Teledentistry

The digital transformation of oral health care. Teledentistry and electronic commerce.
Bauer JC, Brown WT
J Am Dent Assoc 2001 Feb 132:204-9

BACKGROUND: Health care is being changed dramatically by the marriage of computers and telecommunications. Implications for hospitals and physicians already have received extensive media attention, but comparatively little has been said about the impact of information technology on dentistry. This article illustrates how the digital transformation will likely affect dentists and their patients. CONCLUSIONS: Based on recent experiences of hospitals and medical practices, dentists can expect to encounter revolutionary changes as a result of the digital transformation. The Internet, the World Wide Web and other developments of the information revolution will redefine patient care, referral relationships, practice management, quality, professional organizations and competition. PRACTICE IMPLICATIONS: To respond proactively to the digital transformation of oral health care, dentists must become familiar with its technologies and concepts. They must learn what new information technology can do for them and their patients and then develop creative applications that promote the profession and their approaches to care.

Practicing dentistry in the age of telemedicine.
Golder DT, Brennan KA
J Am Dent Assoc 2000 Jun 131:734-44

BACKGROUND: This article examines teledentistry and some of its current legal issues. Topics include licensure, malpractice, technology and ethics. General recommendations for the dental practitioner are included. The literature review includes state and federal laws, the Telemedicine Report to Congress and numerous articles (both printed and electronic) associated with the topic. Sources were selected for timeliness and relevance to legal issues and implications of telemedicine/teledentistry for the dental practitioner. CONCLUSIONS: Numerous issues require resolution before telemedicine and teledentistry will truly realize their enormous potential to increase access to health care while decreasing health care costs. These issues include interstate licensure, jurisdiction and malpractice, as well as technological, security and ethical questions. PRACTICE IMPLICATIONS: Telemedicine and teledentistry are relatively new to the dental field. Many of the legal issues reviewed have yet to be resolved by the legislature or the courts. Furthermore, technology has not yet progressed to the point where the practitioner can be certain that no technological failure will occur during a teledental consultation. In spite of these problems, the potential of telemedicine and teledentistry is tremendous. Improvement in accessibility of health care and lowered health care costs are only two of the many advantages that will emerge as telemedicine and teledentistry become integrated with, and fundamentally change, the practice of medicine and dentistry.

The future of teledentistry.
Birnbach JM
J Calif Dent Assoc 2000 Feb 28:141-3

Teledentistry is a rapidly forming subset of telehealth, a field that already has considerable impact on the health care industry. Recent advances have created new opportunities for teledentistry, and changes in diverse technologies have created new tools for the practitioner. Technologies currently available are beginning to change the dynamics of dental care delivery. As teledentistry evolves, it will offer new opportunities to improve the level of patient care and reshape current business models

Teledentistry: what is it now, and what will it be tomorrow?
Clark GT
J Calif Dent Assoc 2000 Feb 28:121-7

A few years ago, teledentistry involved calling an expert on the telephone for advice. Now it involves consulting experts using the Internet. This article explains the basic ideas underlying teledentistry. It involves the local dentist digitizing and electronically transmitting drawings, diagrams, photographs, and X-rays to a specialist. Along with these data, the dentist will most likely need to fill out a standard consult form from the specialist's Web site. In return, the specialist will develop and return a confidential consultation report to the dentist or physician requesting help. For this service, a time-based fee will be paid to the expert. Unfortunately, it is likely that some doctors will use the Internet to set up and seek direct patient contact, thus becoming "cyberdentists." In most cases, cyberdentistry will not be in the best interests of the public. However, teledentistry should not only be a practice builder for the local dentist, but also has the potential for helping dentists better serve their patients while increasing their own knowledge.

Computer-based oral health records on the World Wide Web.
Schleyer TK, Dasari VR
Quintessence Int 1999 Jul 30:451-60

Recently, the World Wide Web has emerged as a platform for computer-based oral health records. Web-based patient records can make teledentistry an instant reality. Because an increasing number of dental care providers can access Web pages, traditional barriers to exchanging information are dropping. Web-based records also make cumulative, longitudinal patient records possible. Sophisticated security mechanisms can ensure the integrity and confidentiality of patient information. Because Web-based systems are simpler to install and configure, the cost of operating them may be reduced. However, their development is complex, difficult, and expensive because the Web was not developed as a programming environment. Furthermore, the technologies underlying the Web are constantly evolving, forcing developers to continuously reengineer their systems. In addition, several policy questions, such as storage of and access to computer-based patient records, have to be answered. This article describes CMSWeb, a Web-based clinical information system implemented at Temple University School of Dentistry.

