The Rise of Teledentistry

The coronavirus disease 2019 (COVID-19) pandemic may have halted many things, but not teledentistry . . . it did just the opposite. Teledentistry has enabled many dentists not only to provide patient care while mitigating COVID-19 transmission but also more readily consult with colleagues and specialty practices to ensure optimal patient outcomes.¹

In April 2020, the American Dental Association’s Health Policy Institute released a report stating that 1 in 4 dentists nationally (many of whom were new to teledentistry) were using teledentistry to perform limited evaluations.² However, teledentistry has traditionally extended the reach of dental care for more than a decade by using an allied team member, such as a dental hygienist or expanded-function dental assistant.³

Definition

Teledentistry, which is the use of health information and communications technology to deliver oral care, consultations, and education, includes the remote provision of dental treatment (screening, diagnosis, consultation, and treatment planning) or advice using encrypted patient electronic data via the use of electronic health records, videoconferencing, and/or intraoral photographs and radiographic images.⁴

Teledentistry allows for adaptability as it can occur in real-time using synchronous communication methods or it can be asynchronous, meaning there is no real-time interaction between the provider and patient so information is stored and forwarded.⁵ Additionally, rapidly developing information and communication technologies for teledentistry have increasingly shown improvements in cost effectiveness, accuracy, and efficiency.⁶

Benefits and Risks

Increasing access to care, providing safeguards to mitigate risk, demonstrating an innovative ability to deliver care, and creating convenience for patients are some of the benefits of teledentistry. However, dentists may risk professional liability claims and licensing board actions when using teledentistry. To manage these potential risks, dentists should comply with state laws and regulations related to teledentistry and always provide a standard of care that aligns with their state’s standards of practice.

Security Requirements

In addition to benefits and risks associated with teledentistry, dentists also have the responsibility to ensure the confidentiality and integrity of information obtained and exchanged. Consulting security experts when setting up these systems to exchange information may be very helpful.

Dentists also should be aware that systems and processes being used to transmit images and data need to meet security requirements under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as well as any state-specific requirements as a general rule. However, there is an exception to HIPAA security requirements during the COVID-19 public health emergency.

COVID-19 Waivers

Effective March 17, 2020, the Department of Health and Human Services Office for Civil Rights exercised enforcement discretion (authorized by Section 1135 of the Social Security Act) to allow the Centers for Medicare & Medicaid Services (CMS) to waive certain requirements during national emergencies.

CMS has decided to waive — through the use of 1135 Waivers (“Waivers”) — potential penalties for violations of the HIPAA privacy, security, and breach notification regulations for providers and their business associates serving patients through everyday communications technologies. Under the Waivers, providers who want to use audio or video communication technology to provide telehealth to patients during the emergency period may use any nonpublic-facing remote communication product to communicate with patients. The Waivers temporarily relax the strict rules for technological security that – under the HIPAA security rule – would otherwise limit providers to the use of technologies with proven security controls.⁷ Therefore, dentists may use applications such as Apple FaceTime, Facebook Messenger, and Zoom during this time period.⁸

Using Teledentistry in Practice

When using teledentistry in their practices, dentists are responsible for:

• Developing criteria to conduct teledentistry.
• Creating and having teledentistry policies and procedures in place.
• Evaluating patients’ ability to participate in teledentistry.
• Obtaining patients’ informed consent to participate in teledentistry.
• Ensuring HIPAA requirements are met while conducting teledentistry; i.e., maintaining the privacy and security of patient information (see the COVID-19 Waivers exception on Page 2).
• Documenting all teledentistry services in the patient’s dental record. (If images are being sent for a second opinion, the referring dentist should note that in the record. The returned opinion also should be documented in the record as well as how it factored into any treatment decision.)
• Educating staff on how to use related technologies and transmit files securely. All staff education and training should be documented in employee files.
• Properly documenting images to ensure they are linked to the correct patient. Documentation includes patient name, identification numbers, date and time of the examination, name of facility, type of examination, anatomic orientation, and amount and method of data compression.
• Retaining images to meet state or local requirements.
• Maintaining patients’ rights by actively involving them in treatment decisions and services that are provided in accordance with applicable laws and regulations related to the privacy and security of protected health information (PHI).⁹

Tips for Starting a Teledentistry Program

For any dentists interested in starting teledentistry in their practices, here is some helpful advice:

• Read your State Dental Practice Act to determine what is permitted. If unclear, contact the State Dental Board office or Dental Association office.
• Check with your professional liability carrier to determine whether you are covered for any teledentistry or telehealth practice.
• Find a HIPAA-compliant solution for either a store-and-forward method, synchronous method, or both methods (see COVID-19 Waivers exception on Page 2).
• Educate office staff on creating a workflow for implementation.
• Inform current patients of the availability of teledentistry in your practice, and educate them about when teledentistry is appropriate and when in-person care is required.¹⁰

In Summary

To successfully implement and maintain teledentistry, dentists should understand professional guidelines and state and federal governmental regulations, confirm that they have the necessary liability and licensure protection, adhere to the state’s standard of care, and ensure the secure exchange of information from their systems.

As with regular dental care, staying focused on safe and best practices will help to minimize the occurrence of adverse events when using teledentistry in the dental practice. For more information, see the American Dental Association’s Policy on Teledentistry.

Endnotes

¹ National Society of Dental Practitioners, Inc. (2020). Teledentistry: Risk management considerations for dentists. Risk Management Newsletter, 35(1). Retrieved from www.aawd.org/wp-content/uploads/2020/08/TeledentistryManagementforDentists.pdf

² Suter, N. (2020, September). Teledentistry applications for mitigating risk and balancing the clinical schedule. Journal of Public Health Dentistry, 80 Suppl 2:S126-S131. Doi: 10.1111/jphd.12421. Retrieved from https://pubmed.ncbi.nlm.nih.gov/33306848/

³ Ibid

⁴ National Society of Dental Practitioners, Inc., Teledentistry.

⁵ Ibid.

⁶ Irving, M., Stewart, R., Spallek, H., & Blinkhorn, A. (2018). Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative, systematic review. Journal of Telemedicine and Telecare, 24(3), 129-146. doi: 10.1177/1357633X16686776. Retrieved from https://journals.sagepub.com/doi/10.1177/1357633X16686776

⁷ National Association of Community Health Centers. (2020, March 19). Memorandum. Retrieved from www.nachc.org/wp-content/uploads/2020/03/20200319-CMS-1135-Waivers.pdf

⁸ U.S. Department of Health and Human Services. (2021, January 20). Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. Retrieved from www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html?language=en

⁹ National Society of Dental Practitioners, Inc., Teledentistry.

¹⁰ American Teledentistry Association. (n.d.). Startup guide for implementation of teledentistry in your practice. Retrieved from www.americanteledentistry.org/