. In talking to axiUm users both at our dental school as well as across the country, it is obvious that usability is not one of the application’s strong suits. My weekly experience in using the product with students routinely exposes usability and workflow design flaws, both minor and major. Dentrix, on the other hand, has made an effort in improving usability across the board in recent years, which will be especially evident in upcoming products.
  • I’m hoping that positive changes in software engineering and change management will follow. axiUm is largely a robust product, but it is also very complex. In consequence, implementing even minor version upgrades is no trivial undertaking. I cannot tell you how many times database changes in axiUm that were either poorly or not at all documented broke existing functionality, especially reports, at our school. Other schools are no exception.
  • One very positive result of this partnership should be increasing clout for dentistry with respect to the HITECH Act and Meaningful Use regulations. As many of you know, dentistry and many other healthcare providers were not really written into the original HITECH legislation. However, both Schein and axiUm have Meaningful Use-certified products which are now being implemented according to the CMS’s EHR Incentive Program. This will enable dental schools as well as other dental care providers to participate in the Medicare/Medicaid incentives for electronic health record adoption. This should make dentistry more a player in how electronic health records are used in general in the future.
  • I also see some potential for informatics innovation diffusing from dental schools to Dentrix. Quite a few dental schools, many of them part of the Consortium for Oral Health Research and Informatics, are experimenting with diagnostic codes, standardized medical history forms, risk assessment and quality assurance. These are welcome developments since they are focused on how we can use electronic data to improve oral health, not on how we document care so we can bill and don’t get sued. In talking to Pam Reece, the Director of Enterprise and Specialty Solutions at Schein, the other day, I learned that the company is working on a caries risk assessment module for Dentrix Enterprise. If so, it might be a great opportunity may be to translate some of the academic advancements in this domain to broader practice.
  • I am not quite sure how this move will affect the growing call for integrating medical and dental data, which my colleagues made so eloquently in their new book. (Rumor has it that a second edition of this book is in preparation.) Clearly, there is a strong move in the country towards interoperability of health records, health information exchanges, and looking at care in a more holistic fashion than we have done to date. It would be interesting to see what Schein’s/Exan’s plans are for connecting to the electronic medical record industry at large.
  • Last, I have always wished for a closer connection between the EDR systems that dental students use in school and what they will encounter in practice. Well, it looks like I got my wish! Time will tell how Schein leverages its new position in dental schools with regard to marketing to graduates.

I’m going to stop here since this blog post has been going on for too long already ;-). I’d be interested in hearing your thoughts on this new development.



P.S. Disclosure: I don’t have any formal or contractual relationship with either company mentioned in this blog post.

– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics




Integrating the old and new worlds: The example of the dental recall postcard

Integration of software, hardware and services is an important aspect of health information technology, as well as technology in general. When things are not well integrated, we notice: the automated blood pressure meter which doesn’t transmit its readings to the electronic health record; the DiagnoDent value that we have to write in the progress notes because there are no fields for it in the electronic dental record; or, the intraoral camera that does not automatically switch the imaging program to “capture” when we taken it out of the delivery tray. All these breaks in integration make us notice (and get annoyed about) technology. Technology gets in the way of us getting real work done. We wrote about some of these and other integration issues in a 2004 article in a JADA supplement. (Not to burst your bubble beforehand, but not much has changed since then.)

This situation is all the more reason to notice (and appreciate) instances of integration done well. I came across such an instance during a presentation about Dentrix’s eServices product suite the other day. It is not quite clear to me what exactly Dentrix eServices are. Dentrix’s Website on this is full of marketing-speak and thus less than useful. The gist of it seems to be anything where information gets sent around to process transactions (like appointment reminders and patient payments).

The great example of well-done integration came in the form of a postcard to remind a patient about an upcoming appointment.

Okay, so the front of the card is less than overwhelming. The interesting story is on the back.

