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Biomedical Informatics Training for Dental Researchers

Office of Dental Informatics, School of Dentistry, University of Michigan, 1011 North University Avenue, B322D DENT, Ann Arbor, MI 481309-1078, Lynn.A.Johnson{at}umich.edu

	Abstract

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
Dental researchers collaborating closely with biomedical informaticians have achieved many advances in oral health research, such as in mapping human genetics and addressing oral health disparities. Advances will continue to increase as dental researchers and biomedical informaticians study each others’ disciplines to increase the effectiveness of their collaborative research. The combined skills will greatly increase the effectiveness of dental research. This manuscript summarizes the core of biomedical informatics curriculum (biomedical informatics knowledge, data management, and software engineering) for dental research. It also summarizes the obstacles that must be overcome for all dental research students to receive the training in biomedical informatics they require. These issues are: a lack of biomedical informatics faculty, a lack of biomedical informatics courses, and a lack of accreditation standards. Last, intra- and inter-institutional collaboration solutions are described.

"The decades ahead will be witness to advances in science and technology as yet unforeseen. Dentistry will benefit from these advances and must be intimately involved in their progression." (American Dental Association, 2002)

KEY WORDS: Dental education • graduate education curriculum • biomedical informatics training

	Why Dental Researchers Need Biomedical Informatics Training

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
The need for the dental researcher to be knowledgeable in biomedical informatics is just beginning to be recognized. Recent scientific and technological advances in dental research and patient care have combined with new information technologies to reveal this need (Giles, 2002). During the past decade, advances in information technology have increased computer speed by a factor of 100, and an increase by a factor of 1000 is expected in the next decade (Dunning et al., 2002). These accelerating advances in information technology are having a parallel impact on the techniques used to conduct dental research and consequently on the methods and materials used to provide oral health care to patients. The impact on dental research has helped increase our knowledge of dental caries, oral candidiasis, periodontal disease, and other oral health diseases in addition to helping to map the human genome (Venter et al., 2001).

A genetics example illustrates the impact of informatics on biomedical research. For example, in the past, a researcher studying the genetics of dental caries would limit his/her investigation to the candidate genes that had already been identified and sequenced. DNA from multiple people with and without caries would be analyzed for potential sequence changes, known as single nucleotide polymorphisms (SNPs) within a gene. Once a SNP was identified, additional DNA samples would be screened to determine if the sequence change was associated with caries. As a result of the complete sequencing of the human genome, there is now a SNP database that documents thousands of SNPs that can be searched by gene name. The location of the SNP within the gene, the frequency of its occurrence, and the surrounding sequence are easily found in the database, and genotyping of samples can be started immediately. This information gathered from the database saves the researcher time and accelerates the speed with which the gene of interest can be investigated (Slayton, 2003). Without the contributions of biomedical informatics, this database would not have been built. Now, with the appropriate amount of training in informatics, dental researchers can learn to select and use a variety of information tools to accelerate and enhance their research.

In addition to traditional dental research, biomedical informatics is also advancing educational and clinical research. Biomedical informatics supports educational research through simulations of biological systems to improve the understanding of the roles and interactions of biological systems for students and practitioners (Brown and Herbranson, 2004). Robotic devices simulate sensing and manipulation for expert clinicians (Johnson et al., 2000b; Thomas et al., 2001), and software has been developed for dental and professional education and assessment of competence (Johnson et al., 1997, 1998b) Biomedical informatics also supports research to improve diagnosis, patient care, and patient care management. Intra-oral cameras and digital radiography enable practitioners to store and retrieve, manipulate, and analyze visual patient information (Johnson, 1994; Iplikcioglu et al., 2002), and decision support tools assist in planning treatments that require the integration of many disciplines and many types of clinical information.

Communication and collaboration strategies are accelerating information dissemination and connecting remote researchers and clinicians. Teledentistry permits clinical consultations to occur between practitioners in differing locations, and videoconferencing enables education and professional collaboration to be conducted (Johnson et al., 2000a; Chen et al., 2003). The Internet makes global communication possible and is creating alternatives to scientific journals, books, and reports as means for the dissemination of information (Schleyer et al., 1998). Software can support the education and maintenance of professional competence in a world where the number of facts greatly exceeds the ability of even the exceptional practitioner to remember these facts (Altman, 2002).

