Medical Record Department, College of Health Sciences, Public Authority for Applied Education and Training, Kuwait
Henry WW Potts
UCL Institute of Health Informatics, University College of London, London, UK
Noura Hassen Alajmi
Oral and Dental Health Department, College of Health Sciences, Public Authority for Applied Education and Training, Kuwait
Rihab Abdullah Alwatayan
Central Department of Primary Healthcare, Ministry of Health, Kuwait
Received date: December 15, 2017; Accepted date: December 21, 2017; Published date: December 28, 2017
Dental informatics; EDRs; Dentists; Primary care; Kuwait
EDRS: Electronic Dental Records; HITS: Health Information Technology System; EHRS: Electronic Health Records; ADA: American Dental Association; USA: United State of America
Many dentists are not familiar with health informatics systems or how they relate to clinical practice , even though health informatics applications are known to enhance the quality of healthcare delivery and improve the workflow of clinical practitioners . Electronic patient record systems are an element of health information systems (HITS), covering software and hardware (e.g. computers, digital X-ray processors, printers) and electronic health records (EHRs).
In the early 1990s, the American Dental Association (ADA) began collaborating with other associations to create specific computerized dental records like those used in other healthcare settings. They established a Standards Committee for Dental Informatics to promote patient dental care using information technology for clinical and administrative aspects of dental clinics, to develop specifications and guidelines for computer equipment and facilitate information exchange throughout the healthcare system . In 1995, the Institute of Medicine produced a report calling for more integration between medicine and dentistry . In 2001, Schleyer and Spallek  discussed the potential of informatics systems for practicing dentists, citing the benefits of monitoring oral disease trends and clinical data. However, the uptake of electronic recording systems in healthcare is slow [6,7] and this is associated with negative perceptions of clinicians. The Kuwaiti Ministry of Health recognized the need for an accurate, national HIT for recording data, generating accurate statistics, assisting with treatment planning, evaluation and decision-making, and facilitating high-quality care. They developed various schemes to improve healthcare quality in primary, secondary and tertiary care and HITS are now used in every primary healthcare center in Kuwait. The entire care process is automated across physician, dental and nursing pathways, and laboratories and pharmacies .
The objectives of this study were to assess the perceptions of dentists in Kuwait about using electronic dental records (EDRs), to analyze their opinions on the functionality of these systems and their value for accessing and sharing patient information, as well as the major obstacles to their adoption in routine practice.
Subjects and methods
This cross-sectional national survey was conducted during November and December 2016. The total number of dentists in Kuwait was 511. A power calculation using a finite population correction showed that to achieve a 95% confidence interval of ± 5% for a binary outcome with a proportion of 50%, a sample size of 220 was required. This did not adjust for a cluster sampling design, as we considered the intra-class correlation would be negligible. Based on a likely response rate, we decided to distribute 300 questionnaires to practicing dentists from randomly selected clinics in Kuwait’s five healthcare regions (Ahmadi, Capital, Farwaniya, Hawalli, Jahra).
The self-administered questionnaire was developed by referring to similar published studies [9,10] and the authors’ experience. It consisted of two sections, the first relating to socio-demographic factors. The second comprised 44 statements designed to elicit opinions about the benefits, features and functionality, obstacles of EDRs. Each statement required a response on a three-point Likert scale. After piloting the first draft on eight dentists, the adjusted questionnaires were delivered by hand, in sealed envelopes, together with a consent form that explained the purpose of the study and assured participants of confidentiality. They were collected by hand one week later.
The first section of the questionnaire yielded binary and categorical data for demographic factors and background variables. The statements yielded ordinal data, which were analyzed by multivariable analysis, Kruskal-Wallis tests, Mann-Whitney tests and Spearman’s correlations, as appropriate.
