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


Reflections on MOOCs

I just just completed my first MOOC (massive open online course) “Introduction to Infographics and Data Visualization” where I have learned new techniques for visualizations. As one interested in learning technologies, this experience was not only about gathering new knowledge about infographics, but also about how one handles 2,000 students in an online course.

In this blog, I would like to share some of my personal observations and thoughts about MOOCs and post some questions for discussion:

  • How will this trend influence the students who will enter our dental schools (At Berkeley, one of our students reported, undergrads are encouraged to stay home and watch the lectures instead of going to class)?
  • Is there an opportunity for dental educators to move some of the preclinical classes to an online delivery mode (especially when you lack the basic science faculty to teach them)?
  • Can information about student behavior collected during online classes support research in the realm of Scholarship of Teaching and Learning?
  • Does any of you have any experience with courses delivered through Udacity, Coursera or edX?

My first observation has to do with motivation: You have to be a self-motivated, self-disciplined individual to finish a MOOC. There is very little external pressure to go on, especially peer pressure is low in an online environment. We all have experienced that online communication works best when you interact with people whom you have previously met face to face. Well, I did not know any of my 2,000 peers.

One way to reduce the dropout rate is to engage students which brings me to my second observation which I made during the course participation. The course director, Alberto Cairo who teaches Information Graphics and Visualization at the School of Communication at the University of Miami, made great efforts to keep us, online students, attentive and motivated. He used many techniques of peer review and peer rating of project (not grading!) to facilitate this process. In essence, each assignment included a mandatory part of posting at least two comments. In addition, he gave us the freedom to do whatever we want for our final project instead of a very prescribed assignments. He had us choose a topic, gather the appropriate information, and present the idea of how to show that information in graphic form. The first part of the assignment was to do sketches and write a short description outlining our goals and then share them in the discussion forums to get feedback from peers. We were also supposed to comment on other people’s proposals. Then, we had two weeks to produce our infographic and post it—again the assignment included to comment on the projects of our peers. While I did not check out all submissions, from the ones I reviewed, I can say that many students picked a topic which was either related to their daytime job or otherwise close to their heart. So, they were not only interested in the visualization techniques, but also felt passionate about the topic—I believe that made a difference.

Nicholas Carr, the author of The Shallows: What the Internet Is Doing to Our Brains (http://amzn.to/rD635C), published an interesting piece about MOOCs in Technology Review addressing, among other aspects, the dropout issue (see this and other links at the end). The article explores historical analogies, like the correspondence courses of the 1920ies, and talks about newer concepts, like the flipping of the classroom Khan Academy style. In general, the discussion centers around the efficiencies of MOOCs versus the lack of meaningful interactions between students and teachers resulting in high dropout rates. “Scholars who are skeptical of MOOCs warn that the essence of a college education lies in the subtle interplay between students and teachers that cannot be simulated by machines, no matter how sophisticated the programming.”

Yes, I will get a certificate, but “no formal course credit of any kind is associated with the certificate.” This brings me to my next observation, the question of proctoring technologies in these MOOCs. I do not have to elaborate on the issue of cheating in an environment where everyone is alone in front of a computer. I do think that both remote and face-to-face proctoring business is going to grow because of these new course modalities. Technology Review recently featured an article about upcoming technologies in that area: “In Online Exams, Big Brother Will Be Watching. How can you tell if an online student has done the work? That’s where webcam proctoring comes in.”
I have chronicled my journey during this MOOC experience in my blog if you are interested to learn more:

Let me conclude with a quote by Nicholas Carr: “Whether massive open courses live up to their hype or not, they will force college administrators and professors to reconsider many of their assumptions about the form and meaning of teaching. For better or worse, the Net’s disruptive forces have arrived at the gates of academia.”

MOOC Resources
NYT article about MOOCs: http://www.nytimes.com/2012/11/04/education/edlife/massive-open-online-courses-are-multiplying-at-a-rapid-pace.html
Nicholas Carr: http://www.technologyreview.com/featured-story/429376/the-crisis-in-higher-education/
Coursera: https://www.coursera.org/
Udacity: http://www.udacity.com/
edX: https://www.edx.org/
The Big Three, at a Glance: http://www.nytimes.com/2012/11/04/education/edlife/the-big-three-mooc-providers.html
In Online Exams, Big Brother Will Be Watching: http://www.technologyreview.com/news/506346/in-online-exams-big-brother-will-be-watching/
Wikipedia: http://en.wikipedia.org/wiki/Massive_open_online_course

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, 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.