The back of the card displays a two-dimensional barcode, also called a Quick Retrieval (QR) code, on the right-hand side. For those of you using smartphones, not a big deal. The great thing, though, is what happens when you scan the QR code: It brings up a window on your smartphone that lets you confirm your dental appointment right then and there. If I remember correctly, it also puts it on your calendar for good measure. (I was trying to get a slide with a picture of the app from Dentrix, but so far no luck.) If you don’t have a smartphone, you can use the Web address on the card to do the same thing on your computer.

The nice thing about this example of integration is how easy it bridges the hardcopy with the electronic world. Scan the card with your smart phone, push a few buttons and you can move on with your life – while not forgetting your dental appointment down the road. Wouldn’t it be great if technology worked this smoothly all the time?

All the best!


– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics



How do we effectively get innovations in human-computer interaction into real-world software applications?

The other day, I got a Tweet from Ben Shneiderman at the University of Maryland about a human-computer interaction (HCI) innovation called Manylists. Ben is one of the world’s topmost HCI experts and one of my favorite Twitter leaders. Ben has an extremely high signal-to-noise ratio in his tweets, and if there was only one person I could follow on Twitter, he would be one of my top choices.

ManyLists is a product comparison tool that compares product features using spatial layouts with animated transitions. In simple terms, ManyLists arranges product features in a table in such a way that makes it easier to compare multiple products. The layout facilitates rapid scanning by the user, something I think we would all appreciate when buying a washing machine, a digital camera or junk food.

ManyLists looked similar to another tool developed in Ben’s lab, a medication reconciliation tool called Twinlist that I saw at a conference last year. Twinlist facilitates easy comparison/merging of a patient’s medication lists. For instance, a patient may be discharged from a hospital stay with a list of medications that may not be the same as she usually takes. Medication reconciliation, as it is typically done, is a relatively error-prone and effortful process. Twinlist does not fully automate the task, but provides clear advantages in helping the healthcare provider decide which medications to keep and which ones to drop.

Right after I got Ben’s tweet, I talked with Catherine Plaisant, an Associate Research Scientist who leads these projects. I was interested in the answers to two questions. The first one was what kind of HCI innovations Twinlist and ManyLists represented. Were they real breakthroughs or just incremental improvements? Catherine’s answer indicated that she thought they were somewhere in between. She pointed out that the applications really integrated several aspects of HCI done well: good graphic design, good choice of fonts and colors, and helpful animations to make  computational processes and their decomposition explicit.

The second question was more difficult to answer: How was she going to get these innovations into real-world software applications in an efficient and effective way? All over the world, programmers are busy creating medication reconciliation software. If they knew about her work, they could maybe improve on what she had done, instead of reinventing the wheel. Catherine did not have a good answer for that. Yes, the code and designs are openly available on request (just email plaisant at cs.umd.edu). But, it is an unsolved mystery for how to get these innovations into the hands of developers better than we are able to today (which is to say, not very well).

A few years ago, I came across the Common User Interface, a project by Microsoft in Great Britain, that offers a fairly large set of well-designed and tested user interface components for electronic patient records. I have always dreamed of plugging a new patient record together from these components. That would be certainly less work than writing it from scratch!



– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics


How can we improve the design of Electronic Dental Records (EDR)?

Those of us who develop systems for dental clinicians to use during patient care face a perennial quandary: How can we design systems that work like the intended users need (and want) them to? The way people usually try to answer this question goes something like this:

Programmer to dentist: “Tell me what the software should do.”

Dentist to programmer: “Well, I need it to do A, B and C. Also, we need to keep a record of D, E and F. … Tell you what. Here is a copy of the paper record we use – just make it do something like that.”

[3 weeks, months or years later] Programmer to dentist: “Here is the software I wrote for you.”

Dentist plays around with it for a while, then says: “That’s not what I needed …”

(A cartoon illustrating this phenomenon is here.)

