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EZCodes: A diagnostic terminology as the foundational step of quality for the dentalprofession

Kalenderian-Groenewegen, E.

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Citation for published version (APA):Kalenderian-Groenewegen, E. (2013). EZCodes: A diagnostic terminology as the foundational step of quality forthe dental profession.

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9

CHAPTER 1

Introduction

EZCodes: a diagnostic terminology as the foundational step of

quality for the dental profession

Chapter 1

10

Introduction

Fundamental requirements for a proper indication of oral care

As in medicine, dental treatment should be based on the complex integration of

a multitude of factors including the patient’s chief complaint, medical and dental

history (anamnesis), findings discovered during intra- and extra-oral examination, the

patient’s preferences, and social context, among others.1 In modern society, the patient

should be able to expect dental treatment proposals that are based on the best available

evidence. When taking this view, even preventive measures, such as tooth brushing

instructions, must be seen as “treatment” and ought to be evidence based. In reality,

however, patients are often advised to undergo preventive treatments where the

evidence for actual oral health improvement is uncertain at best.

Evidence-based research is frequently performed in controlled environments,

such as academic clinics, because field research lacks the ability for proper registration

of all variables required for treatment evaluation.2 As a result, controlled environments

are often not representative of the “field” or are not easily generalizable to the

practicing dentist in the private or community clinic setting. Attempts should be

undertaken to standardize documentation of dental treatment by the non-academic

dentist in such a way that structured epidemiologic and clinical evaluations are

possible. Currently, dental treatment documentation is reasonably well established in

many countries throughout the world. This is because rather often, dental providers

cannot generate income without adequate documentation in place. However, to

enhance evidence-based research in oral care, documentation of treatment alone is

insufficient. At a minimum, it has to be combined with the dental diagnosis that

formed the basis for the indication of treatment. For example, when one wants to study

the longevity of a Class IV restoration of the upper frontal incisor, it is of interest to

differentiate between the diagnoses “fracture due to trauma from being hit by a hockey

stick” and “severe caries”. It is not unreasonable to expect that a diagnosis of trauma

may influence the longevity of the restoration differently than a diagnosis of disease.

The diagnostic terminology must be clear and indisputable, allowing for a

straightforward, consistent collection of dental diagnostic information. When dental

providers enter terms validly and efficiently, information gained will enhance teaching

and digital evaluation, research and outcomes analyses, and ensure quality

improvement.

Introduction

11

Existing diagnostic systems for medicine and dentistry

The development of a standardized diagnostic terminology does not have as

long of a history as that of the medical lexicon in general. Where modern medicine can

trace its roots back to Hippocrates and Galen, whose writings include anatomic,

pathologic, and therapeutic terms that remain still in use today,3 the development of

diagnostic terminologies started a mere 250 years ago. After attempts by Sauvage,

Cullen, and Farr, Bertillon created the first generally adopted set of standardized

medical diagnoses in 1893. His “Bertillon Classification of Causes of Death” formed

the basis for the current ICD diagnostic terminology used world-wide.4 The history of

the development of ICD is documented in Figure 1.1.

Figure 1.1: History of ICD

While the International Classification of Diseases (ICD)5 is undoubtedly the

international standard diagnostic classification used in the medical clinic,

epidemiological studies, health management and economics, it does not have adequate

coverage of oral and dental diagnoses.6, 7

The U.S. developed ICD-CM (Clinical

Modification), which has more information and detail than ICD. The current ICD-10-

CM version contains 68,000 terms; ICD 10 has far less terms. Both terminologies’ oral

health chapters lack sufficient detail for prudent documentation of dental diagnoses.

