The Dental Diagnostic System:
A core element of Electronic Health Record (EHR) in dentistry
A standardized terminology capturing oral diagnoses at a level of detail appropriate for the provision of oral healthcare is an essential part of a dental EHR as well as a prerequisite for any provincial, national, and international dental health record1. The Dental Diagnostic System was developed to address the need of an acceptable and readily available standardized dental terminology2. A standardized terminology enables the capture, storage, sharing, retrieval, and aggregation of oral health data by different professionals across specialties and sites of care, ensuring that descriptions of diagnoses and treatments are presented consistently. This improves continuity of care across different care settings and locations1,3-6. Classifications such as ICD help with back-end storage, by aggregating the data specifically for billing and report functions. Terminologies, such as SNOMED identify data at the point of care and are used for input such as documentation of care rendered.
Compared to existing diagnostic systems for medicine and dentistry, the Dental Diagnostic System’s 2014 terminology, built as an interface terminology, provides a bridge between existing mandatory terminologies, provides 1,714 terms organized into 106 subcategories and 17 major headings7 that are granular enough to document a detailed diagnosis, but not so expansive that it becomes impossible to create a meaningful interface with the EHR. The International Classification of Disease (ICD), although widely used in medicine, has very limited inclusion of oral health diagnosis, and has been shown to be inadequate for oral and dental diagnoses documentation8-10. The current American version (ICD-10-CM) with 68,000 terms contains more information and detail than the ICD version but its oral health chapter still lacks sufficient detail for prudent documentation of dental diagnoses. Another terminology, the Systematized Nomenclature for Dentistry (SNODENT) Version II with over 7,700 dental terms, was integrated into the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT)11 but has never been implemented into the dental profession in part due to deficiencies in content, coding, ontological structure, and integration into the immense SNOMED-CT structure12.
Benefits of Using the Dental Diagnostic System: