Modelling the way that dentists use information: an audit tool for capability and competency

Key Points

• IT offers many potential benefits to dentists.

• Benefits arise not from the IT directly, but from new ways of working.

• Increased usage of IT must be matched by increased maturity in information management and information governance.

• The Dental Practice Information Maturity Model (DPIMM) offers a tool to help manage this process.

Abstract

Information, and the use of computers to provide that information, is becoming an increasingly important part of all aspects of clinical practice including dentistry. In 2003, a survey of English dental practices found nearly a quarter of practices were not using computers at all. Dental practices, whether NHS or private, can use information technology to provide significant benefits to patients and practices alike. In this article, a model is described for the maturity of information usage in dental practices. The model uses an approach successfully deployed previously in a range of applications in healthcare and other domains. The approach audits current maturity of usage and staff competency to help develop improvement plans for dental practices. The article describes how the model has been made freely available to dental practices over the Internet.

Introduction

In 2003, a survey of English dental practices found that nearly a quarter were still not using computers at all. Of those not using computers, over half (56%) stated that they did not believe they were currently necessary. Around one quarter cited staff reluctance (24%), while slightly fewer said that the systems were too expensive (19%). Only 45% had Internet and email access at this time.¹

In 2002, the document An information technology strategy for NHS dentistry in the 21st century² promised NHS dentists that:

1.2 Delivering 21^st Century IT Support for the NHS outlines a vision for the future of information in the NHS. The priorities and challenges for NHS dentistry fit within this NHS-wide strategic approach to IT

1.3 The overriding theme of Options for change (OfC) is the re-integration of dentistry within the NHS and for dental records to become more connected with mainstream NHS IT

1.4 OfC requires the development and application of a standard oral health assessment and clinical pathways for dentistry, which will need to be applied consistently across the NHS. These will all need the support of an integrated IT strategy

1.5 Electronic records including digitised radiographs will need to be transferable between dentists and other organisations

1.6 To achieve this vision, there will need to be a substantial investment in education, training and change management for dental practice.

The American Dental Association³ claims the following benefits for computerised dental practices:

• Dental office computer systems should be compatible with those of the hospitals and plans they conduct business with. Referral inquiries should be handled easily

• Vendors should be able to supply low-cost software solutions to physicians/dentists which support standards-based EDI. Costs associated with mailing, faxing, and telephoning may decrease

• Administrative tasks can be accomplished electronically. Dentists may have more time to devote to direct care

• Dentists should have a more complete data set of the patient they are treating, enabling better care. More efficient systems may give dentists more time to spend with patients and performing clinical work.

However, experience from other sectors of healthcare has demonstrated that benefits realisation is complex and benefits derive from changes in working practices rather than from the technology itself.^4,5

The authors have developed a model based around two distinct approaches that are combined to model the use of information by dental practices.

The maturity model approach

The first approach is a maturity model to assess process maturity. In November 1986, the US Government asked the Software Engineering Institute (SEI) to provide the federal government with a method for assessing the capability of their software contractors. In September 1987, the SEI released a brief description of the process maturity framework and a maturity questionnaire.⁶ This model, known as the Capability Maturity Model (CMM) is defined as a five-level framework for how an organisation matures its software processes from ad hoc, chaotic processes to mature, disciplined software processes.⁷

Paulk et al.^8,9 describe the levels as shown in Table 1. The SEI CMM is questionnaire-based. Each question is a 'yes/no' audit item.

Table 1 Five levels of the SEI CMM

The second part of the authors' model is based upon competency modelling.

Competency modelling

In 1984 Benner¹⁰ outlined an adaptation of an earlier model of skill acquisition by Dreyfus¹¹ as applied to nursing. Her model suggests a number of stages on the way to becoming a skilled practitioner. Benner describes these levels as being based upon three aspects of overall performance. Firstly, the paradigms shift from abstract rules to life experiences as the basis for behaviour. Secondly, a change in perception of situations, from a collection of disparate equal parts to a complete entity in which some parts have more relevance or importance than others. Third is the move from 'detached observer' to 'involved performer'.

Within this framework there are five stages through which the student will pass on their way to becoming an expert, as shown in Table 2. The key to using this model effectively is that skilled performance is not simply a measure of outcome, or simplistic behaviour, but includes the way in which the individual processes information before acting and then in the way in which they act in order to achieve a desired outcome.

Table 2 Six levels of the Performance Model

A fundamental problem with the Benner model is that, across the board, an individual's performance is not uniform in all aspects of their role. As the model is situational and experientially based, performance in disparate areas will necessarily be at different levels depending on theoretical knowledge and previous experience of the individual. In order to address this, the authors have used the skill acquisition model of performance to relate not to the whole individual, as is the case in Benner's work, but to selected facets of performance expertise against each competency item. Thus a clinician may be an expert in one competency item due to their level of experience and theoretical knowledge, whilst at the same time being a novice in a competency of which they have no experience or background knowledge.

Other limitations to this model are two fold. Firstly, the model of performance is context specific. Because the professional will use past experience as a filter when processing information, the accuracy of performance level measurement is limited to those situations where experience is relevant and related to the situation in which the worker finds him or herself. Thus, expert performance in a primary care setting will not necessarily produce the same level of performance if the individual moved to a secondary care situation. Secondly, the competency model could be regarded as reductionist. The authors argue that the approach deployed as part of this work goes some way to address this criticism. Because the competency items are not written as specific behavioural tasks that are either achieved or not, but rather as areas of clinical skill, the system retains the flexibility and adaptability to provide both clinicians and mangers with high quality data regarding training needs whilst addressing the complexity of developing clinical situations and supporting technologies.

