Resources from Toward a Diagnosis Driven Profession 2016

The Toward a Diagnosis Driven Profession conference was held just last month in conjunction with the AADR in LA, California. Stakeholders from the Government, Dental Professional Organizations, Insurance, EHR and Academic Institutions came together for a full day of presentations and brainstorming.

The major updates from this conference include:

  • The ADA and the Harvard-led team are working together to harmonize SNODENT and the DDS terminologies. All DDS terms will be fully included and represented in SNODENT. As such, SNODENT will be renamed SNODENT Dental Diagnostic System and will function as the full reference terminology for the dental profession. The DDS has been renamed SNO-DDS – to reflect the harmonization with SNODENT – and will function as the interface terminology for the dental profession.
  • Smaller subsets of SNO-DDS are also being created to cater to the specific needs of general dentists (SNO-DDSGD), oral surgeons (SNO-DDSOS) and other sub groups. Please see the SNO-DDS news page for a visual representation of how the major terminologies now interact.
  • SNODENT, SNO-DDS and its subsets are scheduled to go through the ANSI standards process in order to become a national standard by the end of 2016.
  • To access the Speakers’ PowerPoint presentations, please click here. The video presentations of the panels will be available in the near future through the AADR website. In the meantime, you may contact for questions about the availability of these videos.
  • To view/obtain a partial list of the SNO-DDS terms, please click here.
  • Although the SNO-DDS is obtainable free-of-charge, as with other major terminologies (i.e. ICD, SNOMED-CT), they can also be obtained in a ready-to-upload format from PMIC (a third-party vendor) for a small transaction fee. Click here to obtain this version.
  • If you would like to obtain regular updates about the SNO-DDS terminology and its subsets, please sign up here via our Google forms link.
  • For more information, please visit and
  • Thank you again and we look forward to future collaborations!

OHPE Team at Harvard

Invitation to AADR-sponsored conference “Toward a Diagnosis Driven Profession 2016”

Researchers from Harvard School of Dental Medicine and the University of Pittsburgh have been planning with support from the IADR Global HQ staff, Practice Management Information Corporation (PMIC) and Delta Dental a conference about the adoption of standardized diagnostic terminologies (DxTMs) by dental professionals to improve oral health in the United States. The conference will be held on March 19, 2016 in Los Angeles, CA, at the JW Marriott Los Angeles L.A. LIVE. in conjunction with the annual conference of the American Association for Dental Research (AADR). Many speakers have accepted the invitation: among them are numerous players in the terminology research arena, such as keynote speaker Dr. James Cimino, (Chief, Laboratory for Informatics Development, NIH Clinical Center & Prof, Biomedical Informatics, Columbia College of Physicians and Surgeons), important representatives from organized dentistry, such as Dr. Dave Prebble (Vice President, Practice Institute, American Dental Association), nationally renowned interoperability specialists for large scale hospital information technology, such as Dr. John Halamka (CIO, Beth Israel Deaconess Hospital, Co-Chair of the HIT Standards Committee, Professor of Medicine, Harvard Medical School), leading representatives of the dental insurance industry, such as Dr. Bill Kohn (Vice President, Dental Science and Policy, Delta Dental Plans Association), and opinion leaders from large group practices, such as Dr. Lyle McClellan (Director of Doctor Development, Willamette Dental Group).

Together, the participants will explore the three critical challenges to enable the widespread use of DxTMs: (1) improve clinicians’ awareness of the relationship between structured diagnostic data and the ability to monitor quality and costs in their dental practices; (2) enable the interoperability of EHR systems by using mapped DxTMs; and (3) enhance the ease of entering diagnostic terms in EHRs at the point of care.

The conference will try to achieve the following goals:

  • increase understanding of DxTMs and acceptance of their key role in improving health care outcomes,
  • explore the logistical and financial impact of implementing DxTMs on EHR vendors, payers/insurers, and providers,
  • create a working group composed of EHR vendors and informaticians tasked with developing clinician-friendly interfaces for entering diagnostic terms into EHR systems.

Please join us in shaping the future of diagnostic terminology in dentistry, its usability in the EHR, and in discussing the roles of ICD, SNODENT and DDS, the diagnostic terminologies increasingly utilized by dentists globally.

Saturday, March 19, 2016 from 8:00 AM to 5:00 PM (PDT) – Add to Calendar

JW Marriott Platinum Ballroom C – 900 West Olympic Boulevard Los Angeles, CA 90015 – View Map


Stay tuned to learn here at the DIOC blog more about the conference.