The Systematized Nomenclature Of Medicine (SNOMED) was developed in

1965 by the College of American Pathologists as SNOP (Systematized Nomenclature

of Pathology), and later extended into other medical fields. The current version

SNOMED Clinical Terms (SNOMED CT) is a controlled medical terminology for use

in the EHR. As a reference terminology, it has comprehensive coverage of diseases,

clinical findings, etiologies, procedures, and outcomes and contains more than 311,000

unique terms organized into hierarchies.8 SNODENT, a Systematized Nomenclature

for Dentistry, was devised by the American Dental Association (ADA) in the early

1990’s. SNODENT is composed of diagnoses, signs, symptoms, and complaints9 and

Chapter 1

12

currently includes over 7700 terms. In 1998, the ADA entered into an agreement to

incorporate SNODENT Version I into SNOMED. In 2012, SNODENT Version II was

incorporated into the SNOMED CT. Until its recent inclusion into SNOMED CT,

SNODENT was only available by license and was maintained by the ADA. As a

result, SNODENT has never been implemented in the dental profession. The sheer size

of oral health terms makes effective integration into a dental electronic health record

(EHR) difficult and actual utilization improbable.

Clinical terminologies as well as classifications capture detailed data in the

EHR. Where clinical terminologies are the input format, classification systems are the

output format. Though they are designed for different purposes, they should be

considered complementary. ICD is considered a classification or “output” system. As a

result, the primary documentation of clinical care is not its intended use. Indeed, it is

mainly used in the U.S. for external reporting (billing, quality control) requirements. In

contrast, SNOMED-CT is a clinical terminology, and as an “input” system, it is

designed for the primary documentation of clinical care.

It is reasonable to assume that the “one size fits all” principle will not work

when trying to utilize one terminology or classification to fulfill all required

administrative needs of a healthcare organization. For example, with nearly 7700

dental terms and 311,000 medical terms, SNOMED-CT is designed to identify data at

the point of care. Whereas ICD, with around 100 oral health terms and 68,000 medical

terms, (ICD CM has around 320 oral health terms) has the ability to aggregate data and

is more suitable for claims processing. Additionally, which terminology or

classification system shall be used is determined, in part, by regulatory requirements.10

Rationale for the development of a dental diagnostic terminology

Until now, a commonly accepted standardized diagnostic terminology did not

exist for oral diagnoses. However, the dental provider has never documented

diagnoses, whether in electronic or paper format, in a structured way. In contrast,

medicine has used standardized terminologies for over a century, and specifically, ICD

is a requirement of the American billing process. More recently, the U.S. Office of the

National Coordinator (ONC) is requiring the use of SNOMED CT11

terms for

populating the problem list in the EHR for those providers who want to participate in

its “Meaningful Use incentive program”.12, 13

There are a multitude of benefits for documenting diagnoses in a standardized

and consistent way as our colleagues in medicine have been doing “since the bubonic

plaque”14

(or rather one of its later local outbreaks: the Great Plaque of London in

Introduction

13

1665), or to be precise, since 1763.9 They include documentation of the types and

frequency of diseases encountered by the care provider and thus, the ability to track

disorders treated for internal quality control. This enhances communication with

patients and between care providers, especially when care is shared between health

care providers, enables outcomes tracking, and facilitates data sharing across sites.15

It

allows epidemiologists to evaluate disease patterns, treatment patterns, and disease

outcomes. From a research point of view, it will allow health services researches to

study risk-adjusted, cross sectional, and temporal variations in access to health care,

health care quality, costs of care, and treatment effectiveness.16

In the academic

setting, a standardized dental diagnostic terminology will allow both students and

faculty to hone their formal diagnostic skills, emphasizing the link between diagnosis

and treatment and thus enhancing patient care.17

Lastly, the standardization of

documenting diagnoses will allow for the true measuring of outcomes, defined as the

condition of a patient at the end of therapy or a disease process,18

and as such, forms

the foundation of the development of clinical guidelines or recommendations to inform

evidence-based dentistry (EBD).19

Figure 1.2 is a graphical representation of the relations between diagnostic

codes and applications.

