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Teledentistry: the Why and the How

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Teledentistry: the Why and the How CLINICAL PRACTICE Implementing Teledentistry: The Why and the How By Lorri Detrick s the COVID-19 pandemic evolved, social distanc- n Asynchronous: The transmission of radiographs, ing became a primary strategy to mitigate the photographs, video, and digital impressions to a practitio- Aspread of infection. Doctors and their patients were ner through a secure electronic communications system. further separated when dental offices across the nation This information is then used to diagnose or provide a were asked to suspend nonessential and elective dental service. ATA defines asynchronous telemedicine as store-“ procedures. Although some states are beginning to gradu- and-forward transmission of medical images and/or data ally re-open businesses — including dentistry — the need because the data transfer takes place over a period of for social distancing due to the continued presence of CO- time, and typically in separate time frames.” Example: VID-19 is expected to be an ongoing realty for many Texted photos and videos or radiographs that are reviewed months. What the consumer demand for in-person, non- by the dentist at a later time. urgent dental treatment will be is unknown. Some predict n Remote patient monitoring (RPM): Collecting per- pent-up demand will overwhelm dental practices. Others, sonal health and medical data for an individual via elec- however, believe that fear of the disease may keep many tronic medical device technologies. The data are trans- from seeking preventive dental care. mitted to a different location (sometimes via a data Public health officials have called upon physicians and processing service) where a practitioner can access the dentists to maximize the use of telehealth as an alterna- data for monitoring conditions and supporting care deliv- tive to in-person visits. Although teledentistry may not ery. Example: Diabetes management via real-time delivery have been high on a list of priorities prior to the pandem- of blood glucose, weight, and blood pressure data. ic, a combination of these and other factors makes a com- n Mobile Health (mHealth): Health care education, pelling reason why it should be now. As dentists begin to practice, and delivery done over mobile communication re-open for business, a new normal will exist, and tele- devices, such as cellphones, tablet computers, and per- dentistry will be an important part of it. sonal digital assistants (PDAs). Example: Video education around specific oral health topics and/or dental procedures. What is teledentistry? In teledentistry, a provider in one location uses tele- How is teledentistry evolving? communications to deliver care to a patient at a distant Teledentistry has primarily been a tool to drive access site. It is a component of telehealth, where electronic and to care in underserved areas. The pandemic has dramat- telecommunications technologies are used to provide ically changed that. Now, teledentistry has become a hu- care and services at-a-distance. Telehealth involves a manitarian tool essential to our overall health care eco- broad scope of remote health care, including patient edu- system. The Health Policy Institute of the American cation and engagement. Dental Association estimates that in normal circumstanc- Teledentistry consists of various modes of delivering es (i.e., pre-COVID-19), someone visited an emergency oral healthcare services or oral health education from a department (ED) every 14 seconds for a dental condition. distance, such as: In our current climate, to ease the burden on EDs, den- n Synchronous: Live, two-way interaction between a tists have been enlisted to triage the treatment of these person (patient, caregiver, or provider) and a provider patients through teledentistry. Patients can be screened using audiovisual telecommunications technology. The via video chat or text chat with photos. Antibiotics can American Telemedicine Association (ATA) defines syn- be prescribed for infections to delay the need for emer- chronous telemedicine as “interactive video connections gent treatment. Treatment is then scheduled for in-per- that transmit information in both directions during the son visits away from the ED, at a dentist’s office. Many same time period.” Example: Live bi-directional video chat. (Continued on Page 38) 36 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 “As clinicians reengage with patients they should maximize the use of telehealth to determine if an in-person visit is necessary” —Dr. Joneigh Khaldun, Chief Medical Executive, MDHHS This quote comes from a letter from the Michigan Department of Health and Human Services to Michigan Clinicians — May 3, 2020. dentists have played a critical role in the overall