1493 Clinical information coverage of four practice management systems
P. HERNANDEZ1, H. SPALLEK2, and T. SCHLEYER2, 1University of Puerto Rico, San Juan, USA, 2University of Pittsburgh, PA, USA

Approximately 25% of all general dental practices in the U.S. use computers at chairside; 19% of them are completely paperless. The remainder maintains patient documentation both on the computer and paper. Anecdotal evidence suggests that most current practice management systems (PMS) do not represent clinical information with the same degree of completeness and fidelity as paper records, thereby impeding the move to a paperless environment. Objective: Measure the information coverage of four PMSs against a comprehensive dental record. Methods: We compiled a Baseline Dental Record (BDR) from paper records of 4 dental practices, 2 dental schools and 4 commercial sources by merging all data items. The BDR had 37 sections, including chief complaint, soft and hard tissue findings, diagnoses, treatment plan and progress notes. Each section contained one or more data items. We recorded the presence or absence of each data item in each of the four PMSs. Results: Paper records were not uniform in their information coverage. Sections found in all of them included the chief complaint, clinical charting, current medications, past/present illnesses and progress notes. Diagnoses, risk assessment and prognoses were found only in dental school records. For some sections, such as the medical history, the number of data items exhibited significant variability. The paper record with the lowest information coverage contained 30% of the sections in the BDR, while the one with the highest contained 92%. The PMSs covered 27%, 51%, 57% and 73% of the sections in the BDR. Notably, several sections universally present in paper records were absent or poorly represented in PMSs. Conclusions: Paper record information coverage was not uniform, indicating incomplete agreement in the dental profession as to what constitutes clinically relevant information. The PMSs evaluated varied significantly in their information coverage, and sometimes omitted crucial patient information.

Grant support: NLM award 5T15LM07059-17

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