1. Dr Namita Shanbhag
Associate Professor
Government Dental College and Research Institute
Bangalore, Karnataka, India

2. Inter-Intra Rater Reliability Using “E Charting EDR”
In Dental Education Setting
Dr Namita Shanbhag Dr Manjunath Puranik Dr Santhiya
Associate Professor Professor and Head Post graduate student

3. CONTENTS
Background
Aim and objectives
Methodology
Results
Discussion
Summary and Conclusion
Acknowledgement

4. Records are the most important tools for verifying the delivery of predictable wellness-centered care, based on up- to-date evidence-based decision-making that patients want and expect.
As patients become savvier about their healthcare and more frugal with their money, it is of utmost importance that dentists have the latest, greatest, and most innovative technology

5. The introduction of operatory computers has been a popular trend lead by applications such as digital X-ray systems and cosmetic-imaging software.
The information technology revolution coupled with every- day use of computers in clinical dentistry has created new demand for electronic patient records.

6. The Electronic Patient Record (EPR) or “computer-based medical record” is defined by the Patient Record Institute as “a repository for patient information with one health-care enterprise that is supported by digital computer input and integrated with other information sources.1
Digital patient records can improve organization, treatment-tracking, and information retrieval – enhancing communication and optimum patient care
The electronic health record with respect to clinical charting is, by default, a more comprehensive application of software technology in the operatories

7. Dental Charting is a Cloud-based e-charting and statistics generating software produced and compiled by Mr Wouter Put ,Netherlands and has the potential to provide health information management and analysis approach on a large scale, and across populations. 2
This specific software tool automatically generates instantaneous dental health statistics of the charted patients that would be essentially needed to be used to plan or execute any health program or any kind evaluation processes as needed by the health authorities.

8. In order to fully integrate and realize all of the potential of electronic records, many of the roadblocks must be resolved efficiently.
This includes full resolution of issues related to terminology, system interfaces, and agreement on standardized clinical measures.3
The purpose of this study was to assess the inter and intra rater examiner reliability of electronic dental record system using this online e- charting software tool in recording common oral findings.

9. Aim and Objectives
To quantify intra- and inter-examiner reliability of measuring periodontal as well as dental parameters using the e-charting software program.
To suggest any modifications with regard to data cells if any

10. Methodology
Three clinical examiners (SE + 1 ) were assigned to the study.
All examiners attended a review seminar and training session , during which the objectives, measurement parameters, techniques and schedule was discussed.
They would be recording the detailed case history of the calibration subjects on to the online charting tool into a computer independently
Before beginning the study, the three examiners were trained in a calibration process.

11. In a calibration group (not part of the experimental group), 10 study subjects were examined by the two examiners, using a plane mouth mirror and a WHO Probe (Hu-Friedy Co., Chicago, USA), once a week over a period of 2 weeks.
The standard examiner (SE) discussed each criteria being used for each aspect of the dental and periodontal examination and discussed how to enter the data into the software
The examination process was repeated until each examiner had substantial correlation Kappa agreement of 5 kappa values in the range 0.81–0.92, and the all items gave a kappa value of 0.88.
Once the examiners were trained, the study was initiated.

12. ETHICAL CONSIDERATIONS
The Institutional Ethics Committee of Government Dental College approved the study
The calibration subjects were recruited based on their willingness for participation and after signing the informed consent following guidelines of the Helsinki Declaration.

13. Intra rater calibration session
A total of 50 adult calibration subjects (18 years of age or older) with a range of periodontal health and dental caries were recruited for the study by the standard examiner over a period of 2 weeks
Only 5 subjects were evaluated by the SE each day
A total of only 31 subjects volunteered for repeat examination that were conducted by the SE after one week

14. Inter-rater calibration
Recruitment of 50 subjects (6 subjects per day were examined and the oral findings were recorded independently by the standard examiner on to the computer using the dental charting clinic management charting software.
A total of only 36 subjects volunteered for repeat examination.
They were assessed again after one week consecutively by the other two examiners.
Dental caries was scored using DMFT, ICDAS and CAST indices
Gingivitis was assessed by the presence of bleeding on probing
Periodontitis was assessed by measuring probing depths , loss attachment and presence of gingival recession
50 subjects

15. Statistical Analysis
The prevalence of dental caries and periodontal disease was instantly generated through the inbuilt statistical software in the dental charting software program.
The baseline record of each patient was analyzed further with regard to the following variables namely the Age, Gender ,Gingivitis(BOP), Periodontitis(Pocket depth, LOA, Gingival Recesion), Dental caries(DMFT, ICDAS, CAST).
This data was manually entered into excel spreadsheet and subjected to statistical analysis using SPSS for Windows software ver 22.0.(IBM Corporation, Chicago, USA).