public What drivers are promoting the implementation of health response to the crisis by reducing the load placed teledentistry? on front-line health care workers. In response to COVID-19, the Office of Civil Rights has Most significantly, with offices closed or operating relaxed HIPAA restrictions for the implementation of tele- with fewer staff members and a limited schedule, den- dentistry. Technology applications such as Zoom and tists are using teledentistry to efficiently assess a pa- Facebook Messenger video chat have been specified as tient’s needs and to determine if an in-person visit is nec- acceptable options to use for remote patient communica- essary. Social distancing is maintained by limiting the tion. Penalities for HIPAA violation are being waived, and need for office visits. This has proven to be an effective Business Associate Agreements are no longer required. way to maintain patient contact, address many routine Most dentists are now able, from a technology perspec- needs, and create patient satisfaction. tive, to begin providing teledentistry immediately using a The impact of this surge in utilization of teledentistry smartphone, tablet, or laptop. may have a lasting impact on its long-term use. Prior to Teledentistry facilitates compliance with CDC guid- the pandemic, the use of smart phones and tablets for ance on social distancing and pre-screening of patients taking photos and holding face-to-face chats was widely during the COVID-19 crisis. Patients can complete forms adopted. Many in business were using remote conferenc- remotely for touchless import into the patient’s record. ing technology. During the pandemic, the use of these Postoperative evaluations, consultations, treatment plan tools has exploded throughout society as we all try to presentations, and case management can each be con- keep connected. Our patients are now at ease using ducted without an additional office visit. these methods of communication and they will likely ex- Teledentistry will never replace hands-on, in-person pect to use them in the future. Patient demand for the dentistry. However, our collective society will expect the ability to interact with dental service providers through convenience and safety of digital interaction going forward. text and/or video chat, may make it difficult for payers People will be encouraged to social distance for months, if and regulators to dial back benefit coverage and require- not longer. Those who are aging or have chronic conditions ments for use of teledentistry to pre-pandemic levels. that make them at higher risk will surely re-enter main- Flowchart — Teledental Emergency Flowchart for COVID-19 Impacted Dental Coverage By phone, telehealth, video, as approved Bill Code: Initiate Patient-DMD/DDS/RDH D9995 Teledental Encounter (D9996 only if Bill Code: asynchronous) Limited use: D0350 Access, review, update and/or Initiate triage protocol Collect records via interview, create pt. record, med hx (ADA, CDC, etc.) patient photos/video Include COVID-19 Screening Follow current state Bill Code: orders and CDC/ADA Limited use: D0XXX Conduct salivary- Use most based antigen or current ADA recommendations antibody test when guidance or triaging appropriate and screening Bill for patients procedures provided Flow chart courtesy of In DMD/DDS office — follow current Refer to medical professional or DentaQuest Partnership for CDC/ADA guidance to minimize need ED only if warranted Oral Health Advancement. for aerosol-producing procedures www.DentaQuestpartnership.org 38 JOURNAL OF THE MICHIGAN DENTAL ASSOCIATION • JUNE 2020 stream life cautiously. Maintaining patient contact may be Technology. In the short term, relaxing of HIPAA re- further challenged with unemployment at unprecedented strictions has permitted use of existing technology to ad- levels. Taking time away from work will be more prohibi- dress an urgent need. There likely will come a time when tive than ever. Offering teledentistry is a compassionate patient privacy concerns and HIPAA requirements will way to address these concerns and expand on face-to-face return to pre-pandemic status and technologies selected care. for the short term may need to be replaced. Desirable fea- Digital connectivity increases dental office accessibili- tures to look for in teledentistry solutions include the ty and helps maintain relationships, which in turn fosters ease of integration with patient records, practice man- loyalty to the practice and promotes patient retention. agement/billing software, imaging systems, laboratory Teledentistry provides opportunities beyond emergency intractability, patient communication platforms, and fi- triage. Consumers and dental practices alike can benefit nancial reporting tools. Many software options are from its use for a wide range of services that can
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