In order to operationalise this model each individual is assessed against the matrix by selecting the appropriate row for his or her role. This provides a benchmark of the performance required in each competency item. Variance from this standard defines the presence, or absence, of development or training need. The authors have, with others, used this approach in a variety of settings to support the production of competency performance sets for general nursing, cancer nursing, public health, information management, mental healthcare and teenage sexual health.^5,12,13 Through the use of a single matrix, all of these competency performance sets and all professional, and non-professional roles, can be managed on a unified system.

The dental practice information maturity model

The dental practice information maturity model (DPIMM) combines the two approaches to model the use of information by dental practitioners. We will start by defining three types of information activity:

• Information Technology: the technology associated with information: computers, wires, keyboards, etc. Contrary to popular opinion, whilst technology can really get in the way if it is not right, it cannot deliver benefits on its own

• Information Governance: the processes needed to ensure that you process information safely, securely and in accordance with best ethical and professional practice

• Information Management: the way you manage your information is crucial to gaining benefits from information. It is all about making sure that you have the right information in the right format at the right time and in the right place.

Each of these elements must be kept in balance with the others (Tables 3 and 4). Within our domain, the maturity levels are defined as follows.

Table 3 Three strands of information activity

Table 4 Maturity levels for the Dental Practice Information Maturity Model

In order to balance information technology, information governance and information maturity activities, the DPIMM model defines a distinct maturity for each strand. In an ideal world, the maturity level for each would be the same indicating balanced development. Problems will ensue if variations in maturity exceed one level between the strands.

The model itself has been developed through discussion with dental practice managers as part of an educational programme. The first strand to be considered is information technology, which is concerned with the technology, but also with the management processes required to manage the risks associated with the technology. For example, the audit items required to achieve level 1 maturity are:

1.1 Do you have a computer system in the practice?

1.2 Do all of the dentists in the practice have access to a computer system in the place where they deliver care?

1.3 Do you have a log of problems and errors with the systems?

1.4 Does the organisation use adequate virus protection software?

1.5 Do you back up all your data at least once a week?

1.6 Do you back up new information every day?

1.7 Is the system protected against an interruption in the power supply?

The model will define a maturity level, and define the tasks required to achieve the next level. Once the information technology maturity level is defined, next to be considered is information management maturity. If it emerges lower than the IT maturity then the practice is not getting the best from your technology. If it emerges higher, then the practice is doing well, but as improvements in information management are facilitated by technology so further improvements may be inhibited by limitations in technology.

Information management is key to achieving benefits. Benefits are derived not from the use of technology itself, but from the changes in working practices facilitated by better information and information management. Examples of benefits include more reliable recalls, faster and more reliable identification of target patients or groups and more reliable identification of risks to patient safety, such as drug allergies or interactions.¹⁴

The final maturity audit is for information governance. As the use of information increases in both activity and complexity, so the governance issues increase. It is important to balance maturity in information management and technology with appropriate governance activity to keep patient data safe and prevent inappropriate release of data. For example, the use of SMS text messages to remind pages raises concerns over guaranteeing who receives the message.

This is not simply dental data; there are recorded cases of where information released in good faith about attendance for a routine appointment to a partner led to a significant complaint from a patient. The maturity model for information governance is organised into five maturity levels mirroring the levels of the other streams.

In professional liability terms, the fact that technology provides facilities for protecting data (access control, audits of user activity, backup facilities) means that failure to use these facilities leaves practices not using them properly in a worse position than those without them.

The maturity model is mirrored by the staff competency model, defined in terms of the approach pioneered by Benner¹⁰ and developed by Gillies and Howard.⁵ The model of proficiency is defined for each information competency area in terms of the scale shown in Table 5, and the level of proficiency defined for each staff role at each maturity level. A staff member whose own proficiency level matches or exceeds that required for their role is deemed to be proficient.

Table 5 Profi ciency scale used within DPIMM

The model copes with the fact the practice use of information is dynamic. As the practice becomes more mature in their use of information, then the skill levels required by staff will increase, and proficiency levels required to achieve competence increase. The model is defined for each strand of information-based activity and for four staff roles: dentists, nurses, manager, and admin staff. An example is shown in Table 6, showing proficiency levels for dentists in IT in a practice with level 1 information maturity.

Table 6 Required profi ciency values are stored for each role at each maturity level

The model is encapsulated within web-based tools which are available in the public domain.^14,15 The tool is embedded within a portal (http://www.it4dentists.com) designed to provide advice and guidance in improving practice information maturity.

Discussion

Information technology has met with limited enthusiasm from the dental community with perceived high costs and insufficient benefits to justify the expenditure.

In order to achieve benefits to justify the costs of investing in IT, dentists need to have a planned approach to implementation. In order to maximise the return on investment in the technology, it is necessary to match this with improvements in information management. It is also necessary to ensure that governance practice matures at a similar pace to protect against breaches in data protection and confidentiality.

Experience from other sectors has demonstrated that a maturity model plus staff proficiency model can facilitate change, maximise benefits and provide demonstrable evidence of these benefits. Use of a balanced approach around information technology, information management and information governance, together with matched staff competencies maximises the probability of achieving benefits.