16. The results were analyzed statistically by t-test for independent samples and an analysis of variance (ANOVA) to derive significance.(p<0.05)
The intra-class correlation coefficient, , was used to determine both the intra- and inter-investigator reliabilities.
Normalcy-

17. Results
The study was conducted among 100 subjects over a period of 2 months
The mean age of the study subjects was 39.3 years (18-50 years ).

18. INTRA RATER CALIBRATION
Variables
Prevalence (%)
Mean Score (SD)
p-Value
Dental caries
Exam-1
Exam--2
Exam-2
DMFT 81 84
3.26
(1.788)
(1.751)
0.811
ICDAS 71 74
1.74
(1.154)
1.77
(1.175)
0.884
CAST
( 1.788)
Periodontal Diseases
Gingivitis
9.35
(8.716)
9.32
(8.719)
0.975
Periodontitis 48
1.94
(2.205)
2.00
(2.221)
0.963
For the intrarater reliability 31 (16 Males, 15 Females) were included.
The prevalence of DMFT was 81% at the first examination and 84% after one week, while DMFT mean was at 3.26(1.78) during first and second 3.26(1.751) examination.
Mean ICDAS score was 1.74(1.154) and 1.77(1.17%) respectively for 1st and 2nd examiner.
Mean CAST (1-8) score 3.26(1.78) and 3.26(1.75)
Gingival disease scores 9.35(8.71) and 9.32(8.71)
Periodontal Disessase scores1.94(2.20) 2.0(2.221)
t-test for independent samples (intra-examiner reproducibility) to test significance between observations
There was no significant difference found in the values between the two examiners with respect to these variables.

19. INTRA RATER CALIBRATION INTRA CLASS CORRELATION COEFFICIENT
Variables
Intra class correlation
Confidence interval
(95% CI)
Significance
Dental caries
DMFT
0.984
0.000
ICDAS
0.969
0.935 – 0.985
CAST
Periodontal Diseases
Gingivitis
0.999
Periodontitis
0.993
0.986 – 0.997
F test denotes the difference between groups
since the differences between the observations during the two examinations were not signifiant ,it implies that the observations were similar. And there was high intra examiner agreement with regards to the observations
The intraclass correlation for all the variables was 0.9 denoting that there was a highly strong and positive correlation between the two examinations.

20. INTER RATER CALIBRATION
Variables
Prevalence (%)
Mean Score (SD)
p-Value
Dental caries
Examiner1
Examiner 2
Examiner3
Examiner 1
Examiner 2
Examiner 3
DMFT 89 86
2.833
( )
2.972
(1.4439)
2.778
( )
0.225
ICDAS 58 59
1.611
(0.3581)
1.667
( )
1.639
( )
0.823
CAST
Periodontal Diseases
Gingivitis 69
9.78
(8.712 )
9.64
( 8.679)
9.53
(8.507 )
0.185
Periodontitis 36 39
2.11
( 3.003)
2.06
(3.070 )
(3.022 )
0.722

21. INTER RATER CALIBRATION
Inter – item correlation matrix
Intra class correlation
Confidence interval(95% CI)
F score
Variables
Standard examiner(SE)
Examiner 2 3
Dental caries
DMFT 1
0.868
0.897
0.956
0.924 – 0.976
0.000
ICDAS
0.924
0.933
0.974
0.954 –0.986
CAST
Periodontal Diseases
Gingivitis
0.995
0.994
0.999
0.997 –0.999
Periodontitis
0.991
0.996
0.993 –0.998
Against the observations of the SE, how did the other examiners performed.
Against SE, and examiner 2,and 3 did show a high and positive correlation
The intraclass correlation for all the variables was 0.9 denoting that there is a strong agreement between the two examinations.
The inter-rater reliability between the two reviewers was when using Cronbach’s alpha and (95% CI) when using Intra-class Correlation Coefficient.

