25 minute read
C.E. Credit: Evolution of Patient Care Post-Pandemic: Teledentistry the New Norm, a Narrative Review
Antranig Mesrobian, MS, is a DDS candidate, class of 2024, at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.
Karam Korya, BS, is a DDS candidate, class of 2024, at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.
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Kamal Al-Eryani, DDS, PhD, is an assistant professor of clinical dentistry, division of diagnostic sciences at the Herman Ostrow School of Dentistry of USC. Conflict of Interest Disclosure: None reported.
ABSTRACT
Background: The start of the new decade brought an inconceivable affliction. In the first quarter of 2020, humanity faced an invisible enemy, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), known infamously as COVID-19. The virus left every facet of life in a state of disarray, and as we adjust to the new normal, the necessary changes are evident.
Results: Through synchronous or asynchronous interactions, the efficiency, convenience and costeffectiveness of telehealth remain unparalleled. Therefore, as society attempts to move past the pandemic, the progression of patient care and management will be a catalyst in the transformation of health care systems.
Practical implications: Considering the precedent set by teledentistry during the pandemic, the widespread incorporation of this digital medium will benefit both patients and dentists.
Keywords: Teledentistry, pandemic, COVID-19, telehealth, technology, patient care, dental care
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Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease, or what the world knows as COVID-19, has left its mark on humanity. Life came to a screeching halt as the entire world mobilized to take precautions against a virus that has revealed itself to be an enigma. Two years later, the scientific community continues to learn and adapt ways in which humanity can persevere against this unknown enemyand has learned to cope with the substantial amount of loss and devastation.
SARS-CoV-2 left public health, our economy and our way of life in a state of disarray. The novel coronavirus pandemic has spawned four intertwined health care crises that reveal and compound deep underlying problems in the health care system of the United States.[1] Failure to mobilize an effective response compounded with the inability to provide care to all those affected revealed efficiency and capacity as the apparent Achilles heels’ of our health care infrastructure. Current efforts need not look very far in finding a solution in creating a more efficient form of health care delivery, because the foundation already exists. The requisite infrastructure for connectivity is widely available at both ends of the clinical encounter, most readily through the ubiquitous smartphone.[2]
Technology has transformed everyday life, from our professional lives to daily tasks at home. In essence, it has brought a certain level of efficiency and convenience for the user. Technology is a part of virtually every aspect in health care, including education, patient care and communication. In addition, technology has proven to be beneficial in reaching patients via remote access, known as telemedicine. “Most health care systems in private and public sectors have already deployed electronic health records, thereby ensuring continuity of care for their patients. A sizeable proportion of outpatient visits in various settings can be clinically managed effectively from a distance, that is, patients with nonurgent conditions can be triaged to telemedicine service without compromising their health or quality of care.”[2]
The pandemic impacted all facets of health care; dentistry, in particular, came under scrutiny due to aerosolgenerating procedures. However, as time went on, recommendations from the Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) allowed dental offices to provide “essential” services to patients because health cannot take a backseat to anyone or anything. “Oral health is an integral component of systemic health and explains dentistry is essential health care because of its role in evaluating, diagnosing, preventing or treating oral diseases, which can affect systemic health.”[3]
“Teledentistry refers to the delivery of dental advice, care and treatment to patients remotely by exploiting the power of telecommunication, all the while avoiding person-person interaction.”[4] Therefore, from the beginning of the pandemic, the ADA updated its teledentistry policy to better serve dentists who rely on this technology to care for patients, emphasizing the standard that consultations and treatments through teledentistry must be consistent with how they would be delivered in person. Almost two years into the pandemic, teledentistry continues to be a vital tool in reducing the burden on our health care infrastructure while simultaneously being an effective tool in screening, consultations, diagnosing and referring.
Moving forward, dental health care personnel (DHCP) will need to increasingly integrate technology to provide a more efficient and comprehensive form of care. “While the use of teledentistry is already an established function in oral medicine, periodontal conditions and oral surgery, patient care in the post-COVID-19 era will need to leverage technology to offer the best possible treatment outcomes and access to care for all.”[4]
The reader may be wondering, if everything is ready to go, why is it not being applied? Well, that is because it is always a work in progress. “Effective teledentistry requires significant investment in data privacy, adequate training and access to the internet.”[4] Concomitantly, there must be uniformity in confidentiality, ethical standards and the manner in which the medium is utilized between patients and the DHCP. “Automated screening algorithms can be built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers.”[5] These separate facets coming together through the use of technology and integrating into the health care infrastructure will bring about a more productive outcome.
