Dr Namita Shanbhag Associate Professor Government Dental College and Research Institute 1 Inter-Intra Rater Reliability Using E Charting EDR In Dental Education Setting Dr Namita Shanbhag Associate Professor student Dr Manjunath Puranik. Professor and Head Dr Santhiya Post graduate

2 CONTENTS Background Aim and objectives Methodology Results Discussion Summary and Conclusion Acknowledgement Records are the most important tools for verifying the delivery of predictable wellnesscentered care, based on up- to-date evidencebased decision-making that patients want and expect. As patients become savvier about their healthcare and more frugal with their money, it is of utmost importance that dentists have the latest, greatest, and most innovative technology The introduction of operatory computers has

been a popular trend lead by applications such as digital X-ray systems and cosmetic-imaging software. The information technology revolution coupled with every- day use of computers in clinical dentistry has created new demand for electronic patient records. The Electronic Patient Record (EPR) or computerbased medical record is defined by the Patient Record Institute as a repository for patient information with one health-care enterprise that is supported by digital computer input and integrated with other information sources.1 Digital patient records can improve organization, treatment-tracking, and information retrieval enhancing communication and optimum patient care The electronic health record with respect to clinical charting is, by default, a more comprehensive application of software technology in the operatories Dental Charting is a Cloud-based e-charting and

statistics generating software produced and compiled by Mr Wouter Put ,Netherlands and has the potential to provide health information management and analysis approach on a large scale, and across populations. 2 This specific software tool automatically generates instantaneous dental health statistics of the charted patients that would be essentially needed to be used to plan or execute any health program or any kind evaluation processes as needed by the health authorities. In order to fully integrate and realize all of the potential of electronic records, many of the roadblocks must be resolved efficiently. This includes full resolution of issues related to terminology, system interfaces, and agreement on standardized clinical measures.3 The purpose of this study was to assess the inter and intra rater examiner reliability of electronic dental record system using this online e- charting

software tool in recording common oral findings. Aim and Objectives To quantify intra- and inter-examiner reliability of measuring periodontal as well as dental parameters using the e-charting software program. To suggest any modifications with regard to data cells if any Methodology Three clinical examiners (SE + 1 ) were assigned to the study. All examiners attended a review seminar and training session , during which the objectives, measurement parameters, techniques and schedule was discussed. They would be recording the detailed case history of the calibration subjects on to the online charting tool into a computer independently

In a calibration group (not part of the experimental group), 10 study subjects were examined by the two examiners, using a plane mouth mirror and a WHO Probe (Hu-Friedy Co., Chicago, USA), once a week over a period of 2 weeks. The standard examiner (SE) discussed each criteria being used for each aspect of the dental and periodontal examination and discussed how to enter the data into the software The examination process was repeated until each examiner had substantial correlation Kappa agreement of 5 kappa values in the range 0.81 0.92, and the all items gave a kappa value of 0.88. ETHICAL CONSIDERATIONS The Institutional Ethics Committee of Government Dental College approved the study The calibration subjects were recruited based on their willingness for participation and after signing the informed consent following guidelines of the

Helsinki Declaration. Intra rater calibration session A total of 50 adult calibration subjects (18 years of age or older) with a range of periodontal health and dental caries were recruited for the study by the standard examiner over a period of 2 weeks Only 5 subjects were evaluated by the SE each day A total of only 31 subjects volunteered for repeat examination that were conducted by the SE after one week Inter-rater calibration Recruitment of 50 subjects (6 subjects per day were examined and the oral findings were recorded independently by the standard examiner on to the computer using the dental charting clinic management charting software. A total of only 36 subjects volunteered for repeat examination. They were assessed again after one week consecutively

by the other two examiners. Dental caries was scored using DMFT, ICDAS and CAST indices Gingivitis was assessed by the presence of bleeding on probing Statistical Analysis The prevalence of dental caries and periodontal disease was instantly generated through the inbuilt statistical software in the dental charting software program. The baseline record of each patient was analyzed further with regard to the following variables namely the Age, Gender ,Gingivitis(BOP), Periodontitis(Pocket depth, LOA, Gingival Recesion), Dental caries(DMFT, ICDAS, CAST). The results were analyzed statistically by t-test for independent samples and an analysis of variance (ANOVA) to derive significance.(p<0.05)

The intra-class correlation coefficient, , was used to determine both the intra- and inter-investigator reliabilities. Results The study was conducted among 100 subjects over a period of 2 months The mean age of the study subjects was 39.3 years (18-50 years ). INTRA RATER CALIBRATION Variables Dental caries Periodont al Diseases Prevalence (%)

Mean Score (SD) pValue Exam-1 Exam--2 Exam-1 Exam-2 DMFT 81 84 3.26 (1.788)

3.26 (1.751) 0.811 ICDAS 71 74 1.74 (1.154) 1.77 (1.175) 0.884 CAST

81 84 3.26 ( 1.788) 3.26 (1.751) 0.811 Gingivitis 74 74 9.35 (8.716) 9.32

(8.719) 0.975 Periodont 48 itis 48 1.94 (2.205) 2.00 (2.221) 0.963 INTRA RATER CALIBRATION INTRA CLASS CORRELATION COEFFICIENT

Intra class correlation Confidence interval Significance (95% CI) DMFT 0.984 0.966 - 0.992 0.000 ICDAS 0.969 0.935 0.985 0.000