Of 300 questionnaires, 247 were returned (a response rate of 82%) from all five healthcare regions (50 from Ahmadia, 54 from Capital, 56 from Farwaniya, 55 from Hawalli, 32 from Jahra). There were 1-8 dental clinics in each healthcare center (median 3; interquartile range 3–4). Three questionnaires had missing data.
Of the participants, most were male (58%; 143/247) and most were Kuwaiti (72%; 178/247). Their median age was 30-39 years (109 were 29 or less, 77 were 30-39, 33 were 40-49 and 28 were 50+). The years of experience they had in dentistry was 1-40 years (median 5; interquartile range 3-11). They worked each day for 1-12 h (median 6; interquartile range 6-7); 91% worked 6-8 h per day, 6% worked less than this, and 2% worked more.
Dentists’ views and experience of using electronic dental records
There were already fully implemented EDR systems in 112 (45%) of the clinical facilities in our sample. Another 105 (43%) had partially implemented systems and 30 (12%) had no system. When asked if there is a need for patients’ dental records to provide and/or organize effective medical care, just five dentists (2%) said no. When asked about the bidirectional flow of patient medical information between dental practitioner and general doctors/pharmacists, 167 respondents (68%) thought it was “very significant”, 77 (31%) thought it was “moderately significant” and 3 (1%) responded that it is “not significant”.
When asked whether patients need to have access to their records, 113 respondents (46%) said they need complete access, 79 respondents (32%) said they only need partial access and 42 respondents (17%) said patients need no access, with 12 responding that they did not know (5%) and one missing response. Patient referrals were made daily by 130 (53%) clinics, weekly by 86 (35%) and monthly by 31 (13%). Most of dentists (144; 59%) prefer to made referral electronically; 41% (100) prefer manually.
Perceptions about the benefits of EDRs
Table 1 shows the responses to various questionnaire statements (14-27) about the potential value of EDRs. Overall, the participants were very positive about the benefits of EDRs; over two-thirds “agreed” with all statements except for “decrease office expenses” and “increase number of patients”.
|Statements on questionnaire||Likert-scale responses|
|Benefits of EDRs||Disagree||Neither||Agree|
|14||Increase dental practitioner efficiency||8 (3%)||16 (6%)||223 (90%)|
|15||Improve dental diagnosis, planning and treatment||2 (1%)||23 (9%)||222 (90%)|
|16||Increase dental practitioner productivity||6 (2%)||38 (15%)||203 (82%)|
|17||Reduce the time to transfer records||8 (3%)||27 (11%)||212 (86%)|
|18*||Decrease office expenses||9 (4%)||79 (32%)||158 (64%)|
|19||Improve communication between the dental practitioner and other doctors||4 (2%)||17 (7%)||226 (92%)|
|20||Improve communication between the dental practitioner and the patient||10 (4%)||53 (21%)||184 (74%)|
|21||Improve dental record quality||2 (1%)||17 (7%)||228 (92%)|
|22||Improve management of the appointment system||8 (3%)||36 (15%)||203 (82%)|
|23||Increase access to shared patient information||4 (2%)||26 (11%)||217 (88%)|
|24||Increase the number of patients seen by the dental practitioner||47 (19%)||88 (36%)||112 (45%)|
|25||Reduce dental record storage requirements||12 (5%)||60 (24%)||175 (71%)|
|26||Protect the dental practitioner from being exposed to blood-borne diseases (e.g. AIDS, hepatitis)||16 (6%)||43 (17%)||188 (76%)|
|27||Increase patients’ satisfaction||8 (3%)||57 (23%)||182 (74%)|
|Usefulness of functions of EDRs||Not at all||Somewhat||Very useful|
|28||Storing clinical/digital records||2 (1%)||36 (15%)||209 (85%)|
|29||Electronic referral forms||6 (2%)||47 (19%)||194 (79%)|
|30||Paperless charting||3 (1%)||23 (9%)||221 (89%)|
|31*||Digital photography||11 (4%)||63 (26%)||173 (70%)|
