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 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

Is the NMC Horizon Report reliable?

Most of you are probably aware of the release of the new Horizon Report for Higher Education; if not, consider reading it:

“The ninth edition describes annual findings from the NMC Horizon Project, a decade-long research project designed to identify and describe emerging technologies likely to have an impact on learning, teaching, and creative inquiry in higher education. Six emerging technologies are identified across three adoption horizons over the next one to five years, as well as key trends and challenges expected to continue over the same period, giving campus leaders and practitioners a valuable guide for strategic technology planning.”

The report reveals technological metatrends and predicts:

  1. People expect to be able to work, learn, and study whenever and wherever they want to.
  2. The technologies we use are increasingly cloud-based, and our notions of IT support are decentralized.
  3. The world of work is increasingly collaborative, driving changes in the way student projects are structured.
  4. The abundance of resources and relationships made easily accessible via the Internet is increasingly challenging us to revisit our roles as educators.
  5. Education paradigms are shifting to include online learning, hybrid learning and collaborative models.
  6. There is a new emphasis in the classroom on more challenge-based and active learning.
  • Time-to-Adoption Horizon: One Year or Less

- Mobile Apps
– Tablet Computing

  • Time-to-Adoption Horizon: Two to Three Years

- Game-Based Learning
– Learning Analytics

  • Time-to-Adoption Horizon: Four to Five Years

- Gesture-Based Computing
– Internet of Things

When reading such predictions, I am asking myself how reliable are they.  Recently, Martin et al. tried to answer exactly this question in a paper* published in Computers & Education. The authors looked at all reports which have been published since 2004 (they received “more than 500,000 downloads a year and have an estimate readership of about 1 million in 75 countries”).  Martin et al. used “bibliometric analysis which technologies were successful and became a regular part of education systems, which ones failed to have the predicted impact and why, and the shape of technology flows in recent years.” The paper includes several very interesting visuals on how technologies most likely to have an impact on education. The authors conclude: “The bibliometric analysis over the predictions highlights that some of the predictions were right, e.g., social networks, user-created content, games, virtual worlds and mobile devices. Other predictions did not have the expected impact, e.g., knowledge Web, learning objects and open content, context-awareness and ubiquitous computing. However, other predictions were successful, although their impact was delayed one or two years, e.g., grassroots videos and collaborative Web.”

Do you think that the Horizon Report trends have an impact on how you evaluate technology for dental education?



* New technology trends in education: Seven years of forecasts and convergence by Sergio Martin, Gabriel Diaz, Elio Sancristobal, Rosario Gil, Manuel Castro, Juan Peire. Computers & Education (2011). Volume: 57, Issue: 3, Pages: 1893-1906

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