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The Role of Information Technology and Informatics Research in the Dentist-Patient Relationship

Department of Medical Informatics, Kaiser Permanente, 500 NE Multnomah St., Portland, OR 97232; michael.kirshner{at}kp.org

	Abstract

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A high-value doctor-patient relationship is based on a set of parameters which include the interpersonal relationship between the patient and the doctor. Based on the Primary Care Assessment Survey model, measures of the interpersonal relationship are associated with communication, interpersonal care, contextual knowledge of the patient, and trust. Despite the proven value of the doctor-patient relationship, current trends indicate that the quality of these relationships is on the decline. The advent of communication and information technologies has greatly affected the way in which health care is delivered and the relationship between doctors and patients. The convergence of communication and information technology with biomedical informatics offers an opportunity to affect the character of the doctor-patient relationship positively. This paper examines the intersection of the key features of the doctor-patient relationship and a variety of Internet-based, clinical, and administrative applications used in dental practice. This paper discusses the role of dental informatics research vis-à-vis the doctor-patient relationship and explores how it may inform the next generation of information technologies used in dental practice.

KEY WORDS: Dentistry • information systems • medical informatics • patient-centered care • physician-patient relations

	Introduction

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A strong doctor-patient relationship is important. The value of a high-quality patient-doctor relationship has been linked to important outcomes of care, which include treatment compliance (Francis et al., 1969; Marquis et al., 1983; DiMatteo, 1995), clinical outcomes of care (Greenfield et al., 1988; Kaplan et al., 1989), malpractice claims (Penchansky and Macnee, 1994; Beckman et al., 1994), and switching physicians (Marquis et al., 1983; Safran et al., 1998b). Despite positive correlations between health outcomes and good doctor-patient relationships, the quality of these relationships is on the decline (Murphy et al., 2001; McKinlay and Marceau, 2002; Chaitin et al., 2003). Contributing to this decline are the rise of consumerism, societal trends toward a decrease in professionalization, and the organizational structure of health-care delivery. However, the influence of communication and information technology (CIT) and a focus on a patient-centered care model may positively re-shape the interaction between patients and their health-care providers. Despite this new paradigm, research and practice have not leveraged and exploited the capabilities of CIT in facilitating quality patient-doctor relationships.

The science of medical informatics, particularly informatics research, can play an important role in improving CIT applications in health care. Research can provide models for improved use of information, help design and implement systems, and evaluate outcomes necessary to optimize CIT applications in health care.

This paper will explore: (1) how communication and information technology affects the dentist-patient relationship and (2) the role of dental informatics in CIT. First, I examine the nature and characteristics of the patient-doctor relationship. Second, I describe dental practice-based CIT and discuss how this technology relates to and affects the dentist-patient relationship. Finally, I examine how informatics research can inform and improve CIT applications.

	The Doctor-Patient Relationship

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The doctor-patient relationship is based on a sustained, open, and trusted dialog as well as on the sharing of information and knowledge (Roter, 2000). The primacy of the doctor-patient relationship is without dispute. The nature of that relationship, however, has come under much scrutiny (McKinlay and Marceau, 2002). Health care has seemingly shifted from placing the patient as a whole person at the center of a therapeutic relationship to looking almost exclusively at the biological (i.e., molecular, chemical, and physical) nature of the patient. This change in focus has concerned many patients and health-care providers. A more current viewpoint incorporates the patient’s perspective and includes the patient as a collaborative partner with his/her doctor (Roter, 2000; Murphy et al., 2001). This collaboration is essential to a high-quality doctor-patient relationship, which leads to quality health care and positive outcomes.

The Primary Care Assessment Survey (PCAS) (Safran et al., 1998a) is a validated instrument that measures a broad range of factors that contribute to relationship quality. Four of the 11 scales of the PCAS (communication, interpersonal treatment, context knowledge of the patient, and trust) measure aspects of the quality of the one-on-one doctor-patient relationship (Murphy et al., 2001). The PCAS provides a framework within which features of a quality relationship are associated with aspects of specific communication and information technologies.

Each of the PCAS scales can be viewed from the perspective of how they measure and identify a quality doctor-patient relationship. Table 1 summarizes the four relationship scales.

The third scale measures contextual knowledge of the patient, which is whether the doctor-patient partnership enables the doctor to elicit patients’ values, attitudes, beliefs, and feelings, and enables the patient to share his/her illness experience on a personal level. Gaining contextual knowledge of the patient involves understanding the patient’s individual experience, responding to his/her needs, treating the patient as unique, tailoring treatment to the patient, and considering the patient as a ‘whole person’, taking into account personal and family preferences. Contextual knowledge is often obtained from third parties or from sources other than the individual and as such can be derived from many formats, both electronic and non-electronic.

