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.

Best

Titus

– Titus Schleyer, DMD, PhD

Assoc. Professor and Director, Center for Dental Informatics

http://www.dentalinformatics.com/members/Titus+Schleyer

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.

11 thoughts on “Does dentistry really need more than one diagnostic vocabulary?

  1. Dear Titus,

    Dentistry does not have two diagnostic vocabularies. Actually, dentistry only has one, the EZCodes that are operational and used in an electrnoic dental record. I use them everyday and they are captured in the electronic dental record. I don’t see SNOMED-CT or ICD used in dentistry at all by anyone. There are currently more than 15 institutions (including one large group of dental practices) that have and use the EZCodes terminology within an electronic health record.

    Frankly, your statements are not helpful for dentistry. Medicine for example has been capturing cause of death since the bubonic plaque and the spainish influenza pandemic, more than a 100 years ago. In dentistry, we don’t capture why pulps die or any other diagnosis. So, quality of care, outcome of care and other important measures of success of our treatments are able to be conducted.

    The world around us in medicine has changed to moving forward with standards of care. If we follow your recommendations, we will always be stuck in the drill, fill and bill days, having no idea why we picked up the handpiece in the first place.

    The EZCodes are an excellent interface terminology developed by dentists for dental use. It is very specific and granular far more so then ICD or SNOMED-CT AND it is available for use today.

    Let’s celebrate the accomplishments and postitive contributions to improve the profession, rather then criticize the precieved weaknesses.

    • Hi everybody,

      Thanks for taking the time to write. This is great! We are actually having a substantive discussion about an important topic (a refreshing departure from the spam this blog usually attracts ;-) ).

      Regarding how many the question of how many dental diagnostic vocabularies there are, I leave that to others to decide. I thought the original article mentioned two, but I must have misread that. Maybe I should have been clearer on one point: I was not advocating that dentistry have zero diagnostic vocabularies. It should just have ONE (a good one).

      Be that as it may, given current developments, it looks like we will have two diagnostic vocabularies in dentistry: One for dental schools and other large institutional providers, and another one for dentists in private practice. That raises the question whether dentistry in dental schools really so different that it needs a dx vocabulary different from that for private practice? Wouldn’t it be nice if we could check our personal, professional and institutional egos, and do something that benefits ALL of dentistry when we have the chance? Or, maybe there is a substantive argument for two different and separate vocabularies that I missing. If so, please tell me.

      I was in no way trying to minimize what Elsbeth and her group have achieved. Putting a dx vocabulary together, evaluating it and implementing it in quite a few settings is a really good achievement. But, even accomplishments like those should never keep us from asking: What can we do better? I wrote my original post in the spirit of constructive criticism. I am sorry if that was not clear.

      Thanks

      Titus

  2. In response to Joel White’s comments. I think the point is to recognize the limitations of non-ontology based standards EZcodes and Snodent.

    As a dentist I do not celebrate a filling that is 90% successful. So celebrating a standard that has no chance of becoming 100% successful is premature. The recognition that standards are important in dentistry is something I would celebrate.

    I believe that an ontology is what we need to aim for in our profession. A collaborative of sorts that will involve all players at the table. I would suggest the Interac model of banking to be the basis for the creation and stewardship of the ontology.

    Just one dentist’s thoughts!!!

  3. Titus, this like many of your communications leaves me unsettled, posing a number of questions for consideration.

    First I must say that the ADA’s business model is important, and it seems to me that any source of revenue that augments dues should be welcomed by ADA members. We all need to recognize that university programs and faculty positions also depend on external funding sources, such as from NIH – I suspect whatever revenue the ADA receives from licensing pales in comparison to these grants.

    Second, is standardization. Something I’ve noticed in my 25 years or so in the standards arena is that in standards activities for most industries, steel, petroleum, electrical, etc., adademia plays and integral, important, and often a leadership role within the formal standards process. I’d like to see academia particpate comparably and more constructively in the standards development processes in healthcare and particularly in dentistry.

