Assessing the completeness of periodontal disease documentation in the EHR: a first step in measuring the quality of care

Our objective was to measure the proportion of patients for which comprehensive periodontal charting, periodontal disease risk factors (diabetes status, tobacco use, and oral home care compliance), and periodontal diagnoses were documented in the electronic health record (EHR). We developed an EHR-based quality measure to assess how well four dental institutions documented periodontal disease-related information. An automated database script was developed and implemented in the EHR at each institution. The measure was validated by comparing the findings from the measure with a manual review of charts. The overall measure scores varied significantly across the four institutions (institution 1 = 20.47%, institution 2 = 0.97%, institution 3 = 22.27% institution 4 = 99.49%, p-value 80%). Our results demonstrate the feasibility of developing automated data extraction scripts using structured data from EHRs, and successfully implementing these to identify and measure the periodontal documentation completeness within and across different dental institutions.