|32*||Electronic/virtual models||8 (3%)||59 (24%)||180 (73%)|
|33||Storing clinical/digital records||12 (5%)||44 (18%)||190 (77%)|
|34||Electronic referral forms||13 (5%)||63 (26%)||170 (69%)|
|Importance of various features of EDRs||Disagree||Neither||Agree|
|35||Oral health status form||0||24 (10%)||223 (90%)|
|36||Medical history form||1 (<1%)||5 (2%)||241 (98%)|
|37||Patient booking management system||19 (8%)||69 (28%)||159 (64%)|
|38||Treatment plan form||2 (1%)||24 (10%)||221 (89%)|
|39||Dental radiographic images/films||0||15 (6%)||232 (94%)|
|40||Oral health examination list form||2 (1%)||44 (18%)||201 (81%)|
|41||Periodontal form||1 (<1%)||50 (20%)||196 (79%)|
|42||Dental and medical alerts (e.g. patient allergies, recent number of X-rays, blood-borne disease list)||0||19 (8%)||228 (92%)|
|43||Oral health progress notes||1 (<1%)||45 (18%)||201 (81%)|
|44||Oral health diagnosis||0||31 (13%)||216 (87%)|
|45||Extra-oral images||7 (3%)||62 (25%)||178 (72%)|
|46||Patient education form (e.g. instruction before and after tooth extraction)||8 (3%)||45 (18%)||194 (79%)|
|Value of accessing/sharing EDR information||Disagree||Neither||Agree|
|47||With general physicians||3 (1%)||40 (16%)||204 (83%)|
|48||With other dental practitioners||0||9 (4%)||238 (96%)|
|Obstacles to using EDRs||Disagree||Neither||Agree|
|49||Technical training||57 (23%)||53 (21%)||137 (55%)|
|50||Dental practitioner resistance to use of the system||66 (27%)||75 (30%)||106 (43%)|
|51||Incompatible software or hardware||33 (13%)||74 (30%)||139 (57%)|
|52||Cost of equipment||61 (25%)||101(41%)||85 (34%)|
|53||Work legislation (laws/policy)||62 (25%)||95 (38%)||90 (36%)|
|54||Unclear instructions and guidelines of how to use the system||44 (18%)||78 (32%)||125 (51%)|
|55||Confidence with technology||59 (24%)||77 (31%)||111 (45%)|
|56||Security or privacy issues||67 (27%)||64 (26%)||116 (47%)|
|57||Maintenance issues||32 (13%)||55 (22%)||160 (65%)|
*One participant failed to respond to these statements
EDR: Electronic Dental Record
Table 1: Statements on the questionnaire and number of dentists responding to those statements.
We produced a total score for each participant by combining their responses to statements 14-27, whereby “Agree”=+1, “Disagree”=-1, and “neither”=0. The total scores varied from -14 (“Disagree” on all items) to +14 (“Agree” on all items) (median score 11; interquartile range 9-13; modal score 14 (24%)). Only 2 participants had overall negative scores. Comparing the total scores with different demographic variables by Kruskal-Wallis testing, we found a significant difference between healthcare regions (χ2 (4)=12.0; p=0.017). Participants in Capital were the least positive about EDRs; those in Jahra were the most positive (Table 2). The median overall score of participants regarding the benefits of EDRs were as follows: Capital 10 (interquartile range 8-13), Farwaniyai 12 (interquartile range 8.5-14), Ahamdia 11 (interquartile range 9-14), Hallwaii 11 (interquartile range 8-12) and Jahra 12 (interquartile range 12-13.5). Using post hoc Mann-Whitney tests, we determined that the participants in Jahra had statistically significantly more positive perceptions than those in most other regions, and marginally greater positive perceptions than those in Farwaniyai. There were no other significant differences. There was also no difference in the total scores 57 in terms of nationality (Mann-Whitney test z=0.5; p=0.6) or gender (Mann–Whitney test z=0.6; p=0.5). There was a small but significant association with years of experience (Spearman’s correlation r=0.18; p=0.005), whereby participants with more experience had more positive perceptions about EDRs; and with age (Spearman’s correlation r=0.16; p=0.014), whereby older participants were more positive. Age and years of experience were highly correlated (r=0.82; p<0.0001).
