The Challenges and Rewards of Teledentistry

The teledentistry service was made available to both patients of record and new patients. From the outset, the service received thousands of calls each week. While many of these calls were for nonclinical inquiries (eg, appointments), on average approximately 150 calls were routed to clinical providers each week. The teledentistry service operated Monday through Friday from 9 AM to 4 PM, but patients were able to leave voicemails after hours and on weekends, which were reviewed and returned the next business day. Calls to the service were fielded by teledentistry service agents who triaged them to the appropriate dental clinical specialists. The clinical provider would then contact the patient via phone and/or video call. Providers had remote access to electronic charts of patients of record and could create charts for new patients. Most teledentistry encounters could be resolved remotely; however, providers were also able to refer patients requiring urgent care to one of the School's affiliated hospital clinics.

NYU Dentistry resumed limited in-person clinical operations on June 29, 2020. The teledentistry service remained fully operational until August 31, 2020, by which time in-person operations had increased. The teledentistry service was then adjusted to operate primarily during holiday breaks and in response to inclement weather or other events that caused the cancellation of in-person appointments.

The NYU Dentistry teledentistry service was a specific response to the pandemic and the suspension of dentistry that was focused primarily on providing emergency care during a time when in-person dental care was largely unavailable. However, it quickly became apparent that an opportunity exists to have a robust and comprehensive teledentistry service that addresses two types of care: (1) provision of emergency care during holidays, weekends, and other office closures, and (2) as a complement to routine consults and dental visits.

The lessons learned from this experience reinforced the obvious: the creation of an effective teledentistry service requires an efficient use of personnel and time, and dental organizations and practices must be prepared with the necessary capital, technology, and commitment to be successful. This investment of resources and energy will be beneficial, as the future of oral healthcare appears strongly aligned with the establishment of successful telehealth systems.¹

Regardless of the type of practice, several resources are necessary for a successful teledentistry service and the challenges that accompany it. Personnel and a sophisticated electronic health record (EHR) with a robust patient portal are the two most significant system investments needed. Consideration must also be given to the hours of operation, number of call agents or answering service employed, training and calibration, system complexity, language services, administrative oversight, and management.

Personnel-For a reliable telehealth service, administrative and practitioner oversight is crucial. The administrative team or answering service conducts the initial screening call and appropriately follows-up on the patient's inquiry or issue by either referring clinical issues to the clinical provider team or practitioner or answering any nonclinical questions. Each inquiry or call can last up to and beyond 30 minutes. Depending on the call volume and extent of the teledentistry service, multiple full-time equivalent administrative personnel or the dental provider may be needed to provide this service.

The clinical team/practitioner is also crucial to success. Again, depending on the call volume and extent of the teledentistry service, call-back, and/or video, a significant number of providers may be needed, across all levels and specialties. While this may impact in-person patient care as demand for remote working increases, it is an opportunity for providers to be able to provide patient care remotely.

Electronic health record-A sophisticated EHR with the ability to easily and securely exchange information among the provider, patient, and administrative team is also a necessity for any teledentistry service. A strong patient portal system must accompany and be linked to the patient's EHR. A robust patient portal allows patients to communicate securely with the office, clinical, and administrative team prior to, during, and after their visit using a variety of media. Often, patients may choose to send photographs prior to their visit, which can assist clinicians by providing a better understanding of the care needed. Also, video visits can more easily be set up through a patient portal. Since the patient portal is also linked to the patient's EHR, the teledental visit and all communications will become a part of the patient's EHR and the provider will be able to accurately document the visit. This will also ensure that patients complete the necessary consent forms in the patient portal, which can often be a challenge with telehealth appointments.

Among the challenges of implementing teledentistry are costs, the patient-provider relationship, and issues involving security and privacy.

Costs-While most dental practices already have an EHR system, robust patient portals are, with the exception of sophisticated medical EHRs, still not common. Having a sophisticated EHR that is linked with a patient portal can incur a large financial cost, as it requires a significant investment in implementation and maintenance.

Regarding reimbursement,in response to the COVID-19 pandemic many states have created or altered existing regulations on billing for telehealth visits. While the NYU teledentistry emergency service that ran from March to August 2020 did not directly bill patients, the teledental visit has been a reimbursable service for Medicaid dental providers in New York State since February 2019.² Many private insurers also include telehealth coverage. Since teledentistry is billable, reimbursements can help offset the costs of operating a teledentistry service.