Figure 1.2: Relationship between diagnostic codes and applications

Financial

The United States is expected to spend approximately 19% of its Gross

Domestic Product (GDP) on health care in 2014.20

In 2011, per capita healthcare

spending rose by 4.6%.21

According to the Kellogg Foundation’s 2011 report titled,

Oral Health Quality Improvement in the Era of Accountability, “the United States

Chapter 1

14

healthcare system spends significantly more money per capita…than other developed

nations” while trailing other developed nations in several health indicators,22

ranking

39th

in infant mortality, 43rd

in adult female mortality, 42nd

in adult male mortality, and

36th

in overall life expectancy. Meanwhile, the mortality rate for American males 15-

60 years of age is worse than in Sweden or Australia,23

countries that are similarly to

the U.S with respect to population wealth (GDP/capita). Additionally, in the U.S.,

where health insurance is predominantly employer-sponsored, increased

unemployment levels, and the subsequent loss of employer-provided insurance, have

served to decrease access to healthcare. Meanwhile, as a result of reductions in dental

insurance benefits, Americans are increasingly paying for oral healthcare out-of-

pocket or foregoing needed dental procedures, to the point where “dental care is

among the largest out-of-pocket health expenditures in the U.S., second only to

prescription drugs”.22

These sobering facts demand not only adjustments in healthcare spending,

becoming more efficient, or making incremental changes, but also true innovation.24

In

response to spiraling healthcare costs in the United States and resultant negative public

health impacts, the “Triple Aim” was developed by the Institute for Healthcare

Improvement (IHI) in an effort to create an improved model of healthcare delivery. Its

three conceptual dimensions are:

(1) improving the patient experience of care;

(2) improving the health of populations, and

(3) reducing the per capita cost of healthcare.

In Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better

Health and Lower Costs, Bisognano and colleagues described how healthcare

innovators have found a way to achieve “measurable progress on the challenges of

quality and costs”.25

The seven innovators present implemented solutions that

produced documented results in improving patient care while controlling costs. The

Triple Aim model is in part an effective model to apply to dentistry in an effort to start

addressing quality and cost issues. However, it might have been better if the architects

of the Triple Aim had included oral health directly into some of their approaches

instead of perpetuating the siloed structure of dentistry and medicine.

One of the most effective ways to improve effectiveness of care is to increase

the degree to which dental and medical providers collaborate with respect to overall

care for their shared patients. This is a significant paradigm shift for both parties since

currently the relationship is most often limited to one of referring for expert treatment

(“cure”). However, only when the dental provider begins to function as a “health care

ambassador” (i.e. monitoring blood pressure), or the medical provider as a “dental

Introduction

15

advocate”, supplying advice and preventive care (i.e. supplying fluoride treatment for

children), will the patient truly benefit through ongoing managed care, instead of

episodic expert “cure”. Dentistry brings well-documented value to the Triple Aim - a

partnership with the medical physician for providing screening, preventive

maintenance care and actively participating as a member of the Proactive Practice

Team. The dentist thereby becomes a partner in the detection of systemic diseases, as a

number of systemic diseases can be first diagnosed orally. Examples include

immunosuppressive diseases (i.e. pemphigus vulgaris), chronic illnesses (i.e. diabetes),

and infectious diseases (i.e. HIV/AIDS, the first AIDS patient was diagnosed in San

Francisco General Hospital as Karposi Sarcoma of the palate.26

) The models

developed by Bellin Health25

and others can be adapted to include oral health

providers. Use of a dental diagnostic terminology will hold the key to moving from

“cure” to care”, as well as improving the capacity for oral public health research

connecting medical and dental care. This in turn will promote collaborative efforts,

and enable oral health data collection that fosters capacity for medical-dental

partnerships.