CAST 0.984 0.966 - 0.992 0.000 Gingivitis 0.999 0.998-1.000 0.000 0.986 0.997 0.000

Variables Dental caries Periodontal Diseases Periodonti 0.993 tis INTER RATER CALIBRATION Variables Mean Score (SD) Prevalence (%) Exam Examin iner1 er 2 Examine Examiner Examiner Examiner 3

r3 1 2 89 86 89 2.833 ( 1.3416) 2.972 (1.4439) 2.778 (1.4165 ) 0.225

58 59 58 1.611 (0.3581) 1.667 ( 1.3732) 1.639 ( 1.3970) 0.823 89 86

89 2.833 ( 1.3416) 2.972 (1.4439) 2.778 (1.4165 ) 0.225 58 69 58 9.78 (8.712 )

9.64 ( 8.679) 9.53 (8.507 ) 0.185 36 39 2.11 ( 3.003) 2.06 (3.070 ) 2.11 (3.022 )

0.722 DMFT Dental caries p-Value ICDAS CAST Periodon Gingivitis tal Diseases Periodonti 36 tis INTER RATER CALIBRATION Inter item correlation Intra class Confidence

matrix correlatio interval(95% n CI) Standa Examin Examine rd er r examin 2 3 er(SE) Variable s F score DMFT 1

0.868 0.897 0.956 0.924 0.976 0.000 ICDAS 1 0.924 0.933 0.974 0.954 0.986 CAST

1 0.868 0.897 0.956 0.924 0.976 0.000 Gingiviti 1 Periodon s tal Diseases Periodon 1 titis 0.995 0.994

0.999 0.997 0.999 0.000 0.991 0.991 0.996 0.993 0.998 0.000 Dental caries 0.000

DISCUSSION This study evaluated intra- and interexaminer reliability among three trained and calibrated examiners while using a e charting tool for data entry of clinical recording of dental and periodontal health among the individuals Rigorous operator calibration were demonstrated as necessary for obtaining reliable records, which can be used for appropriate decision-making. In our opinion, the high intra-examiner reproducibility observed was the result of the calibration and training program, and was not related to the operators experience, as have stated other authors 4-9 There are other variables that could affect periodontal clinical probing and this was avoided by providing sufficient time between the initial and repeated measures and preserving tissue health, thus controlling the likelihood that an operators

memory induced bias. The EPR can be used to assess the quality of care in a large clinic in numerous ways.1 Researchers have suggested that oral health professionals should develop a common record with standard codes, including clinical outcome measures, to make the EHR more useful for recording clinical treatments, facilitating research and improving quality of care. Any electronic dental record should be flexible enough to allow the comparative analysis of patients and by individual or groups of providers. Data from the EPR must be exportable to other software packages for further analyses to support many quality assurance functions. Though the software has an ability to generate statistics instantaneously, further analysis needed an manual approach.

CONCLUSION According to the Office of National Coordinator, the purpose of meaningful use is to use an EHR Improve quality, safety, efficiency, and reduce health disparities, engage patients and family, improve care coordination and population and public health & maintain privacy and security of patient health While the research by Poul Eric Petersen implies that Electronic health information improves patient care by facilitating higher patient safety and quality of care, eliminates bulky folders of patients records, and storage space freed up to make way for consultation rooms, with quick and timely access to a patients updated dental history and any pre-existing medical condition allows more thorough assessments in less time by cutting down on waiting time as patient records retrieval goes electronic

Hence EDR -It turns a promise into reality as to formulating fact-based dental health policies Cloud-based e-charting and statistics processing promises to be the way forward for reliably maintaining patient dental health records. It has the potential to provide the global dentistry community with a health information management and analysis approach on a large scale, and across populations. It turns a promise into reality as to formulating fact-based dental health policies as well as planning and executing health service delivery Improved quality of oral health information systems worldwide may help to strengthen health systems and operational research may assist in translating sound knowledge about prevention programmes and 1.Jane C. Atkinson,,Gregory G. Zeller,, Chhaya Shah, B.A. Electronic Patient Records for Dental School Clinics: More Than Paperless Systems Journal of Dental Education Volume 66, No. 5 634-642 2.John Cutter, Wouter Put. eCharting Public Health Data Acquisition

Efficacy Via Undergraduate Dental Students. Int Dent J; Special Issue: Abstracts of the 105th, FDI World Dental Congress. 2017;(67)Issue 1:73 3.Ira Lamster ,Fiona Collins. Are Oral Health Providers Using Electronic Dental Records? https:/www.colgateoralhealthnetwork.com/article/areoral-health-providers-using-electronic-dental-records accessed on 12/06/2018 4.Poul Erik Petersen, Denis Bourgeois, Douglas Bratthall,& Hiroshi Ogawa .Oral health information system-towards measuring progress in oral health promotion and disease prevention Bulletin of the World Health Organization ;September 2005, 83 (9) 5.Reliability study of clinical electronic records with paper records in the NSW Public Oral Health Service Angela V Masoe, Anthony S Blinkhorn, Kim Colyvas, Jane Taylor, Fiona A Blinkhorn Accessed www.phrp.com.au march 2015 vol25 issue 2 So many thanks to: Argentina Brazil Indonesia Netherlands

Cambodia Philippines Colombia Turkey India USA 31 32

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