Table 2: Post hoc tests comparing views of electronic dental records (EDRs) by region (figures in bold are significant).
Using a parametric model, multivariable analysis of all demographic variables (region, gender, age, nationality and years of experience) was performed to predict overall scores, but was just below the level of significance (F8, 237=1.9; p=0.055). No correlation was found between total scores and hours worked (Spearman’s correlation r=0.02; p=0.7), the number of clinics in individual health centers (Spearman’s correlation r=-0.04; p=0.5), the degree of local implementation of EHRs (Spearman’s correlation r=0.10; p=0.10) or for valuing patient access (Spearman’s correlation r=0.09; p=0.2). We also evaluated how participants’ perceptions about patient access varied in statements 15, 17, 19, 20, 21, 22, 23, 24 and 27 (Table 3). There were some insignificant correlations, but those who agreed that electronic records can “improve communication between the dental practitioner and patient” had more positive perceptions about patient access.
|Statement||Correlation with views on patient access|
|15||Improve dental diagnosis, planning and treatment||0.05||0.4|
|17||Reduce the time to transfer records||0.07||0.3|
|19||Improve communication between the dental practitioner and other doctors||-0.04||0.6|
|20||Improve communication between the dental practitioner and the patient||0.19||0.003|
|21||Improve dental record quality||0.07||0.3|
|22||Improve management of the appointment system||0.11||0.11|
|23||Increase access to shared patient information||0.10||0.11|
|24||Increase the number of patients seen by the dental practitioner||0.08||0.2|
|27||Increase patients’ satisfaction||-0.05||0.4|
Table 3: Correlations between participants’ perceptions about patient access and other issues about electronic dental records (EDRs).
Perceptions about the functionality and other features of EDRs
The “usefulness” of EDRs was assessed using a Likert scale for the responses “Not at all”, “Somewhat” and “Very” (Table 1). Participants considered that all functional aspects of EDRs were very useful. We constructed a total “usefulness” score by combining Likert scores (“Not at all”=0, “Somewhat”=0.5, “Very”=1) for all items. The scores varied from 0.5 (“Not at all” on most items and “Somewhat” on one item) to 7 (“Very” on all items). The median score was 6.5 (interquartile range 5.5-7; modal score 7 (44%)). Comparing total usefulness scores against demographic variables, we found no significant differences between regions (Kruskal-Wallis test χ2 (4)=9.2; p=0.056) or nationality (Mann-Whitney test z=-0.1; p=1.0). There was no significant correlation with years of experience (Spearman’s correlation r=-0.05; p=0.5) or age (Spearman’s correlation r=-0.03; p=0.6), or gender (Mann-Whitney test z=0.4; p=0.7) or hours worked (Spearman’s correlation r=-0.02; p=0.7) or the number of clinics in each health center (Spearman’s correlation r=0.02; p=0.7) or the degree of local implementation (Spearman’s correlation r=0.04; p=0.5) or opinions on patient access (Spearman’s correlation r=-0.07; p=0.3).
Responses about the importance of specific features of EDRs are also shown in Table 1. The most positive responses were to the statements regarding the function of EDRs as medical history forms (98%; 241), for storage of dental radiographic images (94%; 232) and for dental and medical alerts (92%; 228). Least important was the booking-management system. We compared responses to this statement with several other items: level of electronic dental record implementation (Spearman’s correlation r=-0.12; p=0.053), hours worked (Spearman’s correlation r=0.11; p=0.10) and the number of clinics (Spearman’s correlation r=-0.05; p=0.4), but found no statistically significant relationship. Table 1 also shows that the majority of participants considered it useful to be able to access and share electronic records with other dental practitioners (96%; 238) and general physicians (83%; 204).