Since a number of chronic diseases have oral manifestations, dentist-physician

collaboration can increase early diagnosis for patients with chronic illnesses and thus

prevent expensive treatment of complications later on. For example, uncontrolled

diabetes will negatively influence the periodontal status of the patient, and, conversely,

improving periodontal health will positively influence the diabetic status of the

patient.27

One such example of dentist-physician collaboration is seen in twenty

schools that are part of the Consortium for Oral Health Research and Informatics

(COHRI).28

These schools are participating in efforts to engage their patients in simple

primary care screening efforts as participants of the Meaningful Use Incentive

Program,29

a part of the HITECH Act of 2009 that provides payment incentives for

utilizing EHRs. These efforts include blood pressure measurement, tobacco use and

cessation screening, asthma acerbations screening, and assuring pneumonia and

influenza vaccinations. In addition to augmenting medical management of chronically

ill patients, these quality measures also represent a budding partnership with the

patient at the center and the medical and oral health physicians as partners and

collaborators, connected to each other and the patient. The core of this effort is the

ability for the provider to document a medical, as well as an oral health, diagnosis in a

structured and consistent way.

Chapter 1

16

Quality

Documenting diagnoses in a standardized way has to be at the foundation of

any quality effort to reach the Triple Aim of better care, better health, at lower cost.25

Expanding the Institute of Health Improvement’s simple triad illustrates the

foundational role of a dental diagnostic terminology to affecting quality in oral health

(see Figure 1.3). The problem for dentistry, however, is that while ICD is undoubtedly

the international standard diagnostic classification used in the medical arena, it does

not have adequate coverage of oral and dental diagnoses. Conversely, SNOMED, and

the majority of the oral health terms imbedded in it as SNODENT, offers such an

overwhelming number of terms that it effectively becomes unmanageable chair-site.

However, as mentioned earlier, the ability to capture information about oral health

diagnoses in a standardized way is essential for quality of care, epidemiological health

tracking, and research and cost-effectiveness reasons. Entering a diagnosis in a

structured field in an EHR not only reinforces the link between diagnosis and

treatment, but also allows for efficient outcomes assessment and continuous quality

monitoring through data mining. Hence, the need for the development of a dental

diagnostic terminology, intended to reap the benefits of being positioned as an

interface terminology, becomes quite evident.30

Figure 1.3: Diagnosis as the foundation of Quality of Care

Introduction

17

Research

Martin et al., nicely outline the central issues regarding the use of dental

diagnosis in dentistry and dental research when they mention that “(…) currently

dentistry has a disconnect between procedure codes (…) and diagnostic codes….”.31

As a result, there are serious challenges to combining data across disparate sites and

comparing results across studies. As Pitts noted, “Many apparently similar terms are

used interchangeably in the literature, but are taken by different groups of researchers

and clinicians to mean very different things”.32

Clearly, the dental profession’s ability

to conduct research is limited by the lack of clear definitions and standardized

nomenclature to describe diagnoses.

One of the stated goals of the Centers for Disease Control’s (CDC) Healthy

People 2020 is to “prevent and control oral and craniofacial diseases, conditions, and

injuries, and improve access to preventive services and dental care”.33

Toward these

goals, in September 2011, the National Priorities Partnership (NPP), formed by the

nonprofit National Quality Forum (NQF), recommended including three oral health

measures delineated by Healthy People 2020 as measurable objectives. These oral

health measures are:

(1) the proportion of young children aged 3-5 years with dental caries experience in

their primary teeth;

(2) the proportion of adults with untreated dental decay, and

(3) the proportion of children, adolescents, and adults who used the oral healthcare

system in the past year.34

In order to effectively measure these objectives, a standardized dental diagnostic

terminology that is practical and easy to use chair-site will be necessary.

Evidence-Based Dentistry (EBD)

The periodontal community is leading the dental profession by starting the

debate about the absence of a “gold standard…which contains all the information

needed to form a diagnosis”.31

With the ongoing implementation of EHRs in the

dental setting, it is important that, once the diagnosis is made, it is captured

electronically, along with the procedure performed, using a dental diagnostic

terminology. Nevertheless, as Meyers’ argument underscores, “dentists do not have a

set of diagnostic terms or clinical pathways to attain dental health for their patients

based on the best available evidence and accurate risk assessment”.35

Chapter 1

18

Evidence-based dentistry (EBD) is the coming together of three equally

important concepts:

(1) the best available, clinically relevant, scientific evidence relating to the patient’s

oral and medical condition and history;

(2) a dentist’s clinical expertise, and

(3) the patient’s treatment needs and preferences.