    Third, I totally disagree with your first bullet – the standards world has always been beset with chaotic, redundant, competitive, wasteful, and largely ineffective so-called bottom-up efforts. The importance of what is refered to as a bureaucratic process is that it provides formal structure and process, it follows rules, provides the opportunity for anyone to participate, and everyone’s voice must be heard. Its why voluntary consensus standards are important and successful in the US. This is rarely, if ever, the case in bottom-up activities. Granted there are problems, but these are not due to the top-down process but with how some organizations and individuals have corrupted it, for example those that are a standards business rather than a standards activity in a professional organization. The other problem is the unwillingness of some individuals to participate in a democratic process and accept the viewpoints of others – its incredibly poor form for someone to run off to start their own wild-hare standards initiative (“they didn’t do it my way so I quit and I’ll show them”). So, if there is criticism to be made, should it fall on those who may have great ideas but fail to contribute these to established standards activities?

    Now, the fourth bullet. Before we make philosophic arguments, I suggest we understand the purpose for these codes and how these are used in systems. We don’t need great ideas for codes but an actual standard for our vendors to use.

    There’s more, but that’s enough for now.

    Mark

  4. Hi Mark,

    Good to hear from you. I think we can all list standards efforts, either from bottom-up or top-down, that have been successful. Some were set by Standards Developing Organizations, some were de-facto standards set by companies and some emerged from individuals or communities without a formal process. Yes, there are some very successful HC standards, such as DICOM, the HL7 messaging standard and ICD. But, I think there is a lot of work left on healthcare standards, despite a lot of effort in the past.

    But, rather than talk about HC at large, let’s look at dentistry. How many standards has the ADA Standards Committee for Dental Informatics developed over the last 15 years of its existence that are actually implemented in commercial products or other systems? Maybe the dental DICOM extension, but beyond that not much comes to mind. You and I have been part of the process for longer than the SCDI has existed, and can enumerate quite a few reasons for this. But, that does not change a very basic fact: The work of the SCDI has not really influenced the life of that practicing dentist very much. I think we need to take a critical look at the whole process and find out how we can do better.

    You mention that you would like to see academia more involved in the SCDI process. I would say there are quite a few members with academic affiliations on the SCDI. But academicians don’t make products. I think one thing that is missing at the SCDI is that we do not have a very targeted process for assessing the need for standards, involving all relevant stakeholders in the development, and then actually helping implement them within a reasonable timeframe. If the bureaucratic standards setting process is to be successful, it needs to deliver results in real products and services that affect the real world. Just turning out big piles of paper that no one looks at year after year is not enough.

    You and I know that we don’t really disagree on the need for or importance of standards. We may disagree on some aspects of the process, but I think there is one thing we probably would both support: Let’s do better at developing and implementing standards. I and, I am sure, others, are looking for fresh ideas.

    Thanks

    Titus

  5. I’ve just begun to follow the threads of conversation regarding Diagnostic Codes and diagnostic coding used in dental treatment facilities. Additional information would be appreciated regarding how and when the concept would be approached in the dental schools, and/or dental hygiene schools. Your references to the financial realities enjoyed by the ADA with the CPT Program need to be expanded; if only to emphasize the fact that the ADA represents less than three quarters of the total number of practicing dentists in the US, and ADHA enjoying a lesser market share. What exactly is the selling point surrounding the adoption of diagnostic coding? While I applaud those who have attempted to develop a reasonable number of diagnostic codes; I have yet to see how these codes would be put to good and meaningful use alongside the treatment codes ala CPT. Should there be a desire to evaluate the efficacy of dental treatment regimens provided through the titration of diagnostic codes versus treatment codes, captured via the ETR, one outfall might be the capturing of online treatment outcome and quality assessment data. And what effect would this collection of data have on impirical decision making?

    • Dear Larry,

      Thanks for your post!

      > I’ve just begun to follow the threads of conversation regarding
      > Diagnostic Codes and diagnostic coding used in dental treatment
      > facilities. Additional information would be appreciated regarding how
      > and when the concept would be approached in the dental schools, and/or
      > dental hygiene schools.

      Dental schools and other settings are just in the beginning stages of implementing diagnostic codes. Early efforts included the Leake codes (http://www.ncbi.nlm.nih.gov/pubmed/10649589) and a “Reasons for Treatment” (http://www.ncbi.nlm.nih.gov/pubmed/8501287) approach developed by Bader and Shugars. The most current effort in dental education, as discussed above, are the EZCodes.

