- Email: [email protected]
Dental informatics
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& TECHNOLOGY
COVER STORY
Dental informatics A cornerstone of dental practice TITUS SCHLEYER, D.M.D., Ph.D.; HEIKO SPALLEK, D.M.D., Ph.D.
nformation technology, or IT, has transformed society and will continue to do so in the future.1 The way in which children grow up, companies do business, people shop and communities socialize has changed significantly since the beginning of the information revolution.2-8 That revolution also has made its mark in the dental profession. Almost 80 percent of dentists have computers in their offices, almost 30 percent have access to the Internet, and an increasing number use a variety of other technologies, including digital intraoral cameras and 9 How can paperless patient records. Given current technological trends, technological the number and magnitude of changes advances be brought about by IT and its potential made most applications will only increase. We are useful for not far from the day when computers dental practice, will permeate virtually everything we research and do, from how we read our morning treatment education? newspapers to how we make decisions for our patients.10 Within the next five years, experts foresee the commercial availability of electronic paper (paper that functions like a very high-resolution computer screen), a vast array of special-purpose computing appliances, autonomous software agents that enter into transactions on our behalf, an almost ubiquitous highcapacity networking infrastructure and personal digital assistants that rival current desktop computers in performance. How can these technological advances be made most useful for dental practice, research and education? Technological innovation for the health care professions originates from a number of sources, such as the commercial market, research and educational institutions, and people. While companies collectively engage in research
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ABSTRACT Background. Dental informatics is a relatively new field that has significant potential for supporting clinical care. Most dentists are unaware of what dental informatics is, what its goals are, what it has achieved and how they can get involved in it. Methods. The authors conducted a literature review and several round-table discussions with dental informatics experts to discuss the preceding issues surrounding dental informatics. Results. Dental informatics is the application of computer and information sciences to improve dental practice, research, education and management. Numerous applications that support clinical care, education and research have been developed. Dental informatics is beginning to exhibit the characteristics of a discipline: core literature, trained specialists and educational programs. Conclusions. Dental informatics presents possible solutions to many longstanding problems in dentistry, but it also faces significant obstacles and challenges. Its maturation will depend as much on the efforts of people as on the collective efforts of the profession. Practice Implications. Dental informatics will produce an increasing number of applications and tools for clinical practice. Dentists must keep up with these developments to make informed choices.
and development of significant scale and scope, their interests primarily are driven by the profit motive. Most innovations are pursued because they are expected to make money. Other projects, which may be more important or significant but are not deemed as profitable, receive scant attention and resources. One example is the American National Standards Institute, or ANSI, standard digital imaging and communications in medicine, or DICOM, which defines a format for storage and exchange of digital images, including radiographic and visible-light images. DICOM is the almost
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TABLE 1
COMMMON ELEMENTS IN DEFINITIONS OF MEDICAL INFORMATICS. ELEMENT
become a cornerstone of dental practice. WHAT IS DENTAL INFORMATICS?
EXPLANATION
According to Merriam-Webster’s Collegiate Dictionary, informatics is Most definitions cite the improvement of patient Goal care as the goal of medical informatics. derived from the term “information Informatics is a basic and an applied science; that is, Science a continuum spanning model formulation, system science,” which is the development, system installation and the study of collection, classificaeffects.15 tion, storage, reAside from the domain (such as medicine or denMultidisciplinarity trieval and dissemitistry), informatics is composed of several constituent disciplines, such as computer science, nation of recorded information science, cognitive science and knowledge treated telecommunications.16 both as a pure and applied science.12 universal standard for managing images in cliniWhen applied to a specific domain, such as cal medicine.11 Until recently, however, digital medicine, nursing or dentistry, information scidental radiology system vendors have been slow ence becomes “informatics.” Existing definitions to implement DICOM. One reason has been that of medical informatics13,14 share several common dental extensions for DICOM are relatively new, elements15,16 (Table 1). and many vendors may not realize the benefits of A simple, but cogent, definition of dental inforimplementing DICOM. But more importantly, matics is “the application of computer and inforDICOM allows dentists to combine imaging mation science to improve dental practice, redevices and software from several vendors and, search, education and management,” which was thus, removes the “lock-in” that vendors of propriderived from an earlier definition that was coined etary systems have enjoyed so far. in 1992.17 The commercial market has brought many A common misconception is that informatics is innovations to the dental profession. But it is not the same as IT.18 Informatics is focused primarily likely to address many fundamental problems— on research, development and evaluation of inforsuch as controlled vocabularies, open standards mation models and computing applications. IT, on for exchanging patient information among practithe other hand, is concerned with the implementioners, quality assurance for patient outcomes tation and application of computer technology and and mechanisms to represent dental knowledge— telecommunications. Despite the larger concepany time soon. While academic and other institutual division, limited areas of overlap between tions are working on some of these issues, one informatics and IT exist, such as custom developobstacle to progress is the fact that the field of ment of software and evaluation of implemented dental informatics is not very mature. systems. Dental informatics combines dentistry and sevDental informatics can be considered a speeral research disciplines, such as computer scicialty of medical informatics. A number of models, ence and telecommunications. Because it is new, methods and applications can be shared, transthere is confusion relative to its definition, goals, ferred or both between the two disciplines. For opportunities and achievements. Therefore, we instance, the National Library of Medicine’s, or wrote this article to answer several questions: NLM’s, MEDLINE is the world’s largest biomedWhat is dental informatics? What are its goals? Is ical literature database and is equally applicable it a discipline? What are its opportunities and to all health care disciplines. The same applies to challenges? How can the practitioner get involved GenBank, a database of gene and protein seand stay up to date? We wrote this article to stimquence information to which researchers from ulate interest in this emerging field and help several domains contribute. Methods for building expert and decision-support systems, such as readers understand how dental informatics can Universality
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Informatics is viewed as applicable to all activities in the domain, such as research, education and patient care.
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neural and Bayesian networks, can be applied across disciplines.19 Despite much common ground, there also are many aspects that set those informatics domains apart. For instance, most design work that informs the development of computer-based medical records simply is not applicable for computer-based dental records. Dentists collect, display and analyze data differently than do their medical counterparts. While the general medical and medication histories collected by both physicians and dentists share many common elements, the dental history and the oral health status have no equivalent in medicine. As a consequence, developing, implementing and evaluating complete computer-based dental records is both a challenge and an opportunity for dental informatics, as are many other domain-specific aspects.