22. DISCUSSION
This study evaluated intra- and inter-examiner reliability among three trained and calibrated examiners while using a e charting tool for data entry of clinical recording of dental and periodontal health among the individuals
Rigorous operator calibration were demonstrated as necessary for obtaining reliable records, which can be used for appropriate decision-making.
Experience is the most important factor in measurement reproducibility.

23. In our opinion, the high intra-examiner reproducibility observed was the result of the calibration and training program, and was not related to the operators’ experience, as have stated other authors 4-9
There are other variables that could affect periodontal clinical probing and this was avoided by providing sufficient time between the initial and repeated measures and preserving tissue health, thus controlling the likelihood that an operator’s memory induced bias.

24. The EPR can be used to assess the quality of care in a large clinic in numerous ways.1
Researchers have suggested that oral health professionals should develop a common record with standard codes, including clinical outcome measures, to make the EHR more useful for recording clinical treatments, facilitating research and improving quality of care.

25. Any electronic dental record should be flexible enough to allow the comparative analysis of patients and by individual or groups of providers.
Data from the EPR must be exportable to other software packages for further analyses to support many quality assurance functions.
Though the software has an ability to generate statistics instantaneously, further analysis needed an manual approach.

26. CONCLUSION
According to the Office of National Coordinator, the purpose of “meaningful use” is to use an EHR “Improve quality, safety, efficiency, and reduce health disparities, engage patients and family, improve care coordination and population and public health & maintain privacy and security of patient health information”

27. While the research by Poul Eric Petersen implies that Electronic health information improves patient care by facilitating higher patient safety and quality of care, eliminates bulky folders of patients’ records, and storage space freed up to make way for consultation rooms, with quick and timely access to a patient’s updated dental history and any pre-existing medical condition allows more thorough assessments in less time by cutting down on waiting time as patient records retrieval goes electronic
Hence EDR -It turns a promise into reality as to formulating fact- based dental health policies quickly and easily as well as planning and executing health service delivery.

28. Cloud-based e-charting and statistics processing promises to be the way forward for reliably maintaining patient dental health records.
It has the potential to provide the global dentistry community with a health information management and analysis approach on a large scale, and across populations. It turns a promise into reality as to formulating fact-based dental health policies as well as planning and executing health service delivery
Improved quality of oral health information systems worldwide may help to strengthen health systems and operational research may assist in translating sound knowledge about prevention programmes and health promotion for the benefit of the poor and disadvantaged population groups.5

29. Jane C. Atkinson,,Gregory G. Zeller,, Chhaya Shah, B. A
Jane C. Atkinson,,Gregory G. Zeller,, Chhaya Shah, B.A. Electronic Patient Records for Dental School Clinics: More Than Paperless Systems Journal of Dental Education ■ Volume 66, No
John Cutter, Wouter Put. e‐Charting – Public Health Data Acquisition Efficacy Via Undergraduate Dental Students. Int Dent J; Special Issue: Abstracts of the 105th, FDI World Dental Congress. 2017;(67)Issue 1:73
Ira Lamster ,Fiona Collins. Are Oral Health Providers Using Electronic Dental Records? electronic-dental-records accessed on 12/06/2018
Poul Erik Petersen, Denis Bourgeois, Douglas Bratthall,& Hiroshi Ogawa .Oral health information system-towards measuring progress in oral health promotion and disease prevention Bulletin of the World Health Organization ;September 2005, 83 (9)
Reliability study of clinical electronic records with paper records in the NSW Public Oral Health Service Angela V Masoe, Anthony S Blinkhorn, Kim Colyvas, Jane Taylor, Fiona A Blinkhorn Accessed march 2015 vol25 issue 2

31. So many thanks to:
Argentina
Brazil
Cambodia
Colombia
India
Indonesia
Netherlands
Philippines
Turkey
USA