      > Your references to the financial realities
      > enjoyed by the ADA with the CPT Program need to be expanded; if only to
      > emphasize the fact that the ADA represents less than three quarters of
      > the total number of practicing dentists in the US, and ADHA enjoying a
      > lesser market share.

      I don’t really know the details of the finances of the ADA’s CPT licensing program. All I know is that the ADA offers a variety of licenses (most or all of which are fee-based) for the CPT. The ADA also runs a Code Maintenance Committee that ensures that “all stakeholders have an active role in evaluating and voting on CDT Code changes” (see http://www.ada.org/3830.aspx). Presumably, CPT maintenance activities are funded by licensing revenues. Maybe someone from the ADA can explain this.

      > What exactly is the selling point surrounding the
      > adoption of diagnostic coding? While I applaud those who have attempted
      > to develop a reasonable number of diagnostic codes; I have yet to see
      > how these codes would be put to good and meaningful use alongside the
      > treatment codes ala CPT. Should there be a desire to evaluate the
      > efficacy of dental treatment regimens provided through the titration of
      > diagnostic codes versus treatment codes, captured via the ETR, one
      > outfall might be the capturing of online treatment outcome and quality
      > assessment data. And what effect would this collection of data have on
      > impirical decision making?

      You have identified one reason for recording diagnostic codes. If you have data on the condition of a tooth, quadrant or mouth for a patient before and after a clinical intervention (treatment), it should be possible to evaluate efficacy of the treatment. In addition, it would be clearer why a certain treatment was performed. This approach has become the rule in healthcare rather the exception. In many healthcare reimbursement scenarios, providers are actually paid on the basis of a diagnosis, not on what they did (except dentistry, of course). Bader and Shugars make a good case for recording dental diagnoses in a 1997 commentary (http://www.ncbi.nlm.nih.gov/pubmed/9420387). A more recent editorial (http://www.ncbi.nlm.nih.gov/pubmed/19955057) by Bader also discusses the subject.

      A second reason for recording diagnoses is grounded in epidemiology and public health. Let’s say you wanted to find out whether a certain public health intervention reduced the incidence of childhood caries. If you were collecting diagnostic codes on the population of interest, you could track the incidence and prevalence of caries over time and (hopefully) be able to determine whether the intervention was effective.

      Anyway, sorry for the brevity in treating the subject. Hope this helped!

      Best

      Titus


      Titus Schleyer, DMD, PhD

      Assoc. Professor and Director, Center for Dental Informatics

      http://www.dentalinformatics.com/members/Titus+Schleyer

  6. Dear Titus,

    I don’t understand how you can conclude that dentistry will have one diagnostic terminology for dental schools and large institutions and one for private practices.

    The diagnostic terminology that is being used by dental schools and large institutions can also be used by private practices.

    Actually, this would be ideal, as the EZCodes as an interface terminology is ideally suited to work in private practices. The terms contained within the EZCodes are accurate, have been validated and contain everything a private practice would need.

    Other terminologies like ICD and SNOMED are extensive lists with many many terms not used in private practices. In addition, these terms are not granular enough for the needs of dentistry.

    These are reasons why the EZCodes have been developed and implemented in dentistry.

    They are free to all and can be incorporated into an electronic health record.

    For those clinics that need to use ICD for federal or state funding, the EZCodes are mapped to ICD, so they work for everyone.

  7. Hi everyone,

    I must tell you that with my past twenty years of experience in large and small private practices and recent academic experiences (seven years), I agree whole heartedly with Joel.
    The EZCode dental terminology is suitable for the use of both educational and private practice setting. There is no question that we must do more to facilitate terminologies conversions, have dialogs and discussions like the ones on this blog, and help each other to sort out through challenges.
    I Teach EZCode to students not only because of the ease and availability of it, but also because it makes sense to practicing dentists. I know my students who are graduating this year are better of having been trained on Dental Diagnostic Terminologies than those who have not had any exposure to this crucial part of dentistry.

    Shawn Adibi DDS FDOCS MEd

  8. Pingback: Better diagnostic codes for better dentistry : Covering Health

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