Remote working in dentistry in a time of crisis – tools and their uses

Technology for remote working in healthcare

Although remote working is already used in many industries, it has not previously been widely used in healthcare. During COVID-19 it has been necessary to rethink many conventional ways of working, including utilizing remote working with the use of; video conference calling for professionals, apps that allow patients to share photographs with clinicians and the use of telemedicine clinics. When using these tools it is imperative that the highest standards of patient care are maintained, which is emphasized by the General Medical Council statement that ‘digital and technological advances may present a more convenient way for patients to access healthcare, but it is important that these services do not compromise standards of care and patient safety’.⁴

Video conference calling for professionals

Video conference calls allow individuals or groups of people to participate in a call with real time audio and visual input, which is beneficial compared to an audio telephone call as it simulates a traditional face-to-face meeting with the associated advantages of building rapport, aiding understanding and facilitating discussions.⁵ However, there are limitations associated with video calling, including; lack of physical face-to-face contact, delay in the audio-visual feedback and the need for appropriate technology and internet connection to host the call effectively.⁶

Apps for patients sharing photographs with clinicians

Sharing photographs between friends and family is common practice, however, the use of apps for patients to share photographs with clinicians is currently less common. Nevertheless, in times when patients are unable to attend appointments, it may be helpful for patients and clinicians to be able to use such platforms to facilitate clinicians giving advice to patients in the absence of a traditional appointment.

Telemedicine clinics

The ability to have a video consultation with a patient can be useful when patients are unable to attend a face-to-face appointment or to obviate the need to attend an appointment.^7,8 Video consultations are referred to as ‘telemedicine’ clinics, which describes any ‘medical service provided remotely via information and communication technology’.⁴

Telemedicine can reduce clinic space requirements, decrease costs and improve the efficiency of a service.^9,10 When compared to telephone consultations, video consultations have the benefit of allowing the clinician to gain visual information and diagnostic clues, as well as the advantage of the therapeutic presence of the clinician being greater than via an audio telephone call.¹¹ Clinicians and patients communicate by video in the same way as an in-person consultation, with both reporting high levels of satisfaction.^12,13,14 Telemedicine is only appropriate in certain circumstances and clinicians should always ensure that the same standards of care are given in both video and face-to-face consultations.⁴

Data Protection

The General Data Protection Regulation (GDPR) applies to the processing, handling and storage of data within the European Union.¹⁵ Therefore, when using technology for remote working in healthcare, it is essential that the GDPR rules and regulations are complied with. It is advisable that all devices are appropriately secured, that two-factor authentication is used for accessing any apps or platforms that contain patient information, and that no patient data is stored on any mobile devices.¹⁶

During COVID-19, the National Health Service (NHS) produced specific information governance guidance in consultation with the Information Commissioner's Office on the use of information technology during the pandemic.^17,18 The guidance advises that, during the pandemic, clinicians are permitted to use personal devices to communicate with patients and host video consultations and that ‘off-the-shelf’ applications can be used where there is no practical alternative and if the benefits outweigh the risks.^17,18

Aim

The aim of this article is to assess the availability of tools for remote working in dentistry and to summarize the characteristics of the most common tools available.

Materials and method

The three main topics assessed were:

Common search terms for each topic were established by the authors and piloted. The final search terms used are shown in Table 1. The search terms were entered into Google, Bing, the Apple App Store and Google Play search functions on 3/4/2020 and the results were recorded and assessed. Any non-English results were excluded. The results were assessed by the two authors (KP and MC) and a third assessor was consulted to mediate and achieve a consensus in cases of disagreement. The five most common results for each topic were then assessed in more detail with information collated on their main functions.

Results

Overall, the four different search platforms used returned largely similar results for the different search terms used for each topic and there was consistent agreement between the assessors regarding the most common results for each topic.

Video conference calling for professionals

The main results for video conference calling for professionals for the four different search platforms are shown in Table 2.

The five most common results across the different search platforms were: Google Hangouts, Go to Meeting, Microsoft Teams, Skype and Zoom, all of which were found on all four of the search platforms. The salient features of these tools are shown in Table 3.

The five most common tools for video conference calling had many similarities, including allowing multiple individuals to participate in the same meeting with audio and visual feedback, and allowing users to share screens. The main differences were: if meeting participants could collaborate on documents, if meetings could be recorded, and if meetings were encrypted. Some tools are free to download whilst others have different payment options, with the main differences being that, as the price increases, more participants can join a meeting and the limits of meeting durations are increased or removed.