Perceptions about obstacles preventing the use of EDRs
Responses on obstacles to the take-up of EDRs are shown in Table 1. The largest were maintenance issues (65%; 160), incompatible software/hardware (57%; 139) and technical training (55%; 137). The responses to these statements were compared with demographic variables using Kruskal-Wallis tests for healthcare region, Mann-Whitney tests for nationality and Spearman’s correlation for years of experience. No significant relationships were found (Table 4), although one non-Kuwaiti dentist perceived dental practitioner resistance as being less of an obstacle (Table 5). We also compared overall perceptions about obstacles to usage of EDRs with the existing systems at the clinic and to working hours, using Spearman’s correlations (Table 6). Dentists working in clinics with higher levels of implementation regarded “practitioner resistance” as less of an obstacle. There was no significant correlation with the other statements. The perception of security or privacy obstacles was significantly greater among dentists who worked longer hours. No other items showed significant correlations.
|Items||Region||Nationality||Years of experience|
|Kruskal-Wallis test||Mann-Whitney test||Spearman’s correlation|
|49||Technical training||χ2(4)=7.8, p=0.098||z=0.4, p=0.7||r=0.06, p=0.4|
|50||Dental practitioner resistance to use the system||χ2(4)=6.5, p=0.2||z=-2.8, p=0.005||r=-0.02, p=0.8|
|51||Incompatible software or hardware||χ2(4)=5.8, p=0.2||z=-1.5, p=0.1||r=-0.06, p=0.3|
|52||Cost of equipment||χ2(4)=1.0, p=0.9||z=1.4, p=0.2||r=0.10, p=0.1|
|53||Work legislation (laws/policy)||χ2(4)=2.9, p=0.6||z=0.6, p=0.6||r=0.11, p=0.09|
|54||Unclear instructions and guidelines of how to use the system||χ2(4)=4.8, p=0.3||z=0.2, p=0.9||r=-0.05, p=0.4|
|55||Confidence with technology||χ2(4)=2.7, p=0.6||z=-0.5, p=0.6||r=0.02, p=0.8|
|56||Security or privacy issues||χ2(4)=3.8, p=0.4||z=1.1, p=0.3||r=0.02, p=0.8|
|57||Maintenance issues||χ2(4)=3.7, p=0.4||z=0.4, p=0.7||r=0.03, p=0.7|
Table 4: Comparison of responses to obstacles to using electronic dental records (EDRs) by region, nationality and years of experience (figures in bold are significant).
|Disagree||Neither agree nor disagree||Agree||Total|
|Kuwaiti||40 (22%)||53 (30%)||85 (48%)||178 (100%)|
|Non-Kuwaiti||26 (38%)||22 (32%)||21 (30%)||69 (100%)|
Table 5: Participants responding to “resistance” to using electronic dental records (EDRs) by nationality.
|Statement||EHR implementation||Hours worked|
|49||Technical training||r=-0.10, p=0.1||r=0.08, p=0.2|
|50||Dental practitioner resistance to use of the system||r=-0.19, p=0.0024||r=0.09, p=0.2|
|51||Incompatible software or hardware||r=0.02, p=0.8||r=-0.12, p=0.058|
|52||Cost of equipment||r=-0.03, p=0.6||r=0.11, p=0.075|
|53||Work legislation (laws/policy)||r=-0.06, p=0.3||r=0.11, p=0.10|
|54||Unclear instructions and guidelines of how to use the system||r=-0.02, p=0.8||r=0.01, p=0.9|
|55||Confidence with technology||r=-0.07, p=0.3||r=0.11, p=0.086|
|56||Security or privacy issues||r=-0.06, p=0.4||r=0.14, p=0.027|
|57||Maintenance issues||r=-0.07, p=0.3||r=0.05, p=0.4|
EHR: Electronic Health Records
Table 6: Comparison of responses about obstacles to uptake of electronic dental records (EDRs) and local clinic factors (significant differences in bold).