Dissatisfaction among dental professionals with their electronic dental record (EDR) systems shows that there is a lot of work to do to close the gap between EDRs and the requirements of practice. One of my colleagues, Dr. Thankam Thyvalikakath, recently completed her PhD thesis titled “Designing clinical data presentation using cognitive task analysis methods” which has the potential to help narrow this gap.

I would like to talk a little bit about the basic informatics research that Thankam completed so ably. In order to find out how dentists review patient cases and make decisions, she conducted a relatively simple experiment. She asked 10 clinical practitioners individually to work through a set of three patient cases of low, medium and high complexity. The cases were comprehensively documented and presented in a standardized fashion. The experiments were audio- and video-recorded, and coded and analyzed. We then developed an EDR prototype, the DMDProject, to address some of the cognitive requirements which we elicited.

Here is an example:

As the figure shows, the ten study participants reviewed a patient case first by focusing on general patient information, medical history and the social history. They then proceeded to intraoral images and radiographs, followed by hard and soft tissue charts. Towards the end, they reviewed patient notes and refocused their attention on medical issues. The patient case was fairly complex, which was reflected in the participants’ intensive engagement with the patient record.

One of the key results of our analysis was that dental clinicians wanted an “overview” of patients whose record they reviewed for the first time. Strangely enough, very few EDRs offer this feature, which is relatively easily implemented using computer-based records but not paper-based ones. The resulting preliminary design implemented in the DMDProject looks like this:

In this design, the EDR shows a summary of the most relevant facts about Sarah Williams. It integrates demographic, insurance and clinical information. The last progress note is shown, as are scheduled procedures. The clinician also has easy access to the most recent images. (In the design, users can easily “drill down” to more detailed information from the Patient Overview.)

When we tested this design with users in several rounds of experiments, it was clear that it was a winner. Pretty much all clinicians commented very favorably on the usefulness of this view. So, we are hoping that more and more EDR vendors and developers adopt this design paradigm.

Thankam’s PhD thesis contains scores of other examples of how we elicited cognitive requirements of clinicians and then translated them into an appropriate design. Because it is somewhat hard to summarize a PhD thesis in a blog entry, I will come back to Thankam’s work in the future. (Sometime later this year, Thankam’s thesis will be available in Pitt’s D-Scholarship repository.)

All the best!


Titus Schleyer, DMD, PhD
Assoc. Professor and Director, Center for Dental Informatics

Dentists should use their patient data to …

… [your answer here].

In today’s blog posting, I am asking you to get creative. I would like to know what you think dentists should do with their patient data. (I explain why below.) So, the first thing I would like you to do before reading further is to complete the sentence above and post it as a comment in response to this blog posting. (If you have not posted on this blog before, I will have to approve your post, but I promise to do this quickly.)

So, now to the real question of this blog posting: Why am I asking you about what dentists should do with their patient data? The simple answer: Because I think we are not doing enough with them. 

Clearly, many of us use patient records to refresh our memory before an appointment, to answer a clinical question, to get a sense of what needs to be done next, and so on. So, our use of patient record data is primarily focused on supporting the care of individual patients. Nothing wrong with that. (Of course, we also use them to defend ourselves in lawsuits, but that is another story.) 

Beyond that, we also use patient records in the aggregate to some degree. For instance, we may check on groups of patients due for recall and send them a postcard or email to remind them. Or, identify patients who are overdue in completing their treatment plan, so we can call them to finish the care that they need. 

Beyond that … I don’t think we do much with our patient records. 

I think that needs to change. I think there is a lot of useful information locked away in our patient databases. For instance, they contain answers to questions like: Do resin restorations placed with the new bonding agent I started using last year have a higher incidence of postoperative sensitivity? In what kinds of patients does scaling and rootplaning not improve pocket depths? How long do crowns in my practice last? What patients are least likely to complete their treatment? Or, my favorite: What kind of dentist am I? 

Imagine that there was an easy way for individual dentists to ask these questions. Or, for that matter, a way to answer these questions using many dentists’ databases. This is one of the research projects we are working on (see “Data extraction using EDR in dental PBRN”).  