The fourth scale, trust, is perhaps the most significant and influential component of the patient-doctor relationship (Roter, 2000). Trust is a vital aspect of medical and dental practice. Primarily, trust is earned through one’s ability to admit mistakes, honor commitments, respect others, and be non-judgmental. Regardless of the channel or medium of communication, trust can be built or lost. If a positive and meaningful dentist-patient relationship is to exist, all communication must engender trust, not threaten it.

	Dental Communication and Information Technologies

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Communication and information technology provides channels of information for both patients and doctors in dentistry. Examples include office Web sites, e-mail communication, computerized office management systems, electronic oral health records, digital imagery, and teledentistry (Schleyer et al., 2003).

A comprehensive description of a state-of-the-art technology-equipped dental practice (Schleyer et al., 2003) has identified and categorized examples of CIT applications and how they might best be integrated into the dental practice to improve work flow and efficiency.

Schleyer and his co-workers classified CIT into three categories of applications: Internet-based, clinical, and administrative. I have plotted the correlation between typical CIT applications and each of the four PCAS categories in Table 2 as a means of illustrating how CIT applications affect the doctor-patient relationship.

Ready access to information and beliefs about the value of such information dramatically affect the doctor-patient relationship. Some physicians and dentists are concerned about patients who present with information they have received from the Internet, while others embrace the role of the Internet with their patients and provide health information and links to preferred sources of health information on their own Web sites.

With level access to information, patients are more actively participating in their health care. Access to information about the full range of treatment options is enabling patients to collaborate with their dentist in deciding on a course of treatment (Reents, 1999).

Internet-based applications used by a dental practice might include: e-mail or secure messaging; a practice Web site or portal; online scheduling, pre-registration, and pre-visit preparation; patient access to personal dental records; and teledentistry. E-mail communication can prove to be an extremely important relationship-builder (DiMaggio et al., 2001). Convenience, communication, personal knowledge, and trust can all be positively affected with the use of Internet-based applications (Anderson et al., 2003).

Despite its growing popularity and use, some clinicians and researchers believe that e-mail may not have a positive impact on the doctor-patient relationship. Rather, they believe that it will detract from the interpersonal non-verbal communication essential to building a trusting therapeutic relationship (Baur, 2000). Other clinicians believe the opposite and view electronic communication as a positive trend that enhances the doctor-patient relationship (Sands, 1999; Anderson et al., 2003).

Another growing use of the Internet in building dentist-patient relationships is a dental practice Web site. Typically, these Web sites offer general information about the doctor, staff, and dental practice, plus dental health information and links to other relevant health sites. Office philosophy, preventive health information, and other dental health knowledge are made available to prospective and existing patients. When a site includes relevant information about the dentist and practice philosophy and policies, a prospective patient may sense whether his/her own values and preferences fit with those of the dentist. This initial ‘communication’ may lay the groundwork for the doctor-patient relationship by potentially providing a sense of trust and shared values (Reents, 1999).

Providing patients with direct access, via the Internet, to their own personal dental health records can enhance the dentist-patient relationship. Allowing patients direct access to their dental records reduces the asymmetry of power and knowledge and enables patients to feel more in control, which leads to more trust in the relationship. Studies have demonstrated that when patients are given access to their records, they find it easier to talk to their doctors (Elbourne et al., 1987; Ross and Lin, 2003), and the access facilitated "useful discussions" (Stevens et al., 1977). Other studies have shown that patients who had access to their medical records expressed increased confidence and trust in their doctors (Baldry et al., 1986; Miller et al., 1987).

Teledentistry is the delivery of some aspect of dental care where the patient and dentist are not in the same location. Teledentistry currently offers real-time ‘live’ and ‘store and forward’ videoconferencing and consultations. Patients are able to receive care without taking time away from work or home to travel to the dental office. Teledentistry has the advantages of convenience and access. The use of teledentistry for specialist consultations, diagnosis, treatment planning and coordination, and continuity of care provides aspects of decision support and facilitates a sharing of the contextual knowledge of the patient among dentists (Miller, 2001, 2003).

Administrative applications deployed over the Internet enable patients to interact with the organizational aspects of the dental practice. Online appointment scheduling, pre-registration and pre-visit preparations, and out-of-pocket treatment cost estimates all enhance communication and convenience. They also provide contextual knowledge of the patient that can support the integration and continuity of dental care. By having more control and a sense of participation in the administrative processes of the dental experience, the patient may also be likely to trust the dental practice as a whole and potentially have a better relationship with the dentist (Anderson et al., 2003).

