Dental EHR and Usability

The most important part of the dental electronic health record (EHR) is being able to use them- and use them successfully. Barriers and challenges to the adoption of electronic records by dental practices primarily involve poorly designed interfaces and the lack of standardized and structured terminology. It is important that vendors design and create EHRs that can be easily navigated by the dental professionals that use them in their daily practice.

The authors of the article cited below by Walji, et. al (2012) conducted a research study of issues surrounding EHR usability at two dental schools. These schools, Harvard School of Dental Medicine (HSDM) and University of California, San Francisco (UCSF), are teaching institutions as well as have private faculty practices. Both use the same EHR system and dental diagnostic terminology.

The EHR employed by the schools is Exan Group’s axiUm , and is currently used by “75% of North American dental academic institutions.” And the dental diagnostic terminology used is called EZcodes, which has only recently been created by dental professionals at HSDM.

“The purpose of this research was to identify usability challenges of clinicians finding and entering diagnoses selected from a standardized diagnostic terminology in a dental EHR”

And more specifically,

“1) Use of the terminology itself, 2) use of the EHR interface, and 3) use of the terminology as part of clinic workflow” (Walji, et. al, 2012).

By observing the users who were dental students and practitioners, the researchers were able to gather valuable information regarding usability issues.

Most of the problematic areas concerned the interface. Too many choices were available to select a term, whether from an abbreviated list, full list, search or default. The system lacked intuitiveness relating to misspelled search terms, the identifiers and codes, preferred terms and customization. The users also wanted “complete visibility of the category and concepts” rather than truncations and abbreviations. All of these problems were time-consuming to the busy dental students and clinicians.

Diagnostic terminology problems were generally related to “granularity and specificity.” Many dental terms and phrases are used differently among dental professionals and definitions are often confusing. Standardized terms and phrases are difficult to achieve consensus due to variations in definitions. Structuring data is not just a way to reduce confusion, but also a way to improve retrieval and eventual analysis of a practice’s data. Structured data may require a learning curve, but allows for ongoing self-analysis and improvement, including efficiency, quality of care and cost savings.

“For example, “gingivitis of generic origin-NOS”, and “pericoronitis” were suggested to be re-classified into the sub-category “periodontics” instead of under the “pain/altered sensation” sub-category” (Walji, et. al, 2012).

Usability is a critical area that can be a real challenge and barrier for dental professionals that have not yet implemented EHRs. Issues with EHR interface can interfere with providing safe and efficient patient dental care. Standardized and structure dental diagnostic coding lags behind the medical community, though strides are being made to remedy this.

Lessons learned:

  • EHR usability is very important to selecting a system, and testing the system with your kind of patients and treatments is key.
  • Relatively simple things like misspelled search terms and the ability to truncate search terms is still lacking in much EHR software, which makes software un-intuitive to internet-savvy users.
  • Especially while learning, being able to see the entire category structure and not need to memorize abbreviations to use the system is a key consideration for selection and usability.
  • EHR vendors should be cognizant of interface issues and work to improve them. Customization and filtering are still needed.
  • Standardized dental diagnostic terminology is available, yet still needs improvement.

Kalenderian, E. DDS, MPH and Ramoni, R. DMD, Dsc. (2012). 2012 MSDA National Medicaid CHIP Oral Health Symposium: can diagnostic codes work in dentistry. Retrieved 11-4-2012 from

Walji, M.F., Kalenderian, E., Tran, D., Kookal, K.K., Nguyen, V., Tokede, O., White, J.M., Vaderhobli, R., Ramoni, R., Stark, P.C., Kimmes, N.S., Schoonheim-Klein, M.E., Patel, V.L. (2012 Jun 29). Detection and characterization of usability problems in structured data entry interfaces in dentistry. Int J Med Inform. 1-12.