With an unprecedented opportunity to learn from our shortcomings, there is no time like the present to reassess, evaluate and apply the necessary changes needed to make sure teledentistry works. Taking the necessary actions to ensure the expansion of access to care while maintaining patient privacy protocols will ensure a brighter future for the American people regarding health care. “Leaders in health care, business and technology work collaboratively to disrupt the status quo and chart a new course for our country’s health system — a system that is affordable, efficient and accessible for everyone.”[6]
Materials and Methods
This narrative review utilized articles analyzing the scope of teledentistry in regard to history, legality, services, insurance, reliability, infrastructure and treatments. PubMed and Google Scholar databases were searched from their inception to May 2021. An English-only filter was placed for the included papers. These articles are cited within this paper to convey the critical nature of teledentistry.
Results: History of Telemedicine
Telehealth has been used in one way or another since the 1950s, where it was utilized for neurological exams and group therapy sessions. An exponential boom ensued in the following decades as federal agencies such as the U.S. Department of Health, Education, Welfare (now known as the Department of Health and Human Services) and Massachusetts General Hospital launched their telehealth program, thus proliferating the widespread use of technology as a medium for providing services. The 1980s saw telemedicine expand globally, as countries such as Russia, Australia and Armenia formed joint operation partnerships with the United States to provide telehealth services to those in need.[7]
With the global framework settled, the advent of the technology boom in the 1990s led to telemedicine expanding from a handful of disciplines to a means of delivering multiple disciplines of health care. Almost immediately, telehealth became a component of health care that all major institutions, academic or otherwise, added to their repertoire. With the widespread proliferation of this “new” service, federal, state and medical regulatory bodies were established to oversee and fund numerous established programs. Today, telehealth is a tool that improves the health of the population, enhances the patient care experience, provides education to future providers and ultimately allows for many patients to receive care when needed. Telehealth encompasses numerous facets of health care and, concerning dentistry, has reduced the cost of services provided, improved access to dental specialists (i.e., oral surgeons, endodontists, etc.) and increased efficiency through reduced travel times, thus proving to be revolutionary.[7,8]
History of Teledentistry
Oral health is an integral part of general well-being. Technical advances in dental care have documented early diagnosis, preventive treatments and early intervention to prevent or reduce most oral diseases’ progress.
Radiology was the first discipline (1959) to utilize telehealth to diagnose/ treat patients, and other disciplines followed suit. The various benefits telehealth provided led the U.S. military and the Department of Defense to establish a dental informatics system. “The U. S. Army’s Total Dental Access (TDA) project is seen as being at the frontier of teledentistry, which had begun in 1994. TDA is the teledentistry project within the department of defense that enables referring dentists from the U.S. Armed Forces to consult with specialists at a medical center about the status of a patient.”[9] Additionally, TDA aimed to increase access to dental care for patients who lived in rural areas, improving the cost-effectiveness of dental treatments, streamlining dentist-to-laboratory communications and improving dental education.[8]
The success of the TDA was undeniable, as it led to a proliferation of teledentistry in the private sector. “By providing dentists with easy, costeffective access to specialists, it is possible to improve the quality of care by facilitating better and timely information to dentists for better decision-making and better communication between them and their patients.”[10]
With the current pandemic in mind, it is clear how critical teledentistry has been in achieving continuity of care for patients worldwide. The aerosol-producing dental procedures were a significant source of concern regarding the spread of SARS-CoV-2 in the early days of the pandemic. The potential transmission to patients and doctors alike led to a recommendation by the ADA on March 16, 2020, to postpone dental procedures deemed as nonemergency or “elective.”[11] Examples of nonemergency procedures include but are not limited to extraction of asymptomatic teeth, restorative dentistry including treatment of asymptomatic carious lesions, aesthetic dental procedures, initial or periodic oral examinations and recall visits, including routine radiographs, routine dental cleaning and other preventive therapies.[12] Nonetheless, teledentistry flourished, as it allowed for continuity of care between dentists and their patients during these troubling times. “Online conversations allow the exchange of several types of data like written or voice messages for diagnostic doubts as well as therapeutic suggestions, video messages for a better evaluation of a patient’s requirements and descriptions of problems in their own words.”[13]
The evolution of teledentistry is solely dependent on the evolution of existing technologies. The progression of the latter will inadvertently expand the former. That being said, when expanding any aspect of patient care, consideration must be given to the legal protections for both provider and patient.