Every dental practice should consider and research its state's laws on teledentistry, because regulations can vary greatly state by state. For example, in New York State, in order to qualify for reimbursement by Medicaid, there are currently location requirements for providers and patients. The Office of the Governor recently put forth a proposal to eliminate location requirements so patients and dental practitioners would not have to be located in an office setting in order to be reimbursed.³

Patient-provider relationship-In an environment where providers already have concerns about the hurdles and extra time spent navigating and documenting in EHRs, teledentistry services may impose some additional burdens. Providers must be able to use the technology intuitively and create a level of trust and competence with patients, who also may be hesitant. This trusting patient-provider relationship can be especially challenging to achieve remotely, but it can also become a resource for building and maintaining patient loyalty in private practice.

Security and privacy-As telehealth visits and remote work become more prevalent, the issues of offsite access to EHRs related to security and privacy will grow in complexity. To provide a strong teledentistry service, providers must have access to the patient's portal and EHR. Often, providers are not onsite when providing this service, and therefore would need offsite access. An increase in number of individuals and frequency of offsite access could raise the risk to data integrity and privacy. It is important, however, to achieve a balance between security/privacy and accessibility. While this may not be as formidable in a private practice setting as it could be at NYU, providers must still be prepared to consider this tradeoff and be ready to have adequate security measures in place for offsite access.

While significant resources and costs are required to operate a teledentistry service, the potential benefits can be compelling.

Immediacy of care-Foremost among the benefits is the immediacy and continuity of care. Teledentistry allows patients to access referrals, prescriptions, and other clinical advice when they are dealing with an urgent issue without having to wait for an in-person appointment or to travel, which can be especially important during times of poor accessibility, such as on weekends or during weather-related closures.

Efficiency-Teledentistry has the capacity to make in-person appointments and clinical operations more efficient. Medical and social histories, as well as descriptions of any clinical issues, can be done through a teledentistry visit prior to the scheduled in-person appointment. This not only decreases the amount of time needed for the in-person appointment, but also helps prepare providers for the appointment by identifying needs beforehand (eg, staffing, equipment). The decrease in onsite appointment times and better pre-visit preparation helps to streamline patient appointments and, therefore, enhance efficiency and improve patient-centered care.

In an academic dental setting, the students are the primary providers, supervised by licensed dentists. As teledentistry becomes more common, students need be taught this as part of their education and understand how it works. However, involving students in teledentistry service presents some challenges. Students must be supervised by a licensed dentist; thus, they cannot conduct a teledentistry visit on their own. The coordination of this can be difficult. Additionally, because providers cannot be on multiple calls at once, the student-to-faculty ratio becomes one to one. This ratio is typically much higher for in-person appointments, so this can lead to inefficiencies.

Involving students in a teledental program requires balancing the provision of excellent care and teaching students a valuable skill with using faculty time efficiently. As demand for remote work increases and building occupancy limits remain in effect, this could be an option for faculty who choose, or are required, to work remotely.

For dentists in a single or group practice environment or dental service organization (DSO), consideration must be given as to when teledentistry will be scheduled.

This article has presented NYU College of Dentistry's experiences with teledentistry from the start of the COVID-19 pandemic to date. During an especially chaotic and uncertain time the use and implementation of telehealth technology required continuous review and revision. There were times when the utility of such an endeavor in such a large, predominantly teaching organization was questioned. However, careful analysis confirmed that when there were essentially no direct patient care services, and shortages of supplies and PPE were severe and fear of visits to hospital clinics or emergency rooms was prevalent, the College was able to provide a mechanism for managing most oral health issues, establish an appropriate referral pattern, manage prescriptions, and alleviate fears of loss of continuity of care.

Admittedly, challenges related to technology and personnel were complicated and at times expensive. However, the end results, both in experience gained and solutions discovered, provided a foundation to better understand the infrastructure and position of teledentistry so that benefits in oral healthcare and operational efficiency can be realized. In traditional private or DSO settings, teledentistry should be an integral component of the practice and patients should be carefully educated and encouraged to engage teledentistry to enhance overall health and care. The future has been accelerated, and it is now.

Sarah Torosyan, MPA
Manager, Clinical Affairs, New York University College of Dentistry, New York, New York

Amr M. Moursi, DDS, PhD
Professor and Chairman, Department of Pediatric Dentistry, New York University College of Dentistry, New York, New York

Robert S. Glickman, DMD
Associate Dean, Clinical Affairs and Hospital Relations, Chair and Professor, Department of Oral and Maxillofacial Surgery, New York University College of Dentistry, New York, New York

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