We are looking forward to see you in Los Angeles,
Elsbeth and Heiko

Elsbeth Kalenderian, DDS, MPH, PhD, Chair, Oral Health Policy and Epidemiology, Chief of Quality, Harvard Dental Center, Harvard School of Dental Medicine

Heiko Spallek, DMD, PhD, MSBA Associate Professor, Dental Public Health Associate Dean for Faculty Affairs and Executive Director, Center for Informatics in Oral Health Translational Research School of Dental Medicine, University of Pittsburgh

Dental Quality Alliance (DQA) – The Measurement Challenge

The Dental Quality Alliance (DQA) hosted its 2015 conference titled The Roles of Quality Measurement at the ADA Headquarters Building in Chicago on May 1-2, 2015. The goal of the Conference is to develop dental quality ambassadors who can help lead change within the profession.

I gave a presentation titled “Dissemination and Implementation – Routine Practice“ at the Conference. Please find my slides and the references here as PDF. Several speakers during the conference raised the “lack of diagnostic coding available in dental claims limits the ability to collect and report this type of data” as identified in the 2010 NQF report “Oral Health Performance Measurement Technical Report.” This topic will be explored further during the planned dental diagnostic terminology conference titled “Toward a Diagnosis-Driven Profession” which will be held in March 2016 in Los Angeles immediately following the annual conference of the International Association for Dental Research (IADR). If you want to receive further information about the conference please contact Dr. Elsbeth Kalenderian or myself.

About the DQA
In 2008, the Centers for Medicare and Medicaid Services proposed that the American Dental Association take the lead in establishing a Dental Quality Alliance to develop performance measures for oral health care. The DQA is an organization of major stakeholders in oral health care delivery that will use a collaborative approach to develop oral health care measures.

The DQA Guidebook succinctly states why self-evaluation is an important part of dentistry: “The dental profession is taking the lead in developing mechanisms for self evaluation. Self-evaluation will ensure that dentistry as a profession can provide evidence to the community at large that its members are responsible stewards of oral health. A culture of self-evaluation is the key to fostering the best healthcare for our patients ensuring transparency of health care quality and maintaining the credibility of the dental profession.”

However, there are huge barriers in dentistry when it comes to measuring health outcomes: “There is limited knowledge of true oral health outcomes, which occurs in part because dentistry does not have a tradition of formally reporting specific diagnoses or associating such diagnoses with specific services, (ref) especially through the claims process. Further, most dental practices and dental plans lack information systems capable of capturing and transmitting the information necessary for measurement (ref). Although retrospective claims data have many

Promoting Research Using Diagnostic Codes

During the annual COHRI Winter Meeting which was held in Vancouver, Canada, I had a chance to talk to Dr. Elsbeth Kalenderian, Chair, Oral Health Policy and Epidemiology, Chief of Quality, Harvard Dental Center, Harvard School of Dental Medicine about her role in the development and implementation of the EZCodes dental diagnostic terminology. The EZCodes Dental Diagnostic Terminology was developed in 2009 by a diagnostic terminology research workgroup led by Dr. Kalenderian. Catalyzed by the Consortium for Oral Health Research and Informatics, the EZCodes Terminology has been adopted by 15 dental schools and numerous nonacademic institutions in the US and Europe, creating diagnostic centric care for over 2 million patient visits per year. The EZCodes have been mapped to the CDT and SNOMED terminologies. Recently, the group was just awarded ADA Gies Award “Collaborative pilot study of the impact of the use of the EZCodes dental diagnostic terminology in treatment planning on critical thinking skills of dental students as measured by the Health Science Reasoning Test.” The purpose of this project is to investigate whether or not the introduction and use of the dental diagnostic terminology (EZCodes) in treatment planning per the electronic health record (axiUm) can positively impact dental students’ critical thinking skills. This is a collaborative effort between the Medical University of South Carolina, Harvard and UT Houston.

Please watch the interview:

If you are interested in learning more about the EZCodes just contact Dr. Elsbeth Kalenderian at Harvard School of Dental Medicine.

Associate Dean, Office of Faculty Development and Information Management
Associate Professor, Dental Public Health, Center for Dental Informatics
School of Dental Medicine, University of Pittsburgh

Does dentistry really need more than one diagnostic vocabulary?

In case you had to guess, the answer is “no.” Recently, 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.