Telemedicine is used to describe the use of technology to facilitate communication and care between patients and health care providers in separate locations.1–4 Telehealth is a universal term that incorporates technologies that fall under telemedicine, but also transects dentistry, pharmacy, health education, counseling, physical therapy, behavioral health and home health.1,2,5–8 Telehealth employs innovative technologies, such as kiosks, website monitoring applications, mobile phone apps, wearable devices and video conferencing to provide care by permitting real-time, interactive communication between the patient and a practitioner located at a distant site.1,2,5,7,8
The efficacy of telehealth depends on hospitals, dental offices and medical offices converting from traditional paper patient charts to electronic health records (EHRs) that include both medical and dental information. Four modalities of telehealth utilize EHRs: synchronous (live video), asynchronous (store-and-forward transmission, or SFT), remote patient monitoring (RPM), and mobile health (mHealth).1,2,5
In simple terms, EHRs are a systematic, computerized collection of electronic health information.9–12 They allow multiple clinicians to view the same patient record simultaneously, which leads to increased interprofessional communication and more efficient care for the patient.12–14 In addition, interactive software linked to EHRs can be used to educate patients about proposed treatment and expected outcomes, as well as the progression of an untreated condition.14 To be considered multifunctional, EHRs must have at least two of the following: a list of all of the patient’s medications, a preventive care schedule, electronic prescribing capabilities, and medical alerts with respect to potential drug interactions.3,15
The pace of EHR adoption in the United States has been accelerating since the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, which made funding available until 2021 to encourage health care facilities and caregivers to adopt EHRs.3,13,15,16 To assist oral health professionals, the American Dental Association has established an online database called the Systemized Nomenclature of Dentistry. This allows providers to communicate patient information within EHRs using a universal method, thus transcending geography, platforms and care settings.3,12,16,17
The concept of telemedicine began in 1924 as a futuristic cover for Radio News magazine that depicted a physician consulting a patient via a television monitor and two-way radio.3,18 The idea of teledentistry was developed as part of the blueprint for dental informatics, which was drafted during a 1989 conference funded by the Westinghouse Electronics Systems Group in Baltimore.3,4 The birthplace of teledentistry as a subspecialist field of telemedicine can be linked to a 1994 military project of the U.S. Army Total Dental Access Project, which sought to improve care and communication between oral health professionals and dental laboratories.3,4,6,7,18–21 Since that time, acceptance and use of teledentistry throughout the profession have been determined by the preferred mode of communication, type of software and hardware used, and available internet connection.
COMMUNICATING VIA TELEHEALTH
Teleconsultation can take place via live video, SFT, RPM or mHealth.1–6,21–23 In particular, SFT refers to the collection and secure transmission of encoded information, including patient charts and images (e.g., intraoral or extraoral photos and radiographs) for review by a dentist or specialist for consultation and treatment planning.1–6,21–23 Several quantitative systematic reviews demonstrate the effectiveness of teledentistry for various specialties, including endodontics, oral surgery, orthodontics, pediatrics, periodontics and preventive dentistry.4,6,20,21,23 Because the patient is not present during SFT consultations, practitioners can share patient information with multiple providers.2–4,6,23,24 A third method, RPM, is used primarily for managing chronic illnesses from a distance, as patients can either be rurally located, hospitalized or home-based.1–6,21,22 The newest modality is mHealth, which includes web-based services supported by smartphones, tablets, wearable monitors and personal digital assistants that engage the patient through connective health apps.1,2,5,8,24 Besides allowing remote monitoring, apps can be used to send targeted text messages aimed at encouraging healthy behaviors or text alerts regarding disease status or medical emergencies.1,2,5,8,24
Various EHR software programs facilitate more efficient communication and reduced paper trail among providers, specialists and telehealth sites in rural or urban areas. These programs and apps allow:3,25–29
- Electronic claims management
- Patients to complete their registration and medical histories online
- Clinicians to record findings verbally
- The importing and exporting of images and findings into patient files
- Use of digital signatures or fingerprint technology to identify users
- Cloud-based back-up of patient records
- Use of mobile devices to access patient information
At present, most dental offices have the basic infrastructure needed for teledentistry: a desktop computer with substantial hard-drive storage and memory, a speedy processor, broadband high-speed connectivity, intraoral camera, digital X-ray capability, fax machine or scanner, and a webcam for video conferencing.
