Developing an electronic dental record information model for general dentistry

Medical and dental records should support patient care and help improve its quality, enhance the productivity of healthcare professionals and facilitate clinical and health services research. Research suggests that current electronic systems fall short of providing these benefits in general dentistry. Electronic Dental Records (EDR) designed for general dentists vary widely with regard to the degree to which they represent the information their users typically record on paper. It is essential to define and develop an information model for the domain of general dentistry. The information model should identify the various data used for documenting the patient health information in the dental records. Failure to adopt such an information model during the design and development of EDR would lead to the inability of the systems to support clinical documentation completely and accurately.While there are many challenges to designing and implementing EDR, two of the most crucial questions are: 'what' information should an EDR contain and 'how' should it be structured? The research goal of this dissertation was to develop a consensus-based, comprehensive Electronic Dental Record Information Model (EDRIM) that covers at least 80% or more of the clinical information documented in patient's general dental record.A total of 1,100 candidate information items for a general dental information model were generated through a review of paper-based dental record templates, an analysis of four major dental practice management systems and extraction of information from 100 de-identified patient dental records. This information item list was validated through a Delphi technique. After validation, the information item list was structured into an information model in a hierarchical structure with a maximum depth of five levels. The EDRIM consisted of a total of 155 classes with 1,005 information items represented in 63 Subject Areas. The dissertation was a significant step taken towards standardizing the content and structure of the EDRs. The information coverage of EDRIM was measured through a evaluation study. The EDRIM offered a mean coverage rate of 87.75%, exceeding the goal of the dissertation had aimed for. The EDRIM serves as a framework in expanding the model to support the sub-specialties of dentistry.