Legality of Teledentistry
Technology has afforded dentists the ability to communicate with their patients and other dental specialists through various avenues. According to the ADA, teledentistry allows dental professionals to reach a larger patient population, and by doing so, increases access to care. More so, teledentistry must conform to the same legal standards as in-person office visits.[14]
Laws regulating teledentistry vary from state to state. California has some of the most extensive teledentistry laws, with patient rights being the focal point. Prior to the delivery of telehealth, the dental professional must inform the patient that teledentistry may be used and obtain verbal or written consent. Failure to do so will result in unprofessional conduct pursuant to Business and Professions Code 2290.5.[15] Examinations and interventions must follow proper documentation, summary of services, appropriate follow-up care and referral to the emergency department as needed.[14]
Regardless of the medium used, interactions between clinicians and patients must always meet the standards by which prescriptions may be issued. The common practice of prescribing medication before the COVID-19 pandemic was that a physician may issue a prescription only after an appropriate examination had been performed and a medical indication for the prescription had been determined. Moreover, Business and Professions Code section 2242.1 prohibits individuals from prescribing, dispensing or furnishing dangerous drugs on the internet without an appropriate prior examination and medical indication, unless under exceptional circumstances.[16] However, due to the current public health emergency, a special ordinance allowed the dispensing of controlled substances via telehealth to patients for whom they have not conducted an in-person medical evaluation provided:
■ The prescription is used for a legitimate purpose.
■ The practitioner is acting in accordance with federal and state laws.
■ The interaction with the patient occurs via a two-way, real-time audiovisual communication system.
This special ordinance designated by the Secretary of Health and Human Services and the Drug Enforcement Agency will remain in effect for as long as SARS-CoV-2 is deemed a public health emergency. [17]
Teledentistry Services
Teledentistry enables clients to access preventive services completed on-site through different technologies. Patients consult with the dentist via websites, patient portals or phone calls. The use of teledentistry enables hygienists to provide a patient with educational tools required to avoid diseases and which treatment is needed before the patient’s needs progress. It provides portable equipment to hygienists, enabling them to make a treatment room in essentially any area. This enhances access to care in any interior locations, such as schools, nursing homes and conference rooms, which can be changed into a private treatment room. Furthermore, patients who have obligations during normal business hours (i.e., work, child care, etc.) can still connect with their oral health care provider and receive the necessary care. Ultimately, dentists can prevent diseases in patients in remote areas and those with limited resources and elevate the practice of medical providers. Through teledentistry, dentists and hygienists in remote areas can connect to specialists in larger communities. For example, orthodontists can utilize teledentistry as a cost-effective approach to supervising treatment options for patients in remote areas (i.e., tracking the progress of a patient’s dental movements).
Modern information support works in teledentistry such that it helps to increase the dentist’s performance in the diagnosis and treatment of patients’ oral health problems. Teledentistry can separate treatments done remotely from those done clinically by utilizing existing screening software and evaluating the intensity of the issue and the ability of the patient to manage the problem according to the instructions (fIGure 1). Home monitoring devices work in teledentistry because they help save client data and provide a channel and network to participate in the process.
From reducing health disparities in areas with limited physical access to eliminating transportation costs, it is clear that telehealth has found its place within the health care system. Additional benefits telehealth can provide in the future include but are not limited to improving health literacy, reducing hospital readmissions, immediate access to physicians, medication adherence and a host of others.[18]
Synchronous vs. Asynchronous
Telehealth delivery in general falls under three forms: synchronous, asynchronous and remote patient monitoring. Synchronous delivery indicates a live, two-way interaction between the patient and dental care provider. The real-time interaction allows for a live discussion and delivery of care, whether this occurs at the patient’s home or at a designated site (such as in facilitated virtual visits).[18]
Asynchronous telemedicine, also known as “store and forward,” refers to the collection of diagnostic records and medical history, which is forwarded to the health care professional for diagnosis and treatment recommendation. Asynchronous teledentistry is often touted for its efficiency,
as it does not require meeting at a specified time, thus being more convenient for both patient and provider.[18] Lastly, remote patient monitoring consists of clinical evaluation of patients outside of traditional health care settings, i.e., home, an assisted living facility, a remote area, etc.[17] Remote patient monitoring is helpful for patients with chronic illnesses who choose to maintain their independence and live in their preferred environment (TABLE 1).
Besides the factor of live versus store and forward, synchronous and asynchronous telehealth also differ in the manner in which they are classified and coded by insurance. Therefore, appropriate codes must be used for the type of telehealth provided so that insurance reimbursement for services provided is made at the same rate and accuracy as in-person services.