Clinical applications
Non-Internet clinical applications include a wide range of devices and software programs that include: an electronic oral health record (EOHR), which contains medical and dental history, treatment planning, charting, and oral health status; nano-dentistry (Schleyer, 2000); digital imaging; diagnostic applications; and decision support applications.

Among the clinical CIT applications, the EOHR is considered the centerpiece of information. The EOHR can contribute to the dentist-patient relationship by providing a standardized central repository of information about the patient that includes clinical data pertaining to the patient’s oral condition as well as psychosocial and demographic information about the patient. This set of information can provide context about the patient, such as his/her social situation and preferences and values relative to his/her dental care and condition. This contextualization may facilitate meaningful communication, improving personal treatment and building trust.

Due to its penetration among dentists, estimated at over 50% in the US (Dental Technology Consultants, 2003), digital imaging may have the most profound effect on the dentist-patient relationship, due to its immediacy and ease of understanding through recognizable visualizations.

Specifically, intra- and extra-oral pictures allow the patient to see what is actually going on in his/her own oral environment. In addition to pictures of the current state, digital imaging manipulation allows the patient to see the possible effects of various treatments ahead of time. This type of intra-oral imagery can profoundly affect open communication, knowledge of patient preferences and values, and building trust.

Other clinical CIT such as diagnostic, treatment planning, and decision support applications can also support a positive dentist-patient relationship. The use of these technologies can focus communication on the most appropriate and effective treatment and prevention of dental disease. When the technology is implemented in a transparent shared approach that engages the patient and not as a ‘black box’ kept outside of the conversation, then additional contextual knowledge of the patient is likely to be gained. The patient, feeling more included and involved in the care experience and decision processes, will likely relate with the dentist in a more collaborative and trusting manner.

Administrative applications
The applications that fall into the administrative category include most of the aspects of a comprehensive computerized practice management system. Although associated with the dentist-patient relationship, these systems have more effect on the patients’ experience with the dental practice as a whole. Features such as patient registration, billing, insurance claims processing, recall reminders, and appointment scheduling, when used in a patient-centered manner, can positively affect the patient’s attitude toward the dental office policies and procedures. This attitude, in turn, adds a positive foundation for the dentist-patient relationship.

	Dental Informatics

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Dental informatics is the application of computer and information science to improve dental practice, research, education, and management. As such, it draws on a wide range of disciplines, including cognitive science, psychology, decision science, human factors engineering, and mathematics (Schleyer et al., 2003). Friedman defines four categories of informatics research (Friedman, 1995): (1) model formulation—develop the models, taxonomies, and ontologies, which can be used as building blocks for problem solving; (2) system development—design usable systems that will integrate into the workflow and needs of clinicians as well patients; (3) system installation—successfully implement, adopt, and sustain systems by considering the psychology and cultural characteristics of the people and organizations affected by the system; and (4) study of effects—consider the outcomes of the systems on the health of individuals, groups, and populations.

Each of the four categories of informatics research can influence and inform many of the CIT applications used in dentistry. Table 3 presents the intersection between each of the four research categories and the CIT application it may specifically affect. These intersections can guide dental informatics research so that it can successfully evaluate how CIT affects the dentist-patient relationship.

	Informatics research

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First, model formulation research, which consists of creating ontologies and standardized vocabularies, provides a framework for problem-solving. The CIT applications most directly affected by model formulation are the EOHR and personal health record.

Second, system development research focuses on the design and integration of applications and systems. Research domains include data mining, decision theory, human factors engineering, artificial intelligence, and telecommunications. System development research affects the following CIT applications: EOHR, personal health record, teledentistry, treatment planners, decision support, and practice administration.

Third, system installation research looks at the issues associated with the deployment, adoption, and implementation of CIT applications. Associated research fields include organizational and management theory, cognitive psychology, and human computer interface.

Fourth, study of effects research examines the processes and outcomes resulting from CIT applications use. The research domains used in the study of effects consist of established qualitative and quantitative methods. These methods are applied on individual-, system-, and population-based levels. This arm of research provides evidence-based data that will perpetuate the iterative design-develop-test cycle and inform best practices of the doctor-patient relationship components of CIT applications.

Overall, informatics research should provide insight that will inform the design and deployment of the next generation of CIT used in dental practice—applications that will be explicitly designed to facilitate an enduring and trusting dentist-patient relationship.

	Acknowledgments

 
The author acknowledges and thanks the following individuals who contributed to this work: Drs. Dean Sittig, Gerardo Maupome, Titus Schleyer, and Heiko Spallek.

	Footnotes

 
Publication supported by Software of Excellence (Auckland, NZ)

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