Table 2 offers a description of selected computer applications.19,25-43 The list is not inclusive, but rather provides an overview of the breadth and depth of existing applications. IS DENTAL INFORMATICS A DISCIPLINE?
Before we can answer the question of whether dental informatics is a discipline, we should discuss what features characterize a discipline. Requisite features are da core of people who conduct research and publish in the discipline; dan identifiable body of literature: books, journals and other publications; dprofessional societies and related activities, such as meetings and conferences; deducational programs leading to a certificate or advanced degree; dfunded research programs. WHAT ARE DENTAL INFORMATICS’ A core of people who conduct and publish rePRACTICAL GOALS? search in dental informatics exists. An informal The main goal of dental informatics is to improve review of the literature showed that since 1965 patient outcomes. Thus, the disciapproximately 3,500 authors have pline must support and improve diagpublished about 2,200 articles Developing, nosis, treatment and prevention of related to dental informatics and implementing and disease and traumatic injury; relieve computer applications in dentistry pain; and preserve and improve oral evaluating complete in about 420 journals and conference health. A secondary goal is to make proceedings. Journals with significomputer-based the delivery of dental care more efficant numbers of informatics-related dental records is cient; for example, by maintaining or articles include Oral Surgery, Oral both a challenge and Medicine, Oral Pathology, Oral improving cost-benefit ratios. Dental an opportunity for informatics also must support reRadiology and Endodontics; JADA; dental informatics. search and education, and improveDentomaxillofacial Radiology; the ments in these areas should, and Journal of Dental Education; and the British Dental Journal. The often do, translate into improved Journal of the American Medical Informatics patient care. Informatics is key in helping practitioners Association and the International Journal of solve clinical problems and keep current. Most Computerized Dentistry are more narrowly educational programs still subscribe to the philofocused. The first book on dental informatics was written in 1992 and provides a conceptual sophy that everything dentists need to know can overview of the field.44 Other books, such as “The be learned in dental school. The trend toward problem-based learning and the development of Global Village of Dentistry”45 and “Imaging in 20-22 critical-thinking skills tells a different story. Esthetic Dentistry”46 provide more detailed looks Dentists must be as familiar with the problemat some application areas. solving process as they are with the problem Currently, dental informatics has no maindomain itself. Computers can help practitioners stream journal of its own, the emergence of maintain their continuing competency, and many special-purpose journals (such as the Journal of dentists already are using computers to keep Computerized Dentistry) notwithstanding. This is abreast of new developments.23,24 appropriate considering that dental informatics is Many examples of developments in dental in the early stages of development and that, at informatics that have helped improve patient this time, it is more important to educate a broad outcomes (or have the potential to do so if widely audience about the possibilities of dental inforused), education and research can be cited. matics than to provide a specialized forum for JADA, Vol. 132, May 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
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TABLE 2
SELECTED COMPUTER APPLICATIONS IN CLINICAL CARE, EDUCATION AND RESEARCH. AREA Clinical Care
Education
Research
DESCRIPTION
APPLICATION OralCDx25
Method for the screening of oral lesions that involves a brush biopsy and computerized analysis of the histologic slide, allows for screening of more patients for premalignant or malignant lesions earlier
Digital radiology26.27
Equivalent to traditional film for many diagnostic and therapeutic tasks; advantages include reduced radiation exposure for patients and dental personnel, reduced development time, automation of quality assurance processes and the potential for immediate digital analysis
Tuned-aperture computed tomography28
Example of a three-dimensional imaging modality; applications include primary caries detection29 and assessing bone defects at implant sites30
Decision support systems19,31
Aid for dentists to make decisions about therapeutic approaches or complex or rarely encountered conditions; oral radiographic differential diagnosis,32 for instance, supports the diagnosis of radiographic lesions
MEDLINE33
Database that makes a significant portion of the dental literature accessible to practitioners to help answer clinical questions
CEREC34
Fabrication of machine-milled crowns and bridges during the course of an office visit
Dental practice management
Automation of many routine tasks in a dental office, such as electronic claims submission, scheduling and financial management
Oral manifestations of human immunodeficiency virus35
Computer-assisted learning package on the oral manifestations of human immunodeficiency virus of relevance to general dental practitioners
Dental diagnosis and treatment36
Interactive program to provide students or practicing dentists an opportunity to develop and practice their critical-thinking skills for diagnosis and treatment
Simulations37-39
Educational programs designed to closely approximate clinical situations for teaching, continuing education or performance evaluation
Complete distance education programs40
Integrated educational tracks, certificates or degrees offered at a distance
Data mining tools41
Analysis of large sets of data to generate new knowledge or findings
Collaboratories42
Infrastructure to make it easier for large, geographically distributed research groups to work together
Computerized data analysis43
Complex analyses of research data
dental informatics researchers. Over the long term, however, the development of a dedicated, international and multidisciplinary dental informatics journal should be considered. Currently, dental informatics has no dedicated professional society. Rather, its activities are 608
integrated with those of several existing associations, such as the American Dental Education Association, or ADEA; the ADA; and the American Medical Informatics Association, or AMIA. In most cases, a section or special interest group of an association provides a forum for exchange be-
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tween members. Specialized conferences, such as the Conference on Computers in Clinical Dentistry, those sponsored by ADEA, the Consortium for Clinical Information Systems, and the Conference on Computers in Dental Education and Practice have been held in the past. Up until now, these conferences have been arranged on an ad hoc basis, and none has developed into a stable, widely accepted scientific forum. The first educational programs leading to advanced degrees in dental informatics were created in 1996 in response to a request for applications issued by the National Institute of Dental and Craniofacial Research, or NIDCR, in cooperation with NLM. A program at Columbia University and a joint program offered by the University of Pittsburgh and Temple University offer master’s degrees through three-year and two-year programs, respectively. The philosophy of both training programs is grounded in the belief that dental informatics is derived from medical informatics rather than a separate discipline.47 Thus, trainees complete a generalist education in medical informatics and specialize in dental informatics. The programs graduated their first trainees in 2000. Anecdotal evidence suggests that dental informatics research receives only limited third-party funding, such as from the government, the military, foundations and companies. NIDCR and NLM have funded very few grant applications in dental informatics, and some universities have been and are receiving limited corporate support. In contrast, programs sponsored by the European Union have resulted in significant funding in dental informatics research in Europe. Much of the research in dental informatics at this time is conducted as “unfunded” research by faculty at dental schools and universities around the world. It is instructive to compare dental informatics to its parent, medical informatics. The medical informatics research community is extremely active. Medical informatics has its own literature that is segmented into topics such as biomedical engineering, biomedical computing, decision support and education.48 Major informatics journals, such as MD Computing and the Journal of the American Medical Informatics Association, have existed since the early 1990s, and approximately 140 books about medical informatics have been published. Twelve medical informatics training programs funded by NLM exist, and approximately 30 of the 150 medical schools in the
United States have a department or section of medical informatics. Conferences such as Towards Electronic Patient Records and the AMIA’s fall symposium attract several thousand participants each year. Medical informatics research is funded by programs of significant scale and scope at NLM, the National Cancer Institute and the National Science Foundation, as well as by corporations and foundations. Dental informatics is a nascent discipline. To what degree it can mature successfully depends on its ability to take advantage of opportunities and overcome some significant challenges. OPPORTUNITIES AND CHALLENGES