Systematic reviews of published papers are considered the preferred method for

assembling the best available scientific evidence. As such, the results from systematic

reviews may be used for decision making about research and the provision of health

care. A systematic review includes:

A stated clinical question, preferably in “PICO” format that identifies:

Population (the individuals or groups for whom an answer is sought)

Intervention (the treatment or clinical condition of interest, i.e. patient type,

disease)

Comparison (an alternative treatment or control group for comparison to

intervention)

Outcome (the measure(s) used to assess the effects of the intervention)

Example: In persons with adult periodontitis, how does scaling and root planing

combined with local antimicrobial therapy affect bleeding and pocket depths

compared to scaling and root planing alone?36

Clearly, without a well-defined diagnosis that is documented in a standardized

way throughout the literature, it will be difficult to “identify and evaluate all of the

evidence with which to answer a specific, narrowly focused clinical question”.37

As

such, one might argue that a number of the current EBD recommendations have a low

level of certainty of net benefit. As described in the ADA Clinical Recommendation

Handbook, “The ‘level of certainty’ is the probability that the Expert Panel’s

assessment of the net benefit of an intervention is correct. For example, a low level of

certainty may result from a lack of evidence; from studies of inappropriate design;

from studies of appropriate design, which are of poor quality or have meager or no

applicability; from too small and/or too few studies; and from inconsistent results

between studies”.37

When reviewing the American Dental Association Council on Scientific

Affairs’ EBD recommendations, it is clear that standardized documentation of

diagnosis is paramount in the development of such guidelines:

Introduction

19

(1) Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental

Procedures.38

The guideline reviews how “a multitude of indirect evidence was

included in this guideline that investigates particular components of this

complex mechanism”. It states, “Multiple high strength studies link oral

procedures to bacteremia, a surrogate measure of risk for orthopaedic implant

infection”. One might argue that without knowing the diagnosis and thus why a

procedure was performed, it is difficult to understand the surrogate link

between procedure and bacteremia. Extraction of an abscessed tooth occurs in a

quite different oral environment than removal of four pre-molars for

orthodontic reasons.

(2) Nonfluoride caries-preventive agents.39

Several studies recorded dental caries

according to the World Health Organization (WHO) definitions, which include

four caries stages, however, not all four stages were always included in the

statistical analysis.40

This may have impacted understanding the preventive

impact of xylitol on the formation of white lesions.

(3) Dietary Fluoride Supplements.41

The panel concluded, “Owing to known

increases in exposure to fluoride from multiple sources and the increased

prevalence of enamel fluorosis, the panel recommended fluoride supplement

use for children at high risk of developing caries”. The guidelines also note that

“the panel did not identify studies that supported its use specifically in

populations at high or low risk of developing caries” and that “the clinician

should conduct a caries risk assessment to determine the appropriateness of

prescribing dietary fluoride supplements. There is no exact definition of high

risk of developing caries; rather, it can be a continuum”. However, a

standardized diagnostic terminology that not only includes terms for the

various forms of caries, but also includes terms for “High, Moderate and Low

Caries Risk” should significantly help with the risk benefit analysis of

preventing caries versus promoting the incidence of fluorosis.

(4) Evidence-Based Clinical Recommendations for the Use of Pit-and-Fissure

Sealants.42

The report states that “in clinical care settings, diagnosis of caries

implies not only determining whether caries is present (that is, detection) but

also determining if the disease is arrested or active and, if active, progressing

rapidly or slowly”. Additionally, the report states, “Pit-and-fissure sealants are

underused, particularly among those at high risk of experiencing caries”. Only

when the patient’s level of caries risk assessment, as well as level of disease, is

documented in a consistent, standardized way, can we make conclusions

regarding the true effectiveness of the intervention.