Biomedical informaticians who work on diagnostic codes will eventually provide a basis for assessing treatment efficacy and will assist in assessing outcome data for patients and practices (American Dental Association, 2002). Standard vocabularies and structured representations of data and knowledge are being created so that data and knowledge can be exchanged person-to-person, person-to-computer, and computer-to-computer (Eisner, 1993). Collections of information stored in databases are being developed along with the knowledge gained from these data (knowledgebases). These databases and knowledgebases are being used to assist other researchers, such as the caries research performed by the geneticist. These examples illustrate the breadth of the impact of informatics on research and thus the need for the dental researcher to have adequate training in informatics so that he/she can use these tools to accelerate and enhance his/her research (Slayton et al., 2000).

	A Proposed Biomedical Informatics Curriculum for Dental Researchers

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
When biomedical informatics is added to an already full graduate curriculum, care should be taken to balance the training in computer and information sciences with graduate training in the biomedical and clinical sciences. Attention should also be paid to the realities of information technology. Change is guaranteed in informatics, and a single technology is often short-lived. While the biomedical informatics curriculum may consist of a combination of the computer, decision, cognitive, information, and management sciences as well as statistics and health care (Shortliffe and Johnson, 2002), in-depth study of these topics should be avoided by graduate students in biomedical, educational, or clinical research. The education of dental researchers should consist of those technology skills that will help them to learn and understand the current and future technologies that will enhance their research. Thus, the competencies developed for dental researchers in biomedical informatics should be independent of any technology.

The biomedical informatics training a dental researcher receives should consist of either a single course or series of short courses spread over a few years. This course or courses should teach the core competencies, followed by the application of biomedical informatics throughout the students’ remaining graduate education. The biomedical informatics course should consist of core concepts taught via an overview textbook such as Shortliffe et al.’s Medical Informatics: Computer Applications in Health Care and Biomedicine 2001. Shortliffe and Johnson (2002) suggest that the basic competencies from biomedical informatics curricula might provide the basis of the required overview curriculum for dental researchers. This basic curriculum includes: (1) biomedical informatics knowledge, (2) data management, and (3) software engineering. Other topics—such as evaluation, statistics, and research design—are typically covered in other graduate courses. A succinct description of each of the three areas of core competencies follows.

The core biomedical informatics knowledge (concepts, terminology, and methods of the biomedical informatics domain) that will support a successful dental researcher includes basic computer architecture (hardware, software, and networking), data acquisition and signal processing, data and system security, standards (need for standards, vocabularies, and existing standards), and applications in dental education, patient care, and research (Zimmerman, 1990; Abbey and Zimmerman, 1991; Rindfleisch, 1998; Hammond and Cimino, 2001; Horowitz and Anderson, 2001; Lennon et al., 2001; Shortliffe et al., 2001; Wiederhold and Rindfleisch, 2001; Anderson and Allee, 2004). Applications should focus on those that are relevant to the focus of that graduate program. They could include strategies which enable a researcher to conduct effective literature searches, communication and collaboration technologies such as Web-based collaboratives, a common repository for project information that is accessible to all researchers, and videoconferencing in which researchers can meet face-to-face without leaving their home institution (Johnson et al., 1998a; Anderson, 2001; Murray and Johnson, 2001; Schleyer, 2001).

Data management (computational techniques to organize and manage large collections of data) is core to all biomedical informatics systems (Johns, 2002). Data are obtained from patients, other research laboratories, healthcare and insurance providers, and other sources and then transmitted, stored, transformed, summarized (reports generated), and analyzed to assist the researcher in formulating conclusions (Degoulet and Fieschi, 1997). The researcher should be able to create a data flow diagram that represents the sources of the data, the processes for transforming them, and the points in the systems where long-term or short-term data are stored, and where reports are generated or the results of queries presented (Shortliffe et al., 2001). The information that is documented in the data flow diagram is stored in a database, usually a relational database. A relational database management system (RDBMS) is a structured, non-redundant collection of data and their interrelationships. Relational databases have been successful because they use a standardized description and Structured Query Language (SQL) (Codd, 1990). While researchers may not program a database, they should be able to define the data flow diagram as well as the tables and fields included in the RDBMS and their associations.

Software engineering (computational techniques to analyze problems and design, develop, integrate, and test software systems) includes the entire process of developing a computer application—that is, the technical and management aspects of the process. The software development process includes: (1) problem analysis (a knowledge and resource audit, including all supporting documents, rationales, and any associated work); (2) requirements writing (a detailed description of the work that is required to complete the project, including a budget and timeline); (3) development (programming, production of any associated media, and debugging); (4) implementation with users, including formative evaluation; and (5) project evaluation (extent to which the goals in the requirements document are met) (Friedlein, 2001; Johnson and Schleyer, 2003; Schleyer and Johnson, 2003). Carefully managing the software development ensures that the final computer program meets software quality standards and is completed on time and within budget. Project managers develop templates for requirements documents, high-level design documents, detail-level design documents, integration, validation, and system test plans to provide consistency across projects (McCarthy, 1995; Friedlein, 2001). (Additional strategies that guarantee successful development include reviews at predefined milestones, documentation at each step, and version control (mechanism for identifying, controlling, and tracking code so that changes are not overwritten, and keeping an audit trail of updates) (Ball and Douglas, 1999). Techniques that guarantee a high-quality software product meet ISO 9000 standards (International Organization for Standardization, 2003).