Dentistry is an information-intensive activity, and informatics by its very nature supports such activities well. IT already has significantly improved our ability to store, access, manage, filter and apply information. When one considers what progress has been made in a myriad of aspects of human life, it is not difficult to envision how dentistry may be transformed by becoming informatics-based.16 Ultimately, informatics done well simply will let us concentrate on our jobs as dental professionals by improving and maintaining the oral health, and consequently the general health, of our patients. These new and powerful technologies will bring cultural changes to the dental profession itself. The following are some opportunities and challenges that informatics places before us. dLongitudinal, lifetime, comprehensive and patient-centered dental records. Dentistry is still largely a cottage industry. This situation expresses itself in the minimal degree to which patient information is shared. Patientcentered, rather than practice-centered, dental records can eliminate duplicate information gathering, provide a rich context through access to prior diagnostic and treatment records, and allow the practitioner to concentrate on the problem at hand. The book “Futurize Your Enterprise”1 contains an excellent vision of how patient-centered medical records can improve health care. Several computer system vendors offer precursors to such systems already today.49 dUniversally accessible patient records that ensure privacy and confidentiality. As an increasing portion of patient-related information is stored and transmitted digitally, dental informatics has the responsibility to develop, implement and monitor measures to keep it pri-
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vate. While no system is perfectly secure, a baladministered by the ADA, as well as its predeance between privacy and access must be cessor the ASC MD 156 Task Group on Dental found.50,51 Informatics. Unfortunately, after seven years of dSignificant reduction of practice managework, this effort has achieved little. Tangible ment and administrative overhead. A signifiproducts that have been developed include the cant portion of health care expenditures go Concept Model for the Standard Computer-Based toward administration. One of the greatest Oral Health Record56 and the Guidelines for the sources of inefficiency has been the lack of shared Design of Educational Software.57 Neither of these information by health care buyers, sellers and efforts has evolved into a widely accepted and consumers.52 Well-integrated information systems applied standard, but progress may improve can reduce this overhead significantly, through based on the recent formalization of the SCDI. measures from autonomous supply ordering to Another challenge is to increase the quality automated scheduling, billing and recall. and quantity of dental informatics research. The dClinical care based on empirically deterstandards for investigation and scientific inquiry mined best practices. Most patients in indusin new disciplines develop over time, and dental trialized countries already enjoy very high informatics is no exception. What passes for standards of care. However, large variations in research and what does not is a subject of periodic diagnosis and treatment decisions discussion in medical informatics still exist.53,54 As more patients even today.15,58 The scarcity of people Well-integrated become aware of the standard of formally trained in research care, dentists will be forced to prove methods and approaches and the information the quality of their care. While few systems can reduce dearth of interdisciplinary teams dental treatments are based on that can solve complex research overhead definitive clinical evidence obtained questions constrains the volume and significantly, through through randomized clinical trials, quality of research output. Support measures from outcomes data aggregated over large for dental informatics research from autonomous supply grants, contracts and funding agennumbers of practices and patients can help identify best practices. Since cies such as NIDCR or NLM is ordering to many patients use the Internet to minute. The problem, however, is automated access health-related information, two-sided. The lack of qualified scheduling, billing valid and reliable information needs investigators in dental informatics and recall. to be available and recognizable as results in a scarcity of fundable such.55 research proposals. Funding How can the dental profession take advantage agencies, on the other hand, may not view dental informatics as a programmatic priority if demand of these opportunities? A positive circumstance is for research funding is not apparent. that dentistry as a profession is relatively unified. The majority of U.S. dentists are members of the Dentistry is a relatively small segment of the ADA. The ADA and other dental organizations, health care system. Thus, many companies are such as the Academy of General Dentistry and hesitant to invest in research and development because the potential payoff is constrained by the the American College of Dentists, provide small size of the market. Network externalities common ground and political clout on many also are a significant deterrent to investment.59 important issues. Yet success in realizing the present opportunities rests on significant innovation, Products or services, such as the telephone, that research and development in informatics that become more valuable as more people use them most likely will not come from central are said to benefit from network externalities. For organizations. instance, when only a few practices can exchange While it may seem difficult to forge a common patient information using computer-based patient vision for informatics within the dental profesrecords, or CPRs, the collective benefit is small. sion, it is not impossible. One attempt at crafting When most practices use such interoperable a long-term strategy is the development of standCPRs, however, the collective benefit is large. ards related to dental informatics through the Globalization may improve this situation because newly formed, ANSI-accredited Standards Comit increases potential markets. mittee on Dental Informatics, or SCDI, which is The growth of dental informatics also is ham610
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pered because many of its benefits are hard to Association and the British Medical Journal are measure, and achieving them requires significant good sources for keeping up with general medical upfront and ongoing investments. For instance, informatics developments. the quantifiable benefits of a computer system for Meetings and conferences. Venues for inforbilling and electronic claims submission include matics-related topics are the ADA’s technology time and money saved in preparing claims, days, the ADEA’s annual session and AMIA’s fall reduced claim and payment turnaround, and symposium. improved management of accounts receivable. Standards activities, society activities, The advantages of installing a CPR, on the other university committees and vendor focus hand, are much harder to define and measure. groups. The ADA-administered SCDI is an excelEvaluating the return on investment, however, is lent way for dentists to get involved in setting the fraught with difficulties not only in dental inforstandards for tomorrow’s IT applications in denmatics. Nobel Prize–winning economist Robert tistry. Local and regional dental societies, univerSolow said that we see computers everywhere sities and vendors increasingly maintain comexcept in the productivity statistics. Productivity mittees or advisory boards to help shape their growth has slowed every decade from the 1960s strategies for IT, and they often offer interested until the mid-1990s, while investments in IT have dentists a chance to get involved. grown dramatically. This phenomenon has been Computer courses. Colleges and universities termed the “productivity paradox.” offer introductory and advanced However, the dramatic contribution courses in information systems, proThe growth of of computers to the rising producdental informatics is gramming and databases. Many tivity since 1995 may indicate that companies offer courses on specific hampered, in part, we have reached a turning point.60 applications, such as desktop producSince health care in general and den- because many of its tivity and graphics programs. Probenefits are hard tistry in particular still lag in the use grams for bachelor’s or master’s of computers, most benefits still are degrees in a variety of computerto measure, and to come. related areas also are available, and achieving them The current situation simply may requires significant some of the necessary courses can be be symptomatic of a profession findtaken through distance learning upfront and ing its way in informatics. An enprograms. couraging sign is the significant and ongoing investments. Communities. The Dental Inforincreasing interest of many influential stakeholders in dentistry. Hopefully, this interest can be channeled into concerted action that benefits all of dentistry. Success, however, also is predicated on the level of involvement of each practitioner. The next section highlights some opportunities. HOW CAN YOU GET INVOLVED IN DENTAL INFORMATICS?