Apps for patients to share photographs with clinicians

The main results for apps for patients to share photographs with clinicians for the four different search platforms are shown in Table 4.

The five most common results across the different search platforms were: Clinical Cam, Epitomyze, Hospify, Pic Safe and RxPhoto, the main features of which are shown in Table 5.

The results for apps for patients to share clinical photographs with clinicians were variable. Some of these results were for apps designed specifically for this use such as Hospify and Pic Safe, however, more often the results found were for apps aimed at clinicians using their mobile phones to take photographs rather than using traditional medical photography equipment (Clinical Cam, Epitomyze, RxPhoto).

Telemedicine clinics

The main results for telemedicine clinics for each of the four search platforms are shown in Table 6.

The five most common results found across the search platforms were: Attend Anywhere, EMIS Health, LIVI Connect, Nye Phone and Ortus i-Health, the most salient features of which are shown in Table 7.

The search results for tools for telemedicine clinics were varied, with the most common tools providing a range of functions, however, the majority of results did have the feature of enabling telemedicine clinics and could be used within an existing service.

Discussion

At present there are a large number of different tools available to enable remote working which provide a range of different functions. Platforms to enable conference calling between multiple individuals using live video and audio input and feedback are commonly available. There are many different providers of such tools, all of which were easy to find using the search platforms used. The ease of identifying such tools for conference calling may be due to their common use across multiple industries.

The most common tools for conference calling had largely similar features, with the minor differences not obvious without a more in-depth assessment. The main differences between the platforms were the number of individuals who could participate in a meeting, the number of individuals that can be seen on screen at any one time and the ability to share and collaborate on documents. All platforms are straightforward to use and therefore may be chosen based on an individual's requirements, personal preference and any existing use within organizations.

During COVID-19, many meetings, collaborations and teaching episodes have used video conference calling, where previously these were carried out face-to-face. This has demonstrated the flexibility in how video calling can be utilized in healthcare. Depending on the success of this during COVID-19, it will be interesting to see if its use becomes common practice following COVID-19.

The results for apps designed for patients to share photographs with clinicians were varied, with only some of the results being for apps or tools designed for this purpose. Apps that were designed for clinicians to take photographs were commonly found and such apps were not designed for patient use. These results have been included as it accurately reflects the search results and shows that it was not easy to find apps or tools aimed for patient use. This may be a common difficulty facing patients and clinicians when searching for such tools.

The search topic with the least consistent results was telemedicine clinics. This may be due to a lack of sensitivity of the search terms used, less availability of telemedicine software or telemedicine being less commonly searched for. Unfortunately, the specific features of the software often only became clear after in-depth assessment, so it may be challenging for clinicians to find the appropriate tool for their desired use. The ideal position would be to have an agreed consensus and recommendation for a telemedicine software or platform in Dentistry.

Overall, there is much evidence in medicine to support the use of telemedicine, with Table 8 summarizing the benefits for patients and for clinicians.^19,20,21,22 A recent study in Restorative Dentistry found that remote consultations can provide a safe and effective consultation and were not inferior to in-person consultations.²³ It also reported high levels of acceptability for patients and clinicians.²³

The cited limitations and barriers of telemedicine are: technological problems, set-up costs, staff training and the decreased interaction of patients with healthcare professionals.^19,21 For remote working and telemedicine to become successful in routine practice, the appropriate technological infrastructure and clinical protocols are required to ensure effective patient management and to prevent the over or under prescription of care.^19,20

During the COVID-19 pandemic, many individuals have implemented using technology in new ways to enable remote working. These new ways of working have the potential to allow Dentistry to benefit from remote working in ways that were previously not realised.

Suggested applications of remote working in Dentistry

Videoconferencing: These have traditionally been used in Medical Multidisciplinary Team (MDT) clinics, but these can be used for Dental MDTs in hospital. They may also be utilized by the primary care practitioners to gain referral advice from secondary care units or specialists. This format also allows real-time sharing of information and radiographs and images. Finally, it can build professional relationships between colleagues and strengthen clinical networks.

Patient photographs: This can enhance and supplement the diagnosis when giving advice remotely for routine or emergency care.

Telemedicine clinics: This can enhance and supplement the diagnosis when giving advice remotely for routine or emergency care combined with both the clinical history and physical signs. It may also build a rapport and professional relationships between the patients and clinicians.

Conclusion

COVID-19 has brought about an increased utilization of technology which enables remote working in Dentistry. Following the resolution of COVID-19, it will be interesting to see if these new and innovative ways of working are maintained and if there are any subsequent fundamental changes to some of our working practices.