After the overview of the biomedical informatics course, students need to apply the concepts they have studied in the remaining courses of their research training. Depending upon the graduate students’ research focus, they may develop further expertise in biomedical informatics. An educational researcher may study metadata or programming for the World Wide Web; a clinical researcher may study digital radiography or computer-assisted decision making; while a biomedical researcher may study data mining in discipline-specific databases (McCray, 2003). In each of these situations, the informatics researcher who is teaching the "enabling" core course can serve as a mentor to the student researcher. The informatics researcher should also collaborate with the faculty of other dental courses so that they include biomedical informatics examples whenever possible; in return, the informatician should include clinical, evaluation, statistics, and research examples in the core biomedical informatics course whenever possible. The biomedical informatician cannot expect to have biomedical informatics applied in other courses, or to serve as a mentor, if examples from other biomedical and clinical courses are not included in the biomedical informatics course.

	Current Challenges

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
Dental education has three major issues to overcome prior to the routine implementation of biomedical informatics instruction in the education of dental researchers. These issues are: (1) a dearth of faculty with biomedical informatics expertise; (2) a lack of biomedical informatics courses appropriate for dental researchers; and (3) lack of accreditation standards. A brief discussion of each issue follows.

Faculty shortage is a problem in all aspects of dental education, not just in biomedical informatics. However, the problem is more pronounced in informatics. This fact was highlighted at the "Dental Informatics and Dental Research: Making the Connection" conference, held June 12–13, 2003, in Bethesda, MD. While approximately 70 dental researchers from across the country attended, there were only four participants who had been in the informatics field for ten or more years (University of Pittsburgh, 2003). They had diverse backgrounds, and none had graduated from a dental informatics training program.

Currently, there are two informatics training programs for dentistry in the country—at Columbia University (Columbia University School of Dental and Oral Surgery, 2003) and the University of Pittsburgh (University of Pittsburgh School of Dental Medicine, 2002). Combined, the two programs usually have two graduates each year, one of whom finds employment in a dental school (T. Schleyer, personal communication; J. Zimmerman, personal communication).

Because there is a lack of informatics faculty in dental schools, there are also few institutions that offer an informatics course(s) to graduate dental students. While some schools offer electives in informatics to their students (Columbia University School of Dental and Oral Surgery, 2003), a search revealed only one institution, Marquette University (Milwaukee, WI), that requires training in informatics for all graduate students (Robinson, 2003). Marquette University School of Dentistry offers a one-semester-hour course that is required of all graduate students. The course covers core biomedical concepts such as the relationship among data, information, and knowledge, as well as communication technology (Internet, telecommunications, networking, and telemedicine) and information systems (coding schemes, electronic records, and imaging), among other topics. While some of the instructional sessions include hands-on exercises, most of the application of the content is incorporated into the work done in other courses and in the clinic.

A review of the Standards for Advanced Education Programs posted on the Commission on Dental Accreditation Web site (American Dental Association, 2003) revealed that none of the eleven recognized specialties used the terms "informatics" or "information technology" in its accreditation standards. The term "computer" was found as a part of the accreditation standards in only three specialties. Orthodontics and Dentofacial Orthopedics includes a standard that graduates must create patient files using traditional or computer-based techniques to obtain images, radiographs, and cephalometrics of patients (American Dental Association Commission on Dental Accreditation, 2003a). Pediatric Dentistry requires the use of computers in all aspects of instruction and research (American Dental Association Commission on Dental Accreditation, 2003b). Third, Prosthodontics states that the educational facility must include access to computer resources for educational, administrative, and research support (American Dental Association Commission on Dental Accreditation, 2003c).

Dental education is facing a paradox regarding informatics instruction. Without informatics faculty, dental schools cannot offer high-quality informatics courses with standardized curricula that train dental researchers in the informatics skills they require to sustain their research. Without dental researchers’ understanding and using informatics to improve their research, how can there be a sustained call for informatics faculty? To break this cycle, a two-part solution is proposed. First, stronger informatics accreditation standards are needed to serve as a catalyst for incorporating biomedical informatics into the graduate programs. Second, dental schools need to collaborate in informatics instruction until a sufficient number of faculty are available to meet the instructional needs of each institution.