Getting involved in and staying up to date on dental informatics is not as easy as joining a professional society and subscribing to its journal. There are, however, a few options. Articles on dental informatics in major dental journals. Journals in which articles about dental informatics appear periodically include JADA, the Journal of Dental Education, Quintessence International and the Journal of Computerized Dentistry. The Journal of the American Medical Informatics Association, MD Computing, the Journal of the American Medical
matics Section of ADEA and the Dental Informatics Working Group of AMIA allow people interested in dental informatics to network. Both groups maintain Internet discussion lists that include members from all over the world. Joining these communities is free for members of the respective organizations. Dental informatics degree programs. Two dedicated postgraduate programs in dental informatics currently exist.61,62 Both are appropriate for people interested in having a research career in dental informatics. The opportunities available today make this an option particularly attractive for dentists who would like to participate in shaping the development of dental informatics. It is safe to assume that the sources of information and the opportunities for interested dentists to get involved will only multiply in the future. CONCLUSION
“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its
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success, than to take the lead in the introduction of a new order of things.” Niccolò Machiavelli’s words describe the challenge to dental informatics well. Computer technology has reshaped our lives already. The question Dr. Schleyer is an associate professor and the is to what degree it will reshape chair, Department of dentistry. The ubiquitous reach Dental Informatics, Temple University of today’s computer networks School of Dentistry, presages significant change: 3223 N. Broad St., TU 600-00, Philadelphia, dentistry is not an isolated Pa. 19140, e-mail province of health care anymore. “Titus@DENTAL. Temple.edu”. Address We are now, more than ever, reprint requests to Dr. connected to a larger system of Schleyer. stakeholders, regulations, expectations, accountability and risk. The road to clinical practice that is invisibly and seamlessly supported by informatics will be nothing short of arduous. Putting the theories and concepts of informatics into practice requires significant effort and investment. Many projects on this road will fail. Dentistry, however, should learn from the failures as much as it does from the successes. Only then will we realize the promise of informatics. ■ Dr. Spallek is an assistant professor, Department of Dental Informatics, Temple University, Philadelphia. The authors thank Drs. Roger Kenney, Hikmet Umar and Humberto Torres and several other colleagues in dental informatics for their thoughts and insights that contributed to this manuscript. The authors also thank the reviewers for their helpful comments. 1. Siegel D. Futurize your enterprise: Business strategy in the age of the E-customer. New York: John Wiley & Sons; 1999. 2. Tapscott D. Growing up digital. New York: McGraw-Hill; 1998. 3. Martin C. Net future. New York: McGraw-Hill; 1999. 4. Hamel G, Prahalad CK. Competing for the future. Boston: Harvard Business School Press; 1994. 5. NUA Ltd. NUA Internet survey: ecommerce statistics. Available at: “www.nua.ie/surveys/index.cgi?f=FS&cat_id=14”. Accessed Dec. 5, 2000. 6. Jupiter. Research overview. Jupiter Communications Inc. Available at: “www.jup.com/jupiter/research/research.jsp”. Accessed Dec. 5, 2000. 7. CyberAtlas. CyberAtlas: latest market research. Internet.com Inc. Available at: “cyberatlas.internet.com”. Accessed Dec. 5, 2000. 8. Dyson E. Release 2.0: A design for living in the digital age. New York: Broadway Books; 1997. 9. American Dental Association Survey Center. 1997 Survey of current issues in dentistry: Dentists’ computer use. Chicago: American Dental Association; 1998. 10. Hedberg SR. Like oxygen, researchers think computers will be everywhere. IEEE Intell Syst 2000;15(3):2-6. 11. Farr C. Digital dentistry in the 21st century. Dent Today 2000;19(6):96-101. 12. Merriam-Webster Online. Informatics. Available at: “www. m-w.com”. Accessed March 26, 2001. 13. Hasman A. Challenges for medical informatics in the 21st century. Int J Med Inf 1997;44(1):1-7. 14. Patel VL, Kaufman DR. Medical informatics and the science of cognition. J Am Med Inform Assoc 1998;5(6):493-502. 15. Friedman CP. Where’s the science in medical informatics? J Am Med Inform Assoc 1995;2(1):65-7.