Our approach is designed to extract data from a variety of electronic dental record (EDR) systems in a standardized manner for purposes of quality assurance and research. At present, we are pilot-testing it with EagleSoft, but we are planning to add more systems in the future. 

The key philosophy of our approach is that we should be able to extract (for now, de-identified) patient data from a variety of EDRs in a standardized fashion to answer questions such as the ones listed above. This capability could be a highly valuable adjunct to the many clinical research studies being conducted in dentistry. Using data from practices, we should be able to conduct epidemiological, comparative effectiveness and other types of studies. 

Sounds like a good use of patient data to me. Do you agree? If so, what question(s) would you ask of your electronic dental record if you could? Looking forward to your responses!



Titus Schleyer, DMD, PhD
Assoc. Professor and Director, Center for Dental Informatics

Dental informatics rocks at the American Dental Education Association (ADEA) Annual Session in Orlando!

So, Thankam and I are currently driving from the American Dental Education Assocation (ADEA) Annual Session in Orlando to the Annual Meeting of the American Assocation of Dental Research (AADR). I wanted to take this time to tell you about what happened at the ADEA meeting with regard to dental informatics: In one short phrase, “Dental informatics rocked!”

To take a small step back, that was not always the case. I have been affiliated with what was then called the American Assocation of Dental Schools (AADS) (and is now ADEA) for over 20 years. During that time, I have watched dental informatics grow up from a concept that no one was familiar with into a domain that literally permeates all aspects of dental care, education and research.

Ample proof of that are the dental informatics events at the ADEA meeting that is coming to a close. There was a series of presentations on “Data Mining From Electronic Patient Records to Measure Patient and Student Outcomes,” 23 short talks on a variety of dental informatics topics, and the TechExpo, in which faculty and students demonstrated informatics applications hands-on. In addition, there were probably over 20 posters that focused on dental informatics either exclusively or partially, as well as quite a few exhibitors. 

The dental informatics topics at the meeting were as varied as they were interesting. In the data mining session, Muhammad Walji talked about his work on merging the EDR databases of four dental schools into a virtual data warehouse for research. Rachel Ramoni discussed how targeted selection can help identify patients with adverse dental outcomes better than traditional methods. I spoke about our work on data mining of EDRs in private practice to support outcomes, epidemiology and comparative effectiveness research, funded by an NIH grant

In the short talks, we learned about educational applications, such as online courses in dental hygiene, a visuo-audio-haptic system for training in dental caries detection, and an electronic portfolio for enhancing learning in pre-doctoral pediatric dentistry, as well as many other topics.

The TechExpo was a smorgasboard of applications, such as “A Picture Is Worth a Thousand Words: Dental Images Media Library,” “Augmented Reality in Dental Education: An Innovative Approach to 3-D Visualization,” “Dental Histology Online: Creating a Virtual Microscopy Lab to Engage Students in Interactive Computer-Assisted Instruction,” “Engaging Predoctoral Dental Students in State-of-the Art CAD/CAM Technology Through the Use of the Blue Cam” and “Using the iPad 2 to Become an Engaging Educator and More Effective Researcher.”

All in all, it was an energizing experience to see dental informatics research and development thriving at ADEA. As we would say in Germany: “Weiter so!”

All the best and keep in touch!


Titus Schleyer, DMD, PhD
Assoc. Professor and Director, Center for Dental Informatics

Should dentists adopt electronic dental records?

This question is a perennial favorite of mine. I get it a lot when I give talks to dentists or in response to papers we write. It reminds me of a question that many people asked in 1910: “Should I get another horse and buggy, or should I get an automobile?” (Disclaimer: I wasn’t there personally.) The early 1900s were a period of transitions in many ways, but few were as significant as the change in how we got around town. Around 1910, the number of automobiles was surpassing the number of buggies. Thus, we started to give up on a way of transport that had been with us for thousands of years. Horses and buggies were relatively cheap, required little training to use and had a (relatively) predictable standard of performance. Consider what we got in return at the time: The term “automobile” comprised a number of technological contraptions whose variety was only exceeded by the number of ways they could break down. Early automobiles were unreliable, non-standardized and had a variety of not-so-intuitive user interfaces.