To our knowledge, this is the first study to assess perceptions of dental practitioners in Kuwait about the adoption of EDRs in clinic settings. Overall, the participants were very positive about their potential value and mostly supported the benefit of patients having (at least partial) access to their records. The participants agreed that the benefits include improvements in record quality, reduced times for transferring records, improved efficiency and productivity, management of appointment systems, storage of records, and reduced clinic costs. The benefits of most importance included better communication with other physicians and patients, and the ability to share patient information, to improve diagnosis, planning, treatment and patient satisfaction. They also supported the concept of preventing practitioner exposure to blood-borne diseases.
Several studies have shown that positive support from any workforce is necessary for successful uptake of electronic systems, yet this is frequently absent [6,11,12]. Our results in Kuwait are encouraging with respect to expanding the use of EDRs, and are consistent with findings from Canada , the USA and Scandinavia . According to Acharya et al.  most healthcare providers wish to access their patients’ dental records to optimize their medical care, and would welcome improved communication with dentists about their patients. One survey  revealed that physicians were also dissatisfied with the process of manual patient referrals to dentists, showing a preference for electronic referrals. In another study , patients expressed a wish to view their own medical and dental records, and both health workers and patients had positive attitudes to EHRs.
The dentists in our study considered the most important features of EDRs to be their multiple uses: for recording and communicating medical histories, treatment plans, examination lists, patient progress, medical alerts, diagnostic information, managing bookings and storing diagnostic images. Schleyer et al.  studied the value of clinical computing systems in dentistry, in terms of improved operational efficiency, data management and scheduling; another study  reported that dentists require a range of information on patients – on their complaints, symptoms, progress and treatment. This is reflected by our findings and those of other studies that show a clinical need for systems that enable exchange of information between physicians and dentists [14,16,19,20].
Our study revealed that the main obstacles preventing dentists from using EDRs related to issues with maintenance, software/hardware, technical training and guidelines. This aligns with other studies that cite issues with software, guidelines, and lack of comfort with the technology [19,21,22]. Two studies [23,24] indicate that a key barrier to large-scale implementation of health technology is the lack of well-trained practitioners in clinical and technical aspects, and when dentists use technologies at an early stage, the investment in costs and skills is high and the benefits are often not tangible . However, if they were to embrace technological developments more widely, the investment would be lower overall and the advantages more tangible. In this study, “practitioner resistance” was strongly associated with the level of currently implemented systems; dentists working in clinics with systems in place perceived resistance as less of a problem. This is reassuring, and suggests that resistance decreases as practitioners become more familiar with such systems, as backed up by a study of dentists in China , which revealed generally positive attitudes to computerization. The negative aspects of computerization can be amplified by non-users, but clear instructions can reduce resistance [26,27] and promote the concept that technology has tangible benefits if used more frequently. Other researchers report security and privacy as obstacles to the uptake of information technologies [21,22,28].
We have demonstrated that Kuwaiti dentists recognize the need for electronic patient records to optimize the quality of the care they deliver to patients, which should facilitate further uptake of EDR systems. Our participants generally had positive perceptions of EDRs, but identified some key obstacles to uptake, namely technical support and training. Our results show that most dentists in Kuwait value the potential to share EDRs with other healthcare providers and consider that EDRs add value to the care they deliver to their patients.
This study was approved by the Ethics Committee at the Ministry of Health in Kuwait. The paper has not been submitted elsewhere and the authors confirm they have no conflicts of interest.
This study represents an independent research without public or private financing.
The authors would like to thank all those who participated in this study, especially the respondents to the questionnaire and the directors of primary care centers’ for facilitating and supporting the data collection.
All Published work is licensed under a Creative Commons Attribution 4.0 International License
Copyright © 2018 All rights reserved. iMedPub Last revised : January 18, 2018