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medical informatics and nursing informatics distinct disciplines? The 1999 ACMI debate. J Am Med Inform Assoc 2000;7(3):304-12. 48. Morris TA, McCain KW. The structure of medical informatics journal literature. J Am Med Inform Assoc 1998;5(5):448-66. 49. Goedert J. Do-it-yourself online records. Health Data Manag 1999;7:28-9. 50. Hudak J. Emergency care. CIO Magazine. Nov. 11 1999;Web business section 2:34-36. 51. Masys DR, Baker DB. Patient-centered access to secure systems online (PCASSO): a secure approach to clinical data access via the World Wide Web. Proc AMIA Annu Fall Symp 1997;17(3):340-3. 52. Reep JA, Lohman P. Market forces and the environment. MD Comput 1999;16(5):38-9. 53. Bader JD, Shugars DA. Variation, treatment outcomes, and practice guidelines in dental practice. J Dent Educ 1995;59(1):61-95. 54. Bader JD, Shugars DA. Variation in dentists’ clinical decisions. J Public Health Dent 1995;55(3):181-8. 55. Gregory-Mead B. Patients and the Internet: guidance for evidence-based choices. J Am Coll Dent 1999;66(2):46-50. 56. Diehl M. Developing the American Dental Association concept
model for the standard computer-based oral health record. J Am Coll Dent 1995;62(4):30-2. 57. Johnson L, Schleyer T. Development of standards for the design of educational software. Quintessence Int 1999;30(11):763-8. 58. Patel VL, Kaufman DR. Science and practice: a case for medical informatics as a local science of design. J Am Med Inform Assoc 1998;5(6):489-92. 59. Katz M, Shapiro C. Network externalities, competition, and compatibility. Am Econ Rev 2000;75(3):424-40. 60. Sichel D. Computers and aggregate economic growth: an update. Business Econ 1999;34(2):18-24. 61. Temple University School of Dentistry. Dental informatics postgraduate program. Available at: “www.temple.edu/dentistry/di/programs/pg”. Accessed Dec. 5, 2000. 62. Columbia University School of Dental and Oral Surgery. Dental informatics fellowship. Available at: “cpmcnet.columbia.edu/dental/ Dental_Fellows.html”. Accessed Dec. 5, 2000.
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Dental informatics A cornerstone of dental practice TITUS SCHLEYER, D.M.D., Ph.D.; HEIKO SPALLEK, D.M.D., Ph.D.
nformation technology, or IT, has transformed society and will continue to do so in the future.1 The way in which children grow up, companies do business, people shop and communities socialize has changed significantly since the beginning of the information revolution.2-8 That revolution also has made its mark in the dental profession. Almost 80 percent of dentists have computers in their offices, almost 30 percent have access to the Internet, and an increasing number use a variety of other technologies, including digital intraoral cameras and 9 How can paperless patient records. Given current technological trends, technological the number and magnitude of changes advances be brought about by IT and its potential made most applications will only increase. We are useful for not far from the day when computers dental practice, will permeate virtually everything we research and do, from how we read our morning treatment education? newspapers to how we make decisions for our patients.10 Within the next five years, experts foresee the commercial availability of electronic paper (paper that functions like a very high-resolution computer screen), a vast array of special-purpose computing appliances, autonomous software agents that enter into transactions on our behalf, an almost ubiquitous highcapacity networking infrastructure and personal digital assistants that rival current desktop computers in performance. How can these technological advances be made most useful for dental practice, research and education? Technological innovation for the health care professions originates from a number of sources, such as the commercial market, research and educational institutions, and people. While companies collectively engage in research
I
ABSTRACT Background. Dental informatics is a relatively new field that has significant potential for supporting clinical care. Most dentists are unaware of what dental informatics is, what its goals are, what it has achieved and how they can get involved in it. Methods. The authors conducted a literature review and several round-table discussions with dental informatics experts to discuss the preceding issues surrounding dental informatics. Results. Dental informatics is the application of computer and information sciences to improve dental practice, research, education and management. Numerous applications that support clinical care, education and research have been developed. Dental informatics is beginning to exhibit the characteristics of a discipline: core literature, trained specialists and educational programs. Conclusions. Dental informatics presents possible solutions to many longstanding problems in dentistry, but it also faces significant obstacles and challenges. Its maturation will depend as much on the efforts of people as on the collective efforts of the profession. Practice Implications. Dental informatics will produce an increasing number of applications and tools for clinical practice. Dentists must keep up with these developments to make informed choices.
and development of significant scale and scope, their interests primarily are driven by the profit motive. Most innovations are pursued because they are expected to make money. Other projects, which may be more important or significant but are not deemed as profitable, receive scant attention and resources. One example is the American National Standards Institute, or ANSI, standard digital imaging and communications in medicine, or DICOM, which defines a format for storage and exchange of digital images, including radiographic and visible-light images. DICOM is the almost
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TABLE 1
COMMMON ELEMENTS IN DEFINITIONS OF MEDICAL INFORMATICS. ELEMENT
become a cornerstone of dental practice. WHAT IS DENTAL INFORMATICS?
EXPLANATION
According to Merriam-Webster’s Collegiate Dictionary, informatics is Most definitions cite the improvement of patient Goal care as the goal of medical informatics. derived from the term “information Informatics is a basic and an applied science; that is, Science a continuum spanning model formulation, system science,” which is the development, system installation and the study of collection, classificaeffects.15 tion, storage, reAside from the domain (such as medicine or denMultidisciplinarity trieval and dissemitistry), informatics is composed of several constituent disciplines, such as computer science, nation of recorded information science, cognitive science and knowledge treated telecommunications.16 both as a pure and applied science.12 universal standard for managing images in cliniWhen applied to a specific domain, such as cal medicine.11 Until recently, however, digital medicine, nursing or dentistry, information scidental radiology system vendors have been slow ence becomes “informatics.” Existing definitions to implement DICOM. One reason has been that of medical informatics13,14 share several common dental extensions for DICOM are relatively new, elements15,16 (Table 1). and many vendors may not realize the benefits of A simple, but cogent, definition of dental inforimplementing DICOM. But more importantly, matics is “the application of computer and inforDICOM allows dentists to combine imaging mation science to improve dental practice, redevices and software from several vendors and, search, education and management,” which was thus, removes the “lock-in” that vendors of propriderived from an earlier definition that was coined etary systems have enjoyed so far. in 1992.17 The commercial market has brought many A common misconception is that informatics is innovations to the dental profession. But it is not the same as IT.18 Informatics is focused primarily likely to address many fundamental problems— on research, development and evaluation of inforsuch as controlled vocabularies, open standards mation models and computing applications. IT, on for exchanging patient information among practithe other hand, is concerned with the implementioners, quality assurance for patient outcomes tation and application of computer technology and and mechanisms to represent dental knowledge— telecommunications. Despite the larger concepany time soon. While academic and other institutual division, limited areas of overlap between tions are working on some of these issues, one informatics and IT exist, such as custom developobstacle to progress is the fact that the field of ment of software and evaluation of implemented dental informatics is not very mature. systems. Dental informatics combines dentistry and sevDental informatics can be considered a speeral research disciplines, such as computer scicialty of medical informatics. A number of models, ence and telecommunications. Because it is new, methods and applications can be shared, transthere is confusion relative to its definition, goals, ferred or both between the two disciplines. For opportunities and achievements. Therefore, we instance, the National Library of Medicine’s, or wrote this article to answer several questions: NLM’s, MEDLINE is the world’s largest biomedWhat is dental informatics? What are its goals? Is ical literature database and is equally applicable it a discipline? What are its opportunities and to all health care disciplines. The same applies to challenges? How can the practitioner get involved GenBank, a database of gene and protein seand stay up to date? We wrote this article to stimquence information to which researchers from ulate interest in this emerging field and help several domains contribute. Methods for building expert and decision-support systems, such as readers understand how dental informatics can Universality
606
Informatics is viewed as applicable to all activities in the domain, such as research, education and patient care.