Smile for the camera: telemedicine comes to your local dentist's office.
Wheeler T
Telemed Today 1999 Feb 7:14-5, 42

Dentistry has faced the same access issues that have spurred telemedicine development in other fields. However, until recently dentistry has lagged behind in adopting telemedicine. The findings of the Association of Telemedicine Service Provider's (ATSP; www.atsp.org) 1998 Report on US Telemedicine Activity, done collaboratively with Telemedicine Today Magazine, are instructive. Of over 40,000 teleconsults among 139 U.S. programs performed in 1997, only 200 were dental teleconsults--all done by one program. Although that figure represents a significant increase over the 4 dental teleconsults reported in 1996, teledentistry has a long way to go. The first steps are now being taken. At the schools of dentistry at the University of California at Los Angeles and the University of Bristol in Bristol, England, two different approaches to teledentistry are being actively explored. Telemedicine Today spoke with lead researchers at each school to discuss these programs.

The evolution of a teledentistry system within the Department of Defense.
Rocca MA, Kudryk VL, Pajak JC, Morris T
Proc AMIA Symp 1999 :921-4

Total Dental Access (TDA) is the teledentistry project within the Department of Defense. This project enables referring dentists from the US Armed Forces to consult with specialists on the status of a patient. TDA focuses on three areas of dentistry: patient care, continuing education and dentist-laboratory communications. One of the goals of this project is to increase patient access to quality dental care. The other goal is to establish a cost effective telemedicine system. This paper describes the evolution of a teledentistry system, the main features of POTS-based, ISDN-based and Web-based systems used, advantages, disadvantages and cost-effectiveness of these systems. Data has been collected on the frequency of use, technical problems occurred, avoided patient or specialist travel and the total number of consults. A cost-effectiveness analysis has been conducted on the data collected. The results of this analysis will be presented.

Teledentistry: Tackling issues of confidentiality on the Internet

Dr Vinod K Joshi writes about patient confidentiality for web-based referrals.

Dentists and patients have a right to expect that a teledentistry system is secure and will not violate their privacy in any way. The confidentiality of your information is always preserved and measures are taken to ensure that unauthorised interception can be prevented. Even if the transmitted information is intercepted, it cannot be read as it is encrypted. In the interest of confidentiality, your record is only kept online while you are a subscriber to the service. Historical data related to consultations made will be kept offline for the periods required by UK data regulations. Dental-Consults complies with the Data Protection Act 1998.

Dental-Consults is a web-based 'teledentistry' consultation system developed for use by dentists. The referring dentist logs into the secure web server, fills in the patient's details, specific reasons for consultation, chief complaints, and provisional diagnosis information and uploads intraoral images as well as dental radiographs.

The specialist is notified immediately of the new referral. The specialist subsequently logs into the secure web server and reviews the consult and suggests his diagnosis and treatment plan within five working days after receipt of the complete patient case. The referring dentist is then informed by email to retrieve this information. Further discussion, if required, is possible. When the consultation is completed, the dentist is invited to give feedback comments and is also given the opportunity to rate the ease of use and quality of the service.

It is the responsibility of the referring dentist to obtain patient consent before making on-line referrals. The patient must understand that the information will be stored electronically on a secure web server and that reasonable steps have been taken to ensure confidentiality.

The Dental-Consults teledentistry system uses Secure Sockets Layer (SSL) to encrypt the information that flows between your web browser (e.g. Microsoft Internet Explorer) and our web server receiving your referral. When the lock or solid key is showing, the browser has established a secure encrypted connection with the server, meaning it is safe to send sensitive data. An encrypted web-based referral is more secure than a conventional, paper-based referral. It is far easier for someone to intercept and read a paper-based referral letter! The consultants also access our web server via a secure connection with their browser. Confidentiality comes with SSL security during the transmission of patient information.

Unsecured emails, which are not encrypted, are only used for notification and confirmation alerts and never contain any patient identifying information.