Insurance
While teledentistry reduces the cost burden for health care providers and patients alike, the service is not without its limitations, especially as it relates to reimbursements. Medicaid tends to offer reimbursement for synchronous care. However, numerous criteria must be met, such as limited access to care, location of the patient, etc.[18] Medicare, which is health care offered by the federal government for persons ages 65 and older, usually does not cover teledentistry. Private insurance companies show significant variability when reimbursing for teledentistry services, as they are governed by the states in which they operate.
The imbalances between insurance reimbursements are considered significant barriers for teledentistry. However, as COVID-19 engulfed our reality and teledentistry became the most viable option, immediate action was taken to rectify these obstacles. On March 18, 2020, the California Department of Managed Health Care (DMHC) issued an all-plan letter instructing health plans to take immediate steps to allow people to obtain health care via telehealth.[19] Furthermore, the California Department of Health Care Services (DHCS) proposes implementing broad changes with the DHCS Telehealth Proposal to extend these additional benefits for Medi-Cal recipients postpandemic when medically appropriate.
During the pandemic, dental insurance became more flexible in covering teledentistry for initial and follow-up visits. Services were covered as if they were provided in person; however, insurance reimbursement regulations vary widely state by state, and a dentist must check with the patient’s insurance prior to performing services.
As indicated earlier, teledentistry billing must follow the same rate and accuracy as in-person services. Providers who engage in synchronous encounters must indicate CDT code D9995 in addition to other services provided, i.e., diagnostic, treatment planning, etc. CDT coding for asynchronous encounters must be indicated by code D9996 and submitted accordingly. Patient encounters must also include the diagnostic and evaluative procedures completed during each session, such as D0191 (patient assessment), D0140 (limited oral evaluation — problem focused), etc.19 (TABLE 2).
Telehealth Exam Accuracy/Validity
The telehealth examination is important as it reduces the chances of patients getting infected with the virus. The patients do not have to meet with the dentists and other health professionals for health services, reducing interactions with individuals who might be infected with COVID-19.
Telehealth examinations help health practitioners attend to patients in different locations and diagnose their issues without having to meet physically. helping patients protect themselves against threats in post-pandemic care by reducing instances of traveling to receive care.[20] Teledentistry is accurate and produces valid responses to patients through examination. The patients can perform various medical tests in their homes with the right tools getting instructions from the dentist. The results obtained can be validated by the dentist to provide dental care while increasing patient safety.
In teledentistry, the specificity and sensitivity of oral pathology diagnosis is very high, where both percentages exceed 90% in most settings, making teledentistry a very competent method for oral pathology diagnosis.[21]
Teledentistry Limitations
Teledentistry successfully connects and transfers electronic information, remote consultations, assessment and evaluation of patients’ needs. Be that as it may, teledentistry is limited in the types of procedures that can be performed. Any treatment plan that requires operations, crown placements, extractions or alignments must be carried out in person, because teledentistry can only be used in functions that do not require the dentist to be present. with the patient to render care.[9]
Health Insurance Portability and Accountability Act Requirements
The U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects medical records and other personal data. These guidelines extend to any health care provider who is transmitting digital data and cover teledentistry and any related communication, so one should comply with the guidelines when implementing telehealth. The two essential pieces that HIPAA defines on teledentistry are how to handle communication and how the information is stored. HIPAA governs the software used for teledentistry. Under HIPAA, a HIPAA business associate agreement is considered to be an official contract between a HIPAA-covered entity and a HIPAA business associate or downstream business associate. The contract is mainly intended to protect personal health information and abide by HIPAA guidelines. Also, for hygienists to comply with HIPAA guidelines, teledentistry needs to ensure that communication between the client and their provider is encrypted. Rules are provided to ensure the safety of teledentistry data and how providers should handle such information. For example, information must be transmitted over an encrypted connection. This means that third parties should not access data in transit.[22] Therefore, the software made to transfer medical data should have encryption built into the system. All company stores are required to store the client’s personal information on their encrypted servers. Encrypting information is the best practice for cybersecurity and a requirement for any health care provider that stores information. To ensure that ethics are not violated in a nontraditional area, high clinical standards of protection, efficiency and sterilization should be used. The services must be tracked using cloud-based software and sent to the patient’s insurance provider directly. The Department of Health and Human Services conducts periodic evaluations to ensure that certain laws are followed. Companies that fail can face hefty fines and public relations issues, so most teledentistry businesses make sure they follow all of the rules (FIGURE 2).