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neural and Bayesian networks, can be applied across disciplines.19 Despite much common ground, there also are many aspects that set those informatics domains apart. For instance, most design work that informs the development of computer-based medical records simply is not applicable for computer-based dental records. Dentists collect, display and analyze data differently than do their medical counterparts. While the general medical and medication histories collected by both physicians and dentists share many common elements, the dental history and the oral health status have no equivalent in medicine. As a consequence, developing, implementing and evaluating complete computer-based dental records is both a challenge and an opportunity for dental informatics, as are many other domain-specific aspects.
Table 2 offers a description of selected computer applications.19,25-43 The list is not inclusive, but rather provides an overview of the breadth and depth of existing applications. IS DENTAL INFORMATICS A DISCIPLINE?
Before we can answer the question of whether dental informatics is a discipline, we should discuss what features characterize a discipline. Requisite features are da core of people who conduct research and publish in the discipline; dan identifiable body of literature: books, journals and other publications; dprofessional societies and related activities, such as meetings and conferences; deducational programs leading to a certificate or advanced degree; dfunded research programs. WHAT ARE DENTAL INFORMATICS’ A core of people who conduct and publish rePRACTICAL GOALS? search in dental informatics exists. An informal The main goal of dental informatics is to improve review of the literature showed that since 1965 patient outcomes. Thus, the disciapproximately 3,500 authors have pline must support and improve diagpublished about 2,200 articles Developing, nosis, treatment and prevention of related to dental informatics and implementing and disease and traumatic injury; relieve computer applications in dentistry pain; and preserve and improve oral evaluating complete in about 420 journals and conference health. A secondary goal is to make proceedings. Journals with significomputer-based the delivery of dental care more efficant numbers of informatics-related dental records is cient; for example, by maintaining or articles include Oral Surgery, Oral both a challenge and Medicine, Oral Pathology, Oral improving cost-benefit ratios. Dental an opportunity for informatics also must support reRadiology and Endodontics; JADA; dental informatics. search and education, and improveDentomaxillofacial Radiology; the ments in these areas should, and Journal of Dental Education; and the British Dental Journal. The often do, translate into improved Journal of the American Medical Informatics patient care. Informatics is key in helping practitioners Association and the International Journal of solve clinical problems and keep current. Most Computerized Dentistry are more narrowly educational programs still subscribe to the philofocused. The first book on dental informatics was written in 1992 and provides a conceptual sophy that everything dentists need to know can overview of the field.44 Other books, such as “The be learned in dental school. The trend toward problem-based learning and the development of Global Village of Dentistry”45 and “Imaging in 20-22 critical-thinking skills tells a different story. Esthetic Dentistry”46 provide more detailed looks Dentists must be as familiar with the problemat some application areas. solving process as they are with the problem Currently, dental informatics has no maindomain itself. Computers can help practitioners stream journal of its own, the emergence of maintain their continuing competency, and many special-purpose journals (such as the Journal of dentists already are using computers to keep Computerized Dentistry) notwithstanding. This is abreast of new developments.23,24 appropriate considering that dental informatics is Many examples of developments in dental in the early stages of development and that, at informatics that have helped improve patient this time, it is more important to educate a broad outcomes (or have the potential to do so if widely audience about the possibilities of dental inforused), education and research can be cited. matics than to provide a specialized forum for JADA, Vol. 132, May 2001 Copyright ©1998-2001 American Dental Association. All rights reserved.
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TABLE 2
SELECTED COMPUTER APPLICATIONS IN CLINICAL CARE, EDUCATION AND RESEARCH. AREA Clinical Care
Education
Research
DESCRIPTION
APPLICATION OralCDx25
Method for the screening of oral lesions that involves a brush biopsy and computerized analysis of the histologic slide, allows for screening of more patients for premalignant or malignant lesions earlier
Digital radiology26.27
Equivalent to traditional film for many diagnostic and therapeutic tasks; advantages include reduced radiation exposure for patients and dental personnel, reduced development time, automation of quality assurance processes and the potential for immediate digital analysis
Tuned-aperture computed tomography28
Example of a three-dimensional imaging modality; applications include primary caries detection29 and assessing bone defects at implant sites30
Decision support systems19,31
Aid for dentists to make decisions about therapeutic approaches or complex or rarely encountered conditions; oral radiographic differential diagnosis,32 for instance, supports the diagnosis of radiographic lesions
MEDLINE33
Database that makes a significant portion of the dental literature accessible to practitioners to help answer clinical questions
CEREC34
Fabrication of machine-milled crowns and bridges during the course of an office visit
Dental practice management
Automation of many routine tasks in a dental office, such as electronic claims submission, scheduling and financial management
Oral manifestations of human immunodeficiency virus35
Computer-assisted learning package on the oral manifestations of human immunodeficiency virus of relevance to general dental practitioners
Dental diagnosis and treatment36
Interactive program to provide students or practicing dentists an opportunity to develop and practice their critical-thinking skills for diagnosis and treatment
Simulations37-39
Educational programs designed to closely approximate clinical situations for teaching, continuing education or performance evaluation
Complete distance education programs40
Integrated educational tracks, certificates or degrees offered at a distance
Data mining tools41
Analysis of large sets of data to generate new knowledge or findings
Collaboratories42
Infrastructure to make it easier for large, geographically distributed research groups to work together
Computerized data analysis43
Complex analyses of research data
dental informatics researchers. Over the long term, however, the development of a dedicated, international and multidisciplinary dental informatics journal should be considered. Currently, dental informatics has no dedicated professional society. Rather, its activities are 608
integrated with those of several existing associations, such as the American Dental Education Association, or ADEA; the ADA; and the American Medical Informatics Association, or AMIA. In most cases, a section or special interest group of an association provides a forum for exchange be-