The Dental-Consults web server is stored in a secure environment within our office, to which only authorized personnel have access. We do not share information with any third party. The server itself is password protected to restrict access to its data. The service is for registered dentists only and members are verified after a formal application; members are required to log on using a unique username and password. All Internet access to the web server is logged and monitored. The server also has a firewall that blocks and permits certain forms of data traffic; it acts as a filter to prevent unauthorised access to the server. It is far easier for someone to break into a dental practice and take paper-based patient records from a filing cabinet.

The referring dentist can identify a patient either by using initials, a pseudonym, a reference number or the real name of the patient. Patient confidentiality is increased by not using the real name. However this increases complexity. Unless the dentist has a brilliant memory, he will find it a headache to remember all his patients’ alias names. Using the real patient name is more convenient and also avoids the risk of confusion when patients share the same initials. Pseudonyms could be reserved for well-known patients. However, these names should not stick out like a sore thumb. It would be foolish for the referring dentist to identify these patients by a number, such as '123456', and draw attention. There needs to be a balance between functionality and the need for confidentiality.

It is illegal for anyone to gain unauthorised access to the server. In the event of an expert hacker bypassing all our layers of security and gaining access to our web server, it is unlikely that (s)he will publicise any patient information. Publication would make it easier to trace the hacker and an arrest could lead to a prison sentence. There is no financial benefit in hacking a teledentistry web server.

Internet shopping is safer than you think. A recent survey conducted by the MORI Social Research Institute for the DTI - Department of Trade and Industry - (www.mori.com/polls/2001/dti-e-commerce.shtml) found that 47% of the population were concerned about credit card fraud. The survey demonstrated that perceptions of security risks on the Internet turned out to be far worse than actual experience.

Among the Internet users, only 3% said that they had experienced card fraud on the net. Credit card fraud on the Internet is a mere trifle compared to the total credit card fraud. Most credit card crime on the Internet is due to unscrupulous merchants fraudulently using customer information. It is far easier for someone to get a job as a waiter in order to steal your credit card number when you pay the bill at a restaurant.

Dental-Consults does not store credit card details on its web server. We use Streamline, a trustworthy member of The Royal Bank of Scotland Group, to process all on-line credit card transactions. Our 'third-party' credit card payment system implements the highest of security measures.

Teledentistry: E-consultations

Dr Vinod Joshi describes the advantages of the newest use of the Internet: e-consultations.

Patients are becoming more knowledgeable and are demanding access to a full range of high quality treatment options. The quality of care that a dentist renders to a patient is often limited by his ability to make the proper diagnosis and formulate an appropriate treatment plan. The general dentist does a fine job providing routine care but possesses limited experience in treating unusual oral disease. When a dentist is unsure of the diagnosis, it is usually in the best interests of the patient for the dentist to seek another opinion.

'Teledentistry' allows for a whole new way of providing this specialist advice. Through the use of tele-communication and computer technologies, it is now possible to provide interactive access to specialist opinion that is not limited by the constraints of either space and time. This could not have been done even two years ago. The time is now as more and more practices become computerised and connected to the Internet. Many practices now have access to an intra-oral or extra-oral digital camera, which can be used to support treatment plan acceptance for their private patients. Most dentists have thus acquired the kind of skills needed to take advantage of this form of electronic consultation.

DENTISTRY MAGAZINE ARTICLE 9 February 2002 Teledentistry: E-consultations Dr Vinod Joshi describes the advantages of the newest use of the Internet: e-consultations. Patients are becoming more knowledgeable and are demanding access to a full range of high quality treatment options. The quality of care that a dentist renders to a patient is often limited by his ability to make the proper diagnosis and formulate an appropriate treatment plan. The general dentist does a fine job providing routine care but possesses limited experience in treating unusual oral disease. When a dentist is unsure of the diagnosis, it is usually in the best interests of the patient for the dentist to seek another opinion. If you are the typical dentist, you refer to the nearest consultant at the nearest hospital and hope that your patient will be seen soon. It is not uncommon for patients to wait 6-12 months to be seen by a specialist. A problem also arises when the specialist is far removed from the referring dentist. In some cases, due to a multitude of factors, the dentist may not be able to obtain a consult. When this happens, the quality of patient care can, and does, suffer. It would be nice to have easier access to specialist advice on a personal basis. A new approach 'Teledentistry' allows for a whole new way of providing this specialist advice. Through the use of tele-communication and computer technologies, it is now possible to provide interactive access to specialist opinion that is not limited by the constraints of either space and time. This could not have been done even two years ago. The time is now as more and more practices become computerised and connected to the Internet. Many practices now have access to an intra-oral or extra-oral digital camera, which can be used to support treatment plan acceptance for their private patients. Most dentists have thus acquired the kind of skills needed to take advantage of this form of electronic consultation. In 2001, bolstered by significant activities on the Internet and substantial technological resources, Dental-Consults embarked on a mission to create a world-class tele-consultation service for dentists. Dental-Consults aims to be the leading provider of fee-based dental consultation services. Wherever the practice, the dentist can now have access to a specialist opinion, for diagnosis, treatment planning and education through the Internet. The dentist will be able to save the patient the time and cost of travelling and be able to provide a faster and better quality of service. Distance and specialist availability are no longer a barrier.