	Potential Solution—Collaboration

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
Due to a lack of faculty with expertise in informatics, dental education is currently unable to teach its dental research students biomedical informatics skills. Dentistry is similar to the other biomedical professions in this dilemma in its search for a solution. The key to current successful solutions is intra- and inter-institutional collaboration. The informatics training programs at both Columbia University and the University of Pittsburgh are examples of intra-institutional collaboration in which the dental school is a part of a broader health sciences graduate program in biomedical informatics. Graduate dental students at the School of Dental and Oral Surgery at Columbia University can study in the Department of Biomedical Informatics program that is a collaboration among the Schools of Dentistry and Oral Surgery, Nursing, Public Health, and the Columbia Genome Center, Computer Science Department, Department of Psychiatry, Center for Advanced Technology (CAT) in Information Management, Columbia University Health Sciences Library, and New York Academy of Medicine (regional medical library), and numerous clinical departments in the College of Physicians and Surgeons (Shortliffe and Johnson, 2002). The University of Pittsburgh School of Dental Medicine’s Center for Dental Informatics collaborates with the Center for Biomedical Informatics in a graduate training program in biomedical informatics (University of Pittsburgh, 2003a).

The nursing profession has developed an inter-institutional collaboration that attempts to solve the dual problems of a nursing informatics faculty shortage and the need to engage students in varied research projects. The University of Iowa, University of Wisconsin-Madison, Indiana University, and the University of Michigan have formed a collaboration with the Committee on Institutional Cooperation (CIC) to enhance health and informatics education and research training opportunities. (Founded in 1958, the CIC is a consortium of 12 research universities, including the 11 members of the Big Ten Athletic Conference and the University of Chicago. For more inforamtion, see the CIC Web site at www.cic.uiuc.edu.) The initial course offering was the nursing informatics research course, "Integrated Seminar in Nursing Informatics" (Committee on Institutional Cooperation, 2003). This is the first course to be offered in the CIC CourseShare system that enables students at CIC member institutions to register, pay tuition, and receive grades and credit for inter-institutional courses at their home institution (Committee on Institutional Cooperation, 2003). The first time this course was offered, twelve students participated from the four cooperating CIC institutions. The distance learning strategies of Web-based videoconferencing and Web-based course management were combined with traditional teaching and learning strategies. The four institutions shared the hosting of the Web-based class sessions, and participants at eleven locations were bridged for each session, including the four participating universities, Ohio State University, the National Library of Medicine, and the University of Iceland. This model collaboration demonstrates how technology can overcome the barriers of traditional education and can be bridged to bring together faculty and students from geographically disparate locations to share knowledge and expertise. In addition, it is an excellent example of how successful cross-institutional relationships can be developed for the benefit of researchers and students. In the ADA report, Future of Dentistry—Today’s Vision: Tomorrow’s Reality, the recommendation is made that dental schools explore collaborations, specifically through distance learning, as a way to reduce costs and enhance quality in dental education (American Dental Association, 2002). The nursing/CIC collaboration exemplifies the collaboration called for by the ADA and would help in the teaching of biomedical informatics to our future dental researchers.

	Discussion

TOP Abstract Why Dental Researchers Need... A Proposed Biomedical... Current Challenges Potential... Discussion References

 
Biomedical informatics is changing the way dental research is being done. These changes are becoming so pervasive that dental researchers require a background in biomedical informatics. This instruction needs to be carefully planned to meet the needs of educational and clinical researchers as well as biomedical researchers. Instruction should include an overview of biomedical informatics, followed by the application of biomedical informatics in subsequent research courses. However, a lack of dental faculty trained in biomedical informatics, combined with few bioinformatics training programs and minimal accreditation standards, presents obstacles dental schools must overcome. Yet these problems are not unique to dental education. Inter- and intra-institutional collaborations in the health sciences have been proven successful in overcoming the barriers of traditional education. Dental educators need to join together and support those pioneers who are willing to try new approaches to biomedical informatics training. Only then will we create a dental research community in which biomedical informatics enables new knowledge to be efficiently and effectively generated and disseminated.

	Acknowledgments

 
On behalf of all of the conference participants, I thank Titus Schleyer, the Program Committee, the sponsors, and staff at the University of Pittsburgh Center for Dental Informatics for their efforts in organizing the conference. I also thank Pat Anderson, Dental Librarian, University of Michigan School of Dentistry, for her insightful feedback and suggestions and Diana Blackford for her editorial assistance.

	Footnotes

 
Publication supported by Software of Excellence (Auckland, NZ)

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This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Johnson, L.A. Search for Related Content PubMed PubMed Citation Articles by Johnson, L.A.