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tween members. Specialized conferences, such as the Conference on Computers in Clinical Dentistry, those sponsored by ADEA, the Consortium for Clinical Information Systems, and the Conference on Computers in Dental Education and Practice have been held in the past. Up until now, these conferences have been arranged on an ad hoc basis, and none has developed into a stable, widely accepted scientific forum. The first educational programs leading to advanced degrees in dental informatics were created in 1996 in response to a request for applications issued by the National Institute of Dental and Craniofacial Research, or NIDCR, in cooperation with NLM. A program at Columbia University and a joint program offered by the University of Pittsburgh and Temple University offer master’s degrees through three-year and two-year programs, respectively. The philosophy of both training programs is grounded in the belief that dental informatics is derived from medical informatics rather than a separate discipline.47 Thus, trainees complete a generalist education in medical informatics and specialize in dental informatics. The programs graduated their first trainees in 2000. Anecdotal evidence suggests that dental informatics research receives only limited third-party funding, such as from the government, the military, foundations and companies. NIDCR and NLM have funded very few grant applications in dental informatics, and some universities have been and are receiving limited corporate support. In contrast, programs sponsored by the European Union have resulted in significant funding in dental informatics research in Europe. Much of the research in dental informatics at this time is conducted as “unfunded” research by faculty at dental schools and universities around the world. It is instructive to compare dental informatics to its parent, medical informatics. The medical informatics research community is extremely active. Medical informatics has its own literature that is segmented into topics such as biomedical engineering, biomedical computing, decision support and education.48 Major informatics journals, such as MD Computing and the Journal of the American Medical Informatics Association, have existed since the early 1990s, and approximately 140 books about medical informatics have been published. Twelve medical informatics training programs funded by NLM exist, and approximately 30 of the 150 medical schools in the
United States have a department or section of medical informatics. Conferences such as Towards Electronic Patient Records and the AMIA’s fall symposium attract several thousand participants each year. Medical informatics research is funded by programs of significant scale and scope at NLM, the National Cancer Institute and the National Science Foundation, as well as by corporations and foundations. Dental informatics is a nascent discipline. To what degree it can mature successfully depends on its ability to take advantage of opportunities and overcome some significant challenges. OPPORTUNITIES AND CHALLENGES
Dentistry is an information-intensive activity, and informatics by its very nature supports such activities well. IT already has significantly improved our ability to store, access, manage, filter and apply information. When one considers what progress has been made in a myriad of aspects of human life, it is not difficult to envision how dentistry may be transformed by becoming informatics-based.16 Ultimately, informatics done well simply will let us concentrate on our jobs as dental professionals by improving and maintaining the oral health, and consequently the general health, of our patients. These new and powerful technologies will bring cultural changes to the dental profession itself. The following are some opportunities and challenges that informatics places before us. dLongitudinal, lifetime, comprehensive and patient-centered dental records. Dentistry is still largely a cottage industry. This situation expresses itself in the minimal degree to which patient information is shared. Patientcentered, rather than practice-centered, dental records can eliminate duplicate information gathering, provide a rich context through access to prior diagnostic and treatment records, and allow the practitioner to concentrate on the problem at hand. The book “Futurize Your Enterprise”1 contains an excellent vision of how patient-centered medical records can improve health care. Several computer system vendors offer precursors to such systems already today.49 dUniversally accessible patient records that ensure privacy and confidentiality. As an increasing portion of patient-related information is stored and transmitted digitally, dental informatics has the responsibility to develop, implement and monitor measures to keep it pri-
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vate. While no system is perfectly secure, a baladministered by the ADA, as well as its predeance between privacy and access must be cessor the ASC MD 156 Task Group on Dental found.50,51 Informatics. Unfortunately, after seven years of dSignificant reduction of practice managework, this effort has achieved little. Tangible ment and administrative overhead. A signifiproducts that have been developed include the cant portion of health care expenditures go Concept Model for the Standard Computer-Based toward administration. One of the greatest Oral Health Record56 and the Guidelines for the sources of inefficiency has been the lack of shared Design of Educational Software.57 Neither of these information by health care buyers, sellers and efforts has evolved into a widely accepted and consumers.52 Well-integrated information systems applied standard, but progress may improve can reduce this overhead significantly, through based on the recent formalization of the SCDI. measures from autonomous supply ordering to Another challenge is to increase the quality automated scheduling, billing and recall. and quantity of dental informatics research. The dClinical care based on empirically deterstandards for investigation and scientific inquiry mined best practices. Most patients in indusin new disciplines develop over time, and dental trialized countries already enjoy very high informatics is no exception. What passes for standards of care. However, large variations in research and what does not is a subject of periodic diagnosis and treatment decisions discussion in medical informatics still exist.53,54 As more patients even today.15,58 The scarcity of people Well-integrated become aware of the standard of formally trained in research care, dentists will be forced to prove methods and approaches and the information the quality of their care. While few systems can reduce dearth of interdisciplinary teams dental treatments are based on that can solve complex research overhead definitive clinical evidence obtained questions constrains the volume and significantly, through through randomized clinical trials, quality of research output. Support measures from outcomes data aggregated over large for dental informatics research from autonomous supply grants, contracts and funding agennumbers of practices and patients can help identify best practices. Since cies such as NIDCR or NLM is ordering to many patients use the Internet to minute. The problem, however, is automated access health-related information, two-sided. The lack of qualified scheduling, billing valid and reliable information needs investigators in dental informatics and recall. to be available and recognizable as results in a scarcity of fundable such.55 research proposals. Funding How can the dental profession take advantage agencies, on the other hand, may not view dental informatics as a programmatic priority if demand of these opportunities? A positive circumstance is for research funding is not apparent. that dentistry as a profession is relatively unified. The majority of U.S. dentists are members of the Dentistry is a relatively small segment of the ADA. The ADA and other dental organizations, health care system. Thus, many companies are such as the Academy of General Dentistry and hesitant to invest in research and development because the potential payoff is constrained by the the American College of Dentists, provide small size of the market. Network externalities common ground and political clout on many also are a significant deterrent to investment.59 important issues. Yet success in realizing the present opportunities rests on significant innovation, Products or services, such as the telephone, that research and development in informatics that become more valuable as more people use them most likely will not come from central are said to benefit from network externalities. For organizations. instance, when only a few practices can exchange While it may seem difficult to forge a common patient information using computer-based patient vision for informatics within the dental profesrecords, or CPRs, the collective benefit is small. sion, it is not impossible. One attempt at crafting When most practices use such interoperable a long-term strategy is the development of standCPRs, however, the collective benefit is large. ards related to dental informatics through the Globalization may improve this situation because newly formed, ANSI-accredited Standards Comit increases potential markets. mittee on Dental Informatics, or SCDI, which is The growth of dental informatics also is ham610
