Development of a general information system for dental and oral disease targeting electronic medical record.

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A major breakthrough in medical field has been progressed including information technology and standardization of medical term and data exchange protocol. However, its development has been more slowly in dental field than in common medical field. From such a background, we had been tried to examine the method of digitization and standardization of dental region, and to construct total information system trying for electric health record (EHR) of dental hospital and/or clinic for the purpose of providing advanced and efficient dental health care services.Summary of the research and the results were as follows.1) For the EHR platform named "DEXR", ready-made dental insurance claim system for personal clinic had been introduced in our hospital for the purpose of training for accurate and efficient description of clinical record.2) The DEXP was improved by adding rich-text editor for SOAP description and image filing viewer. The improved DEXP has satisfied for general dental clinic use as … More EHR.3) The improved DEXP was connected to hospital information system, imported patient's data from ordering database and exported disease and treatment data to hospital claim system.4) Among three requirements for EHR in Japan (authenticity, readability and availability), authenticity was achieved to encoding daily backup data by electric signature.5) EHR based on dental insurance claim system may be reasonable and agreeable method for developing dental EHR system.6) Standard dental disease master corresponding to the ICD-DA and standard dental treatment master have been worked out at MEDIS-DC. Unfortunately, formal version was not released in the research period, so that we could not adopt the standard master to our EHR system.7) As to data exchange between different dental EHR or hospital information system, we have tried to use XML schema as lower class of data exchange format. It must be standardized medical term and upper class of data exchange format (e.g. HL7, DICOM or MERIT-9). Less