According to the ADA, teledentistry can be an important way of expanding dental practitioners’ reach by reducing the impact of distance barriers, which increases access to treatments. Teledentistry can extend the scope of the dental practice to a population within reasonable geographical distances by offering necessary dental treatment. Thus, the ADA provided compliance guidelines for teledentistry. The services must be provided in the same way as in-person services to achieve this objective.[23] Examinations and subsequent procedures performed via teledentistry must focus on the same quality of information as those performed in-person. It is the legal duty of the dentist to ensure that all documents collected for diagnosis and treatment are suitable for the dentist. Patients who receive telehealth care need to be tracked appropriately, including a description of the patient’s services. To provide satisfactory follow-up treatment for patients during the telehealth experience, a dentist who uses telehealth must be familiar with the availability and scope of local dental services.
Technological Infrastructure and Software Requirements
The ADA developed an online database known as the systemized nomenclature of dentistry that enables efficient communication of patient data by health providers within the electronic health records (EHRs). This technology is required when practicing telehealth. EHRs are a computerized, systematic array of electronic health data. They allow numerous clinicians to access the same patient record, resulting in improved interprofessional communication and more efficient patient care. Patients may also be educated about proposed interventions and potential results.
Teleconsults can also happen via live video, collection of secure encoded data or remote patient monitoring. Therefore, innovative technologies are required, like website monitoring applications, kiosks, mobile devices apps and videoconferencing, which engage patients via connective health apps. These technologies ensure care is provided by allowing real-time, interactive communication between patients and the provider located at a distant site. They can also be used to send messages for encouraging healthy behaviors.
Conclusion
Dentistry is an integral part of our health care system, and teledentistry is a functioning component of that system. Once considered impractical, teledentistry proved its worth during the pandemic. By limiting in-office, aerosol-generating procedures, the virtual medium of teledentistry allowed continuity of care between dental care providers and their patients. The sky is the limit for future teledentistry applications as consultations, treatment planning, preoperative instructions, treatments, postoperative care and a host of other services integrate into this form of dental care delivery. Whether it will increase access to care, reduce unnecessary visits or create a more efficient health care model, it is clear that the virtual doctor’s office is here to stay.
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C.E. CREDIT QUESTIONS
January 2022 Continuing Education Worksheet
This worksheet provides readers an opportunity to review C.E. questions for the article “Evolution of Patient Care Post-Pandemic: Teledentistry the New Norm, a Narrative Review” before taking the C.E. test online. You must first be registered at cdapresents360.com. This activity counts as 1.0 of Core C.E.
1. Teledentistry can be used for which types of patient care?
a. Consultation
b. Assessment
c. Treatment
d. All of the above
2. ADA’s teledentistry policy recognizes the challenges to providing care via teledentistry and emphasizes differing standards for care rendered through teledentistry and care delivered in person.
a. True
b. False
3. Effective teledentistry requires knowledge and use of which of the following? (mark all that apply)
a. Electronic health records
b. Data privacy
c. Uniformity of ethical standards
d. Confidentiality
4. The technology boom helped telemedicine expand from a handful of disciplines to a means of delivering multiple disciplines of health care in which decade?
a. 1970s
b. 1980s
c. 1990s
d. 2000s
5. Radiology was the first discipline to utilize telehealth to diagnose/treat patients.
a. True
b. False
6. The U. S. Army’s TDA project stands for:
a. Today’s Dental Army
b. Teledentistry Access
c. Total Dental Access
d. None of the above
7. Though some states require a dental professional to inform the patient that teledentistry may be used and obtain consent, verbal or written, prior to the delivery of telehealth services, this is not required in California.
a. True
b. False
8. A “special ordinance” designated by the federal secretary of Health and Human Services and the Drug Enforcement Agency permits the dispensing of controlled substances via telehealth to patients for whom an in-person medical exam has not been conducted, if certain conditions are met, for as long as SARS-CoV-2 is deemed a public health emergency.
a. True
b. False
9. Telehealth may be delivered in which of the following ways?
a. Asynchronously
b. Synchronously
c. By monitoring the patient remotely
d. a and b
e. All of the above
10. The specificity and sensitivity of oral pathology diagnosis exceeds 90% in most settings, making teledentistry a very competent method for oral pathology diagnosis.
a. True
b. False
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14. American Dental Association. ADA Policy on Teledentistry.
15. CDA Practice Support. Teledentistry Consent and Notice.
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THE CORRESPONDING AUTHOR, Antranig Mesrobian, MS, can be reached at amesrobi@usc.edu