Chapter 1

20

(5) Professionally applied topical fluoride.43

The guidelines state, “The panel

encourages dentists to employ caries risk assessment strategies in their

practices”. In order to assess effectiveness of this intervention for a single

patient or an entire population, standardized documentation of caries risk level

will be necessary.

(6) Evidence-Based Clinical Recommendations Regarding Fluoride Intake From

Reconstituted Infant Formula and Enamel Fluorosis.44

This report states

evidence-based clinical recommendations regarding the intake of fluoride from

reconstituted infant formula and its potential association with enamel fluorosis.

For ongoing assessment and monitoring of fluorosis among infants,

documenting the various stages of fluorosis in a standardized way will be

paramount.

(7) Evidence-Based Clinical Recommendations Regarding Screening for Oral

Squamous Cell Carcinomas.45

The guidelines state, “When a clinician observes

a persistent or progressive lesion, he or she may consider prompt referral to a

dental or medical provider with advanced training and experience in diagnosis

of oral mucosal disease before performing tissue biopsy”. This will require

consistent documentation of a diagnosis in an easily retrievable manner. The

preference would be an electronic format, since these are easiest to retrieve.

Thus, the use of a diagnostic terminology will be essential.

Research project of this thesis

The study described in this thesis aims to develop a validated dental diagnostic

terminology (called ‘EZCodes’) to enhance a proper registration of diagnostic findings

for, amongst others, research in EBD. Basic principles for terminology development

will be applied. Moreover, the notion to position the terminology as an interface

terminology, interfacing with existing diagnostic and payment systems will be

explored.

Chapter 2 discusses the public health impact of the use of a standardized dental

diagnostic terminology. It provides an overview of how standards are developed and

accepted worldwide. As an interface terminology, the EZCodes terminology is

positioned to play a prominent role in this important, but yet underexplored arena.

In Chapter 3, the iterative process to develop a dental diagnostic terminology

adhering to principles of terminology development is described. Additionally, a first

attempt was made to build an interface terminology consisting of categories and

subcategories. This resulted in 1158 terms that are mappable to:

Introduction

21

(1) ICD for Medicaid billing purposes;

(2) SNOMED, its reference terminology, for Meaningful Use purposes, and

(3) the treatment terminology CDT,46

for general dental billing purposes.

In essence, the EZCodes are the center of serving or informing four crucial entities of

the dental profession (see Figure 1.4).

Figure 1.4: Relationship between diagnostic codes and applications

Chapter 4 describes the validation process of the diagnostic terminology

through a retrospective analysis of the use of Z codes (a subset of the EZCodes) as

they relate to procedure codes. The study showed successful development,

implementation, and utilization of diagnostic codes and terms in an EHR with low

elective utilization but high validity.

Chapter 5 describes the assessment of the EZCodes terminology in two dental

schools. After one year of non-compulsory use, utilization was low; however, validity

was high.

Chapter 6 explores the role of the EZCodes in treatment planning in the EHR.

The study underscores the impact of technology on the fundamental skills of diagnosis

and treatment planning within the modern educational setting.

Chapter 7 describes a short use case that demonstrates the value of documenting

a diagnosis in a standardized way. Four U.S. dental schools have pooled de-identified,

clinical EHR data in a first-ever dental data repository. With one million unique

patients, many who have diagnostic as well as treatment codes documented in their

EHR, it was possible to answer research questions focused solely on the value of

entering a diagnostic term.

Chapter 1

22

In Chapter 8 the general discussion integrates the results of the studies, explores

steps towards future research, demonstrates the value of the EZCodes terminology and

provides a call to action for further integrating of the EZCodes diagnostic terminology

into the curriculum of today’s dental students.

Introduction

23

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Chapter 1

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Introduction

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