The Dental-Consults system enables referring dentists to send a consult, including dental images and radiographs, for a specialist second opinion via the world-wide web. The referring dentist logs into a secure web-server, fills in the patient's details, specific reasons for consultation, chief complaints and provisional diagnosis information and attaches digital intra-oral images and scanned-in or digital dental radiographs. The specialist is notified immediately of the new referral. The specialist subsequently logs into the secure web server, reviews the consult and suggests his diagnosis and treatment plan within five working days of receipt of the complete patient case. The referring dentist is then notified by email to retrieve this information. Further discussion, if required, is possible.

Dental-Consults makes the process of getting a specialist opinion as easy as possible, with the dentist’s patients thinking of the referral as an extension of the dental office. Every small portion of the process would be considered by the patient as a demonstration of the dentist’s care and desire to provide quality dental service that is in tune with their dental needs. The dentist can even make a referral while the patient is in the chair and have a treatment plan ready for when they return the following week. It would be like having a backroom specialist in the practice.

This new mode of consultation will become much more than a mechanism to provide advice to a dentist in practice. It will facilitate interaction between the generalist and the specialist. It will allow the dentist to improve his skills and knowledge during the interaction with the dental specialist, who will be able to provide remote support and guidance as a 'tele-mentor'.

Most forms of CPD today aim to educate the dentist by providing general breadth and depth in a chosen subject. The problem with this form of CPD is that the dentist then has to decide how to apply a 'text book' technique to real life patients, with their different dental and medical histories. It could be said that such CPD improves the dentist’s knowledge but it may not improve the patient’s treatment.

Teledentistry helps the dentist to treat each patient, taking into account their individual needs and unique medical and dental histories. Each patient is different so the treatment plan or specialist advice will always be different. The referring dentist has the added benefit of an 'on the job' training effect through the interaction between the general practitioner and the specialists.

The dentist will continue to develop his skills and knowledge through an exciting, one-to-one interactive course that allows the dentist to establish a rapport with the consultant. It helps the dentist to avoid being overwhelmed by the information explosion and save time that might have been spent acquiring information that may never be used. It is a more meaningful, more effective and better investment for dentists.

Since the specialist has not seen the patient, he cannot truly diagnose the patient. He can only provide an opinion as to what the problem is likely to be and, based on this proposed diagnosis, provide the dentist with recommendations for the most common treatments of this problem. Where they are available, the dentist will be sent the scientific information (e.g. reference citations and abstracts) underlying the suggestions made during the consultation. The advice is based solely on the information that the dentist provides as part of the consultation and this is acknowledged in the consent form that should be printed out and completed by both the dentist and the patient. The referring dentist remains responsible for the patient's primary diagnosis and is responsible for evaluating the report and communicating any information in the report to the patient. For our system to work effectively, the referring dentist must ensure that all the necessary clinical information is contained in the original record. This is relatively easy to achieve in routine cases. However, in unusual and complex cases, it is more appropriate for the patient to have a face-to-face consultation and we would suggest this.

The essence of diagnosis and treatment planning is experience and this can only be obtained by spending time under the supervision of senior people.

Dental-Consults' specialist advice is given by accredited consultants who have this experience. As the dentist clients gain experience, it is expected that the number of referrals they will need to make will decrease. This will be a measure of the system's success.