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Thanks for your thought-provoking blog post! In order to give context to our dialog, I believe it is important to stress that we are discussing measurements of outcomes and not process. There is no doubt that we need, and CODA even mandates this, to educate life-long learners who can assess new knowledge and who will grow during their professional life. So, I do believe dental schools should educate and train—in general terms this distinction is of rather semantic nature indicated by the fact that PhD programs refer to the “training” of students and most institutions call Postdoctoral Associates “post-doc trainees.” When it comes to measuring outcomes, we might want to consider keeping our ultimate goal in mind, which is not just to educate young people in a science, but also to make them competent general dentists.

So, the perfect-world assessment is, in my view, not just measuring learning outcomes, but evaluating whether the individual learner becomes a good practitioner through our efforts. Aside from the tremendous challenges such an assessment would pose, it brings me to my next and more fundamental point: What is the status quo of quality assessment in dental care?

This question was already eloquently answered by Jim Bader in a recent JADA editorial (Challenges in quality assessment of dental care, JADA, Vol. 140, December 2009, p. 1456):

“…the dental profession has regarded quality assessment as an evaluation of clinicians, rather than of the effects of clinicians’ efforts on patients’ health.”

“After apprenticeship, most of a dentist’s learning was experiential, and it resulted in a strong belief in one’s own skills and powers of observation, as well as an exaggerated sense of professional autonomy. These characteristics may continue to be fostered in today’s solo practitioners as well, and they may be manifested in the ‘in my hands’.”

In other words, instead of assessing the quality of care which was defined by the IOM as “the degree to which health services for individual patients and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” we emphasize the “[t]echnical excellence of restorations: Clinicians long have considered these evaluations as the sine qua non of quality, … these measures of technical excellence are not associated strongly with most long-term treatment outcomes, such as the development of caries; endodontic complications; or restoration loss, fracture or replacement.”

Jim does not fail to point out to us, the dental educator community: “little effort has been made to expand performance assessments beyond the strong emphasis on technical excellence in predoctoral dental education. Such a focus helps explain practitioners’ continued acceptance of and reliance on technical excellence as their principal means of quality assessment after graduation.”

So, how can we measure the outcomes of our efforts in such an environment? Here are some of the questions I am asking myself: What are the best proxies which we can use to evaluate the success of our educational efforts? Can the quality of instructions in prosthodontics predict the number of partial dentures that have to be redone in the clinical years? Can technology help us to find trends? Will the installation of a state-of-the-art simulation clinic increase the survival time of restorations placed by our students? Our electronic health record systems—now soon attested as “meaningful”—should be able to help us to get some of the answers. Our schools have invested a great deal of money into these EHR systems; how do these systems help us to answer the questions which are at the core of our schools’ mission: What are the true outcomes of our educational efforts?

CU
Heiko

As a practicing dentist and potential electronic dental records customer, I’ve repeatedly asked logical questions about cost and safety to others promoting EDR adoption, and have been mostly ignored. The few who have argued that EDRs offer dentists savings over paper dental records have never been able to provide data supporting the claim. In fact, when the former CEO of the widely-respected CR Foundation made a reckless proclamation that EDRs offer dentists a “high return on investment” in a Dentistry iQ article in November, he was fired within days, and co-founder Dr. Gordon Christensen took over as CEO.

As for safety – nobody claims EDRs are safer than paper dental records. More alarming still, though the frequency of data breaches from healthcare facilities is said to be at “epidemic proportions,” and doubling every year, stakeholders who are promoting them are not taking the responsibility to warn dentists and their patients of the rapidly increasing risk of financial and medical identity theft.

Did you know that stolen medical identities now bring $50 each while social security numbers only bring $5? When medical histories are stolen, they are often imperceptively altered to reflect the thief’s allergies rather than the victim’s. Like keystroke errors, that life-threatening danger simply never occurs with paper dental records.

So if EDRs are indeed more expensive than paper dental records, aren’t the stakeholders, who stand to gain power and/or profit from their sales, bound by business ethics as well as common decency to warn customers to expect an increase in cost to provide care? And how much do you think HIPAA compliancy adds to the cost of dentistry? HHS isn’t saying.

And if the EDRs are indeed more dangerous than paper dental records, and dentists fail to routinely warn patients to watch for unexplained changes in their digital medical histories, isn’t that counter to the tenets of the Hippocratic Oath?

D. Kellus Pruitt DDS

D. Kellus Pruitt DDS