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pered because many of its benefits are hard to Association and the British Medical Journal are measure, and achieving them requires significant good sources for keeping up with general medical upfront and ongoing investments. For instance, informatics developments. the quantifiable benefits of a computer system for Meetings and conferences. Venues for inforbilling and electronic claims submission include matics-related topics are the ADA’s technology time and money saved in preparing claims, days, the ADEA’s annual session and AMIA’s fall reduced claim and payment turnaround, and symposium. improved management of accounts receivable. Standards activities, society activities, The advantages of installing a CPR, on the other university committees and vendor focus hand, are much harder to define and measure. groups. The ADA-administered SCDI is an excelEvaluating the return on investment, however, is lent way for dentists to get involved in setting the fraught with difficulties not only in dental inforstandards for tomorrow’s IT applications in denmatics. Nobel Prize–winning economist Robert tistry. Local and regional dental societies, univerSolow said that we see computers everywhere sities and vendors increasingly maintain comexcept in the productivity statistics. Productivity mittees or advisory boards to help shape their growth has slowed every decade from the 1960s strategies for IT, and they often offer interested until the mid-1990s, while investments in IT have dentists a chance to get involved. grown dramatically. This phenomenon has been Computer courses. Colleges and universities termed the “productivity paradox.” offer introductory and advanced However, the dramatic contribution courses in information systems, proThe growth of of computers to the rising producdental informatics is gramming and databases. Many tivity since 1995 may indicate that companies offer courses on specific hampered, in part, we have reached a turning point.60 applications, such as desktop producSince health care in general and den- because many of its tivity and graphics programs. Probenefits are hard tistry in particular still lag in the use grams for bachelor’s or master’s of computers, most benefits still are degrees in a variety of computerto measure, and to come. related areas also are available, and achieving them The current situation simply may requires significant some of the necessary courses can be be symptomatic of a profession findtaken through distance learning upfront and ing its way in informatics. An enprograms. couraging sign is the significant and ongoing investments. Communities. The Dental Inforincreasing interest of many influential stakeholders in dentistry. Hopefully, this interest can be channeled into concerted action that benefits all of dentistry. Success, however, also is predicated on the level of involvement of each practitioner. The next section highlights some opportunities. HOW CAN YOU GET INVOLVED IN DENTAL INFORMATICS?
Getting involved in and staying up to date on dental informatics is not as easy as joining a professional society and subscribing to its journal. There are, however, a few options. Articles on dental informatics in major dental journals. Journals in which articles about dental informatics appear periodically include JADA, the Journal of Dental Education, Quintessence International and the Journal of Computerized Dentistry. The Journal of the American Medical Informatics Association, MD Computing, the Journal of the American Medical
matics Section of ADEA and the Dental Informatics Working Group of AMIA allow people interested in dental informatics to network. Both groups maintain Internet discussion lists that include members from all over the world. Joining these communities is free for members of the respective organizations. Dental informatics degree programs. Two dedicated postgraduate programs in dental informatics currently exist.61,62 Both are appropriate for people interested in having a research career in dental informatics. The opportunities available today make this an option particularly attractive for dentists who would like to participate in shaping the development of dental informatics. It is safe to assume that the sources of information and the opportunities for interested dentists to get involved will only multiply in the future. CONCLUSION
“There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its
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success, than to take the lead in the introduction of a new order of things.” Niccolò Machiavelli’s words describe the challenge to dental informatics well. Computer technology has reshaped our lives already. The question Dr. Schleyer is an associate professor and the is to what degree it will reshape chair, Department of dentistry. The ubiquitous reach Dental Informatics, Temple University of today’s computer networks School of Dentistry, presages significant change: 3223 N. Broad St., TU 600-00, Philadelphia, dentistry is not an isolated Pa. 19140, e-mail province of health care anymore. “Titus@DENTAL. Temple.edu”. Address We are now, more than ever, reprint requests to Dr. connected to a larger system of Schleyer. stakeholders, regulations, expectations, accountability and risk. The road to clinical practice that is invisibly and seamlessly supported by informatics will be nothing short of arduous. Putting the theories and concepts of informatics into practice requires significant effort and investment. Many projects on this road will fail. Dentistry, however, should learn from the failures as much as it does from the successes. Only then will we realize the promise of informatics. ■ Dr. Spallek is an assistant professor, Department of Dental Informatics, Temple University, Philadelphia. The authors thank Drs. Roger Kenney, Hikmet Umar and Humberto Torres and several other colleagues in dental informatics for their thoughts and insights that contributed to this manuscript. The authors also thank the reviewers for their helpful comments. 1. Siegel D. Futurize your enterprise: Business strategy in the age of the E-customer. New York: John Wiley & Sons; 1999. 2. Tapscott D. Growing up digital. New York: McGraw-Hill; 1998. 3. Martin C. Net future. New York: McGraw-Hill; 1999. 4. Hamel G, Prahalad CK. Competing for the future. Boston: Harvard Business School Press; 1994. 5. NUA Ltd. NUA Internet survey: ecommerce statistics. Available at: “www.nua.ie/surveys/index.cgi?f=FS&cat_id=14”. Accessed Dec. 5, 2000. 6. Jupiter. Research overview. Jupiter Communications Inc. Available at: “www.jup.com/jupiter/research/research.jsp”. Accessed Dec. 5, 2000. 7. CyberAtlas. CyberAtlas: latest market research. Internet.com Inc. Available at: “cyberatlas.internet.com”. Accessed Dec. 5, 2000. 8. Dyson E. Release 2.0: A design for living in the digital age. New York: Broadway Books; 1997. 9. American Dental Association Survey Center. 1997 Survey of current issues in dentistry: Dentists’ computer use. Chicago: American Dental Association; 1998. 10. Hedberg SR. Like oxygen, researchers think computers will be everywhere. IEEE Intell Syst 2000;15(3):2-6. 11. Farr C. Digital dentistry in the 21st century. Dent Today 2000;19(6):96-101. 12. Merriam-Webster Online. Informatics. Available at: “www. m-w.com”. Accessed March 26, 2001. 13. Hasman A. Challenges for medical informatics in the 21st century. Int J Med Inf 1997;44(1):1-7. 14. Patel VL, Kaufman DR. Medical informatics and the science of cognition. J Am Med Inform Assoc 1998;5(6):493-502. 15. Friedman CP. Where’s the science in medical informatics? J Am Med Inform Assoc 1995;2(1):65-7.
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