Chan WM, Woo J, Hui E, Hjelm NM. The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong. J Telemed Telecare. 2001; 7:38-46
Gray LC, Edirippulige S, Smith AC Telehealth for nursing homes: the utilization of specialist services for residential care. J Telemed Telecare. 2012; 18:142-146
Yeung A, Johnson DP, Trinh N-H, Weng W-CC, Kvedar J, Fava M. Feasibility and effectiveness of telepsychiatry services for Chinese immigrants in a nursing home. Telemed J E Health. 2009; 15:336-341
Wade V, Whittaker F, Hamlyn J. An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities. J Telemed Telecare. 2015; 21:490-493
Guan WJ, NI ZY, Hu Y China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020; https://doi.org/10.1056/NEJMoa20002032
Donaghy E, Atherton H, Hammersley V Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract. 2019; 69:(686)e586-594
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Consultant Orthodontist, Clinical Lead in Orthodontics and Restorative Dentistry, Croydon University Hospital, 530 London Road, Thornton Heath CR7 7YE, UK
This article provides an overview of tools which enable remote working in Dentistry. It assesses the availability of tools for use in three areas of remote working in healthcare: video conference calls between professionals, apps for patients to send photographs to clinicians and platforms for telemedicine clinics and highlights the main features of common tools.
CPD/Clinical Relevance: Remote working in healthcare has become increasingly popular during the COVID-19 pandemic and an understanding of how this remote working can be utilized in Dentistry, and the associated benefits, is relevant to all clinicians.
Article
Coronavirus Disease 2019, or more commonly COVID-19, is a global healthcare crisis with an unprecedented number of deaths and countries taking extraordinary action to try and control the spread of the virus.1,2 During COVID-19, healthcare resources have been directed to fight the pandemic with the cancellation of the majority of routine medical treatment and the cessation of routine Dentistry.3 In the United Kingdom, COVID-19 has led to the implementation of countrywide measures to curb the spread of the virus and to help save lives, including; social distancing, self-isolation and shielding.1 To enable these social distancing measures, the use of technology has allowed flexible and remote working. This has been embraced in healthcare and implemented in a variety of contexts during this time of crisis.
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:
Video conference calling for professionals;
Apps for patients to share photographs with clinicians;
Telemedicine clinics.
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.
Topic
Search Terms Used
Video conference calling for professionals
Video call
Video conference
Video conferencing
Video conference call
Video group call
Apps for patients to share photographs with clinicians
Patient share photos/photographs with clinician
Patient share photos/photographs with doctor
Share patient photos/photographs
Patient share photos/photographs
Share clinical photos/photographs
Share medical photos/photographs
Telemedicine clinics
Telemedicine
Teledentistry
Teleconsultation
Video consultation
Patient video consultation
Video clinic
Patient video call
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.
Google
Bing
App Store
Google Play
BlueJeans
Babble Cloud
BlueJeans
Google Duo
FaceFlow
FaceFlow
Google Hangouts
Google Hangouts
Google Duo
Free Conference
Go to Meeting
Go to Meeting
Google Hangouts
Google Hangouts
Hola
Hola
Go to Meeting
Go to Meeting
House Party
Microsoft Teams
Microsoft Teams
Microsoft Teams
Microsoft Teams
Skype
Pow Wow Now
Skype
Skype
Video Duo
Skype
Video Duo
We Chat
We Chat
Zoom
Zoom
Zoom
Zoom
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.