BEWARE THE BARRIERS TO ELECTRONIC HEALTH RECORDS
As ready as some oral health professionals may be to make the switch to electronic health records (EHRs), barriers exist for many others. The most obvious barrier is cost. When considering the start-up costs for both hardware and software, it’s no exaggeration that going digital is a massive financial undertaking.
Another barrier to adopting EHRs is lack of technological know how. For customers who lack computer skills or training — and who have no desire to learn these skills — shifting from paper to EHRs is simply not worth the required effort.
EHRs also require a significant initial investment of time. That’s because the practice will need to transition each patients’ paper records to digital form. Additionally, once patient health records are digitized, clinicians and staff must learn how to use the system.
For other practices, especially those you might label as “old school,” there may be psychological challenges — routine and comfort may trump the uncertainty of a new approach. Others may say that adoption of EHRs will reduce communication with patients, and therefore hinder relationships. Dental practices may also cite privacy concerns or organizational difficulties.
Dental sales reps are encouraged to known the many benefits provided by EHRs, so they are able to address the barriers and concerns pertaining to their adoption in the dental practice.
PROS AND CONS
Telehealth provides a unique way to overcome the barriers of geography to deliver long-distance treatment, clinical training and continuing education for dentists, dental hygienists, midlevel practitioners and advanced dental therapists at remote clinics.2–4,6–8,21–23 Its application is of great value in rural and urban underserved areas.2–4,6–8,21–23 As noted, the use of telehealth technology increases interprofessional communication, which will improve dentistry’s integration into the larger health care delivery system.3,19 Second opinions, referrals, preauthorizations and other insurance requirements can be realized quickly online with the use of real-time clinical images, thereby making dental care more efficient, resulting in a cost savings for dental offices, patients and third-party payers.3,6,20.22,23
In addition, teledentistry is expected to facilitate greater use of dentists and nondentist providers (such as dental hygienists or midlevel practitioners) in nontraditional settings, and is thereby likely to improve early diagnosis, triage, treatment and referral of patients.3,6,20,22,30,31 For dental and dental hygiene schools, teledentistry allows for the evaluation of patient information (with or without the patient present), permitting interaction and feedback between educators and students, thus improving students’ interprofessional and critical thinking skills.3,6,23
Although telehealth is being used nationally and internationally, barriers to adoption exist. These barriers include legal, financial and ethical concerns. For example, the use of teledentistry sanctions dental hygienists or midlevel practitioners in collaborative agreements to initiate treatment based on their assessment of a patient’s need (without a dentist on site); however, supervision levels vary from state to state, and this affects the services performed by nondentist clinicians using teledentistry in rural, urban and remote settings.3,22,31 Accountability, licensure, jurisdiction, liability, privacy, consent and malpractice are crucial issues to consider when establishing the foundations of a telehealth practice.1–4,6–8,18,19,21
The most significant barrier to nationwide telehealth adoption is the traditional system of state-by-state licensing, because there is no law to clarify the role of the teleprovider and his or her liability.3,18 Currently, several states have telehealth parity laws that seem to imply inclusion of telehealth services, while the federal Centers for Medicare and Medicaid Services permits hospitals and critical access hospitals to utilize a new process to credential and privilege telehealth providers that may conflict with state policies.1,2,8,32–34 The Department of
Veterans Affairs (VA) is the largest provider of telehealth services in the U.S. whose doctors are permitted to maintain one active unrestricted state license in order to practice in any VA facility in the states or territories.1,2,35
The cost of telehealth equipment has also been a matter of concern, and, presently, the cost for virtual teledental consultations is not being reimbursed by insurance companies.3,4,7 Ethically, patients must be made aware that their medical and dental information will be transmitted electronically and, through the use of mHealth apps, the possibility exists that the information will be intercepted, despite considerable efforts to maintain security through the enactment of the Health Insurance Portability and Accountability Act.2–4,6,8,18,19,36 Other challenges include the learning curve of using the telehealth system, bandwidth or internet availability in underserved rural or urban areas, telecommunication regulations and patient health literacy.
