Decision Support to Improve Dental Care for Medically Compromised Patients (Minnesota)

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Summary:

Chronic conditions such as diabetes, heart disease, pulmonary disease, and conditions that cause xerostomia (dry mouth), impact the quality and safety of dental care patients receive. Dentists often fail to follow guidelines for these conditions because they are either unaware of their patients’ chronic conditions or the guidelines. Clinical decision support (CDS) embedded within electronic dental records (EDRs) offers a method of informing and activating dentists to follow these guidelines for their patients with chronic conditions.

This study evaluated the eDental Guides CDS system that integrated dental and medical records with clinical guidelines to improve the quality and safety of dental care for medically complex patients. The three main components to the eDental Guides were a patient medical summary, individualized treatment recommendations, and clinical guidelines. The CDS also had three strategies designed to alert dental providers to the individualized treatment recommendations: (1) active pop-up alerts in front of the EDR that requires the dentist to reference the personalized guidelines; (2) passive alerts in the clinic schedule that encouraged, but did not require, reference to personalized guidelines; and (3) flashing control alerts with a web link to general guidelines.

The specific aims of this project were as follows:

  • Determine the impact that the three alert strategies have on increasing the use of and adherence to evidence-based guidelines. 
  • Determine the impact of the three alert strategies on improving dental care utilization and reducing emergency visits due to adverse events. 
  • Develop strategies to integrate the eDental Guides CDS within community-based health information exchange formats to allow use by community dentists. 

Fifteen dental clinics from HealthPartners, an integrated health system in Minnesota, were randomized to one of the three alert types. During the 12-month study, there was increased utilization of the eDental Guides CDS regardless of the alert type. Overall, the pop-up alert was more effective in encouraging providers to review care recommendations compared to the passive and control alerts; however, the passive alert was the most preferred by dental providers because it was the least intrusive. The project team concluded that future dental care delivery systems and EDRs should expand the use of CDS at the point of care to help dental care professionals integrate medical knowledge into routine clinical practice.

Decision Support to Improve Dental Care for Medically Compromised Patients - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality
  • Grant Number: 
    R18 HS 020846
  • Project Period: 
    July 2012 – April 2015
  • AHRQ Funding Amount: 
    $390,328
  • PDF Version: 
    (PDF, 332.13 KB)

Summary: Chronic medical conditions such as diabetes, heart disease, pulmonary disease, and conditions that cause xerostomia (dry mouth) can, if neglected, have a profound effect on the quality and safety of dental care. Adhering to evidence-based clinical practice guidelines can minimize complications and improve the outcomes of dental care provided to medically compromised patients. Recommendations include changes in chair-side dental procedures, frequency of oral hygiene visits, and timing of followup visits. However, the dissemination of practice guidelines does not ensure their use. Clinical decision support (CDS) software in an integrated electronic health record can inform dentists of when and what changes in clinical protocol are needed for specific medical conditions. However, if not implemented smoothly some CDS can place a burden on clinicians by causing alert fatigue and avoidance.

To change clinical practice, active strategies for alerting clinicians have generally been found to be more successful than passive alerts but they also create more resistance and alert fatigue. This study will determine if providing active or passive CDS improves the quality and safety of care versus a usual-care control. The study design is a three-arm, 2-year prospective group-randomized clinical trial. The three arms include a passive alert CDS, an active alert CDS, and usual care with access to general guidelines through a blinking Web link in the electronic dental record (EDR). The passive CDS utilizes dentist and staff reminders in the clinic schedule to encourage but not require reference to personalized guidelines in a linked Web service. The active CDS utilizes a more obtrusive pop-up alert in the EDR that requires the dentist to reference the personalized guidelines. Outcomes include how often the dentist reviews guidelines, whether s/he changes his/her clinical protocols, and whether this reduces complications in patients.

Specific Aims:

  • Determine the use and acceptability of the active versus passive CDS interventions to increase use of evidence-based guidelines by dental providers compared to the no CDS control group. (Upcoming)
  • Determine the effectiveness of the active versus passive CDS interventions toward changing dental provider behavior to follow clinical guidelines compared to the other control group. (Upcoming)
  • Determine the impact of the active versus passive CDS interventions upon reducing adverse events and emergency care compared to the control group. (Upcoming)

2012 Activities: Dr. Fricton has hired the necessary study staff and the project team is meeting regularly. Institutional review board approval is underway. Dr. Fricton and his team have diagrammed the workflow for use of the CDS and reviewed it with dental leadership. The diagram depicts: 1) the decision tree used by the software to assess and assign patients with targeted conditions to a study arm; and 2) the subsequent actions taken by the dentist. A number of focus groups have been held with clinic dentists and staff to assist with defining alerts, clinical recommendations, and decision support tools. The project team has also defined use cases for the decision support functionality and clinical recommendations for dentists to follow when patients have a chronic illness. Training of providers on the system is expected to begin in 2013. Dr. Fricton and his team are also adjusting to the consolidation of the Minnesota Health Information Exchange (HIE) and the Community Health Information Collaborative into HIE-Bridge, the single State- certified HIE. No significant impact on project plans is anticipated from this change.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and project budget funds are somewhat underspent due to administrative delays.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes, and Other Conditions: Xerostomia

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*This target population is one of AHRQ’s priority populations.

Decision Support to Improve Dental Care for Medically Compromised Patients - Final Report

Citation:
Fricton, J. Decision Support to Improve Dental Care for Medically Compromised Patients - Final Report. (Prepared by HealthPartners Research Foundation under Grant No. R18 HS020846). Rockville, MD: Agency for Healthcare Research and Quality, 2016. (PDF, 7.93 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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