Abstract:
BACKGROUND : Our objective was to measure the proportion of patients for which comprehensive periodontal charting,
periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal
diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to
assess how well four dental institutions documented periodontal disease-related information. An automated database
script was developed and implemented in the EHR at each institution. The measure was validated by comparing
the findings from the measure with a manual review of charts.
RESULTS : The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution
2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value < 0.0001). The largest gaps in documentation
were related to periodontal diagnoses and capturing oral homecare compliance. A random sample of 1224 charts
were manually reviewed and showed excellent validity when compared with the data generated from the EHR-based
measure (Sensitivity, Specificity, PPV, and NPV > 80%).
CONCLUSION : Our results demonstrate the feasibility of developing automated data extraction scripts using structured
data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness
within and across different dental institutions.