TERMS TO LEARN
Telemedicine: Describes the use of technology to facilitate communication and care between patients and health care providers in separate locations.
Telehealth: A universal term that incorporates technologies that fall under telemedicine, but also transects dentistry, pharmacy, health education, counseling, physical therapy, behavioral health and home health; employs innovative technologies, such as kiosks, website monitoring applications, mobile phone apps, wearable devices and video conferencing to provide care by permitting real-time, interactive communication between the patient and a practitioner located at a distant site.
Electronic health records: Also known as EHRs, refers to the systematic, computerized collection of electronic health information; utilized by four modalities of telehealth, including synchronous (live video), asynchronous (store-and-forward transmission, or SFT), remote patient monitoring (RPM), and mobile health (mHealth).1,2,5
Health Information Technology for Economic and Clinical Health Act: A law adopted in 2009 that has made funding available until 2021 to encourage health care facilities and caregivers to adopt EHRs.3,13,15,16
Systemized Nomenclature of Dentistry: An online database hosted by the American Dental Association that allows oral health professionals to communicate patient information within EHRs using a universal method that transcends geography, platforms and care settings.3,12,16,17
Store-and-forward transmission: SFT for short, this refers to the collection and secure transmission of encoded information for review by a dentist or specialist for consultation and treatment planning.
Remote patient monitoring: Also known as RPM, this telehealth modality is designed primarily for managing chronic illnesses from a distance.
Mobile health: The newest modality, widely referred to as mHealth, includes web-based services supported by smartphones, tablets, wearable monitors and personal digital assistants that engage the patient through connective health apps.
Center for Connected Health Policy: Sales reps can refer oral health professionals to cchpca.org to view an interactive policy map with the most recent telehealth-related information.
Among the states that have embraced telehealth technology, Alaska, Minnesota and California are at the forefront. Under Alaska’s Dental Health Aide Therapist (DHAT) program, for example, DHATs and most health care providers in Alaska’s Tribal Health System use telehealth technology. Apple Tree Dental in Minnesota is a nonprofit that operates five regional dental access programs in urban and rural areas of the state.3,37 Telehealth technologies link special care dental clinics with onsite clinics at schools, Head Start centers, group homes, assisted-living centers, nursing facilities, and other community sites for people facing physical, financial and geographical barriers.3,37 The Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco created a “Virtual Dental Home,” supported by EHRs and complete with a portable dental chair, laptop, digital camera, supplies to perform temporary restorations, and a handheld X-ray machine with which registered dental hygienists in alternative practice, registered dental hygienists working in public health programs, and registered dental assistants provide care to underserved populations in schools, nursing homes, community centers and Head Start centers.3,38
While use of telehealth technologies has not yet become an integral aspect of oral health care delivery, it is bound to play a larger role in the future. As such, dental sales reps should learn the basics of this technology and understand how it may change their clients’ wants and needs.
It is imperative that medical and dental providers support the use of telehealth by dental hygienists and midlevel practitioners in nontraditional settings, where access to care for underserved communities presents challenges. At the same time, dental and dental hygiene schools will benefit from the use of telehealth technology that fosters interprofessional learning and collaboration among providers from all disciplines.
That noted, several issues must still be addressed, including varying laws and jurisprudence regarding practitioner licensure and reimbursement. Currently, telehealth practices vary from state to state with regard to private insurance and Medicaid/Medicare reimbursement. Due to the dynamic nature of state telehealth policies, an interactive policy map with the most recent telehealth-related information can be found on the Center for Connected Health Policy website (cchpca.org). The future is dependent on federal and state laws designed to help telehealth interconnectivity transcend state lines, and fair reimbursement for providers and facilities using these advances to provide enhanced care to all populations. Ultimately, broad adoption of telehealth technologies will better unite medical and oral health professionals in treating patients under the greater context of the oral/systemic link. And dental sales reps that are ready to assist their clients with this adoption will be at a true advantage.
This article is adapted from one previously published in Dimensions of Dental Hygiene.
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From MENTOR. January 2018;9(1): 14-18.