Tool
Features
Google Hangouts
Good integration with Gmail
Free and paid options available
No limit to meeting duration
Up to 10 individuals can participate in the same meeting or up to 25 individuals with Google App for Work
Can share screens
Go to Meeting
Not associated with a specific operating system
Free and paid options available
No limits to meeting duration
Up to 25 individuals can participate in the same meeting
Prices start at £9.50 per month – as price increases more individuals can participant in meetings and more ability to share and collaborate on documents
Can share screens
Virtual whiteboard
Can record meetings and have searchable transcript
Microsoft Teams
Fully integrated with Office 365
Used in collaboration with NHS Mail
Free with Office 365
No limit to meeting duration
Simple to create ‘teams’ within an organization, more complex to create ‘teams’ outside an organization
Up to 10,000 individuals can participate in the same meeting
Can see up to four video screens at the same time
Can share screens
Can collaborate on documents
Can blur background to minimize distractions
Can record meetings and have searchable transcript
Skype
Provided by Microsoft
Free
No limit to meeting duration
Up to 50 individuals can participate in the same meeting
End to end encryption
Can share screens
Unable to collaborate on documents
Can record meetings which are stored for up to 30 days
Zoom
Not associated with an operating system and can be used with any operating system
Free and paid options available
Free option – 40 minutes limit to meeting duration
Different price options have different limits to meeting duration and number of participants allowed
Up to 1000 meeting participants and 10,000 viewers
Can see up to 49 video screens at the same time
End to end encryption
Can share screens
Can share documents without having to upload files
Can have virtual background or blur background to minimize distractions
Can record meetings and have searchable transcript
Can have a meeting room where meeting participants wait before being let into the meeting by the host
Can create different breakout groups within the same meeting
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.
Google
Bing
App Store
Google Play
AppwoRX
AppwoRX
Clinical Cam
AppwoRX
Capture Proof
Clinical Cam
Epitomyze
Clinical Cam
Epitomyze
Epitomyze
iConnect
Epitomyze
Hospify
Hospify
MedShare
Hospify
Med Photo Manager
Med Photo Manager
MedXStream
MedShare
Pic Safe
MedXStream
myBody myData
Pic Safe
Rx Photo
Pic Safe
Pic Safe
RxPhoto
The Doctor
RxPhoto
RxPhoto
Smart Share
Zen Snap
Share Smart
Share Smart
The Doctor
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.
Tool
Features
Clinical Cam
App designed for clinicians taking clinical photographs on their mobile phone
Data stored securely
All data regularly deleted from mobile device
Can document patient consent
Can securely transfer photographs to email
Service has to be paid for
Epitomyze
App designed for clinicians taking clinical photographs on their mobile phone
Allows standardized photographs to be taken
Can capture, securely store and share photographs
Unlimited data storage
Service has to be paid for
Hospify
App designed for patients to share photographs with clinicians
Approved and recommended by NHS App Library
Free
Users telephone numbers and email addresses are not revealed, therefore clinician and patient confidentiality is protected
Can create groups of users to share photographs and messages
End to end encryption
Messages and photographs are accessed using a 6 digit code
Messages and photographs are automatically deleted from the server after delivery and from mobile phones after 30 days
Web based version of the app also available – stores data for longer and is designed for healthcare organizations
Hospify Hub also available – for teams of people using mobile and web version, free for up to 10 users, different payment plans for more users
Pic Safe
App designed for patients to share photographs with clinicians
Free
Documents patient consent
As well as photographs, audio and video files can be recorded and sent
Encrypts files prior to sending and deletes all data after sending
Files can be sent securely via email, text message or WhatsApp
Data can be securely transferred to hospital server and uploaded to patient medical records
RxPhoto
App designed for clinicians taking, cataloguing and managing clinical photographs
Allows high quality photographs to be taken using mobile phone
Designed as an alternative to conventional medical photography hardware
Has positioning templates to facilitate taking consistent photographs
Digital patient consent forms available
Photographs can be annotated and marked up
Photographs are encrypted and stored on the Cloud
Service has to be paid for
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.
Google
Bing
App Store
Google Play
AMC Health
accuRx
Babylon Health
Babylon Health
Attend Anywhere
Attend Anywhere
Cyber Clinic
Cyber Clinic
Babylon Health
e-clinic
LIVI Connect
Docly
ClineCall Healthcare
Egton
Mend Telemedicine
Digital GP