Sound familiar? I thought so. We are currently in the process of phasing out the tried-and-true method of documenting patient care in favor of electronic dental records (EDR). This is simply a statement of fact, not a value judgment about which medium is better. In 2006 we conducted a study that found that about 1.8% of all general dentists in the US were paperless. In a recent study, which we just submitted for publication, the figure is about 15%. We are not very close to the moment when more dental practices are completely paperless than those who are not. But, we are heading there. The dental profession is voting with their feet.

Whether to go paperless or not is not only a significant, but also a very personal, decision for dental practices. Not only is “going paperless” it a fairly involved process. It also consumes a non-trivial amount of time, money and resources. (We discussed this transition recently in “Transitioning from Paper to Electronic Records: A Process Guide.”)

In my experience, there are at least three factors that play a big role in the decision to go paperless:

  1. Do you believe that you are better off using electronic than paper records? There are some areas where the computer clearly beats paper – anytime. Just ask any dental office that has lost its records during hurricane Katrina. But, the inverse is also true. Have you ever tried documenting Diagnodent values in an EDR in a systematic fashion? Most EDRs don’t provide structured fields for such diagnostic tests, so you are pretty much left putting them into progress notes. Not a great method for systematic review of these numbers later.
  2. Do you have the knowledge, skill and energy to take on a major computerization project? Many dentists who have made EDRs work in their office are not just geeks, they are computer geeks. They invest the countless hours needed to learn about their EDR, how to configure it optimally in their practice, train their staff and keep it running.
  3. Do you take the long-term view with regard to EDRs? EDRs are an emerging, immature technology. Several studies, including ours (see heuristic evaluation and usability of EDRs), have shown that. Cars weren’t perfect in 1910, and neither are EDRs in 2012. Better EDRs are a matter of time, ingenuity and perseverance.

Clearly, there are many other factors influencing whether to go paperless or not. But, one thing is certain: EDRs are here to stay, and will, sooner or later, replace paper. It is up to all of us to make them into a more useful tool for dental practice than they are now.

What do you think about this?


Titus Schleyer, DMD, PhD
Assoc. Professor and Director, Center for Dental Informatics

The Dental Informatics Blog

Welcome to the blog of the Dental Informatics Online Community! After pretty much all of the world has started to blog, we thought it was high time for the Dental Informatics Online Community (DIOC) to do the same. So, here goes …
Starting a blog is a special experience, so I thought I would tell you about how this came about. Dental informatics is a small, but rapidly growing discipline, as evidenced by a number of things. Gone are the days when a Medline search for “dental informatics” in 1996 yielded only a few hundred “hits” on dental informatics. The DIOC’s Publication Archive today includes more than 2,200 papers on the topic. An increasing number of people do research in dental informatics, some of it funded by the NIH and other organizations. The DIOC itself has been growing rapidly over the years, now totaling over 1,200 members.
Along with the DIOC’s growing presence on social media, such as our Twitter channel and Facebook page, we thought it would be great to have a forum to present and discuss critical issues in dental informatics. This is why we created the DIOC blog. We subheadlined it “Data, Computing and Technology in Dentistry” because we would like to offer broad coverage of dental informatics topics.
We have recruited a great initial team of bloggers: Drs. Thankam Thyvalikakath and Spallek from the Center for Dental Informatics, as well as I, will start us off. However, we don’t want to stop there. We are also looking for contributions from the dental informatics community at large. Do you have a favorite topic that you are passionate/curious/excited/frustrated about? Do you have questions about data, computing and technology in dentistry? What kind of content/topics would you like to see on the DIOC blog? Let us know – the field is wide open!

Titus Schleyer, DMD, PhD
Assoc. Professor and Director, Center for Dental Informatics