Automating clinical documentation in dentistry: case study of a clinical integration model.

Writing in 1973 about automating dental records, S.W. Sharkey and J.M. Murison observed: “What is difficult is to design a method of entry to the computer which can be easily used by the dentist and his assistant, and which can also provide a possible back-up record system.”1 For Sharkey and Murison, the prevailing technology consisted of mark-sense systems, or punch cards. Computers, at that time, occupied entire rooms and the first personal computers were still years away. A quarter century later, the several technical barriers (hardware and software) once thought to preclude such automation have been overcome, and the challenge identified by Sharkey and Murison is being met. Implementation of a user-friendly automated dental record is now taking place at several dental clinics within a military health care system. This automated record has the ability to process the types, amounts and sequencing of information that dentists use in making clinical decisions. The success of this implementation is due in part to a user-focused clinical integration model. In this particular model, clinician workflow is studied, documentation templates based on that workflow and end-user input are developed, case-based training is conducted, and users are supported during initial use. As a result, clinical users feel comfortable with and invested in automation, leading to user acceptance. This clinical automation project includes a documentation application that enables dental clinicians to capture, record, and access patient data in real time at the point of care. By implementing the notewriter under this model, this military healthcare system is working towards the goal of a computer-based patient record (CPR), while ensuring that the dynamics of its dental practices drive the automation of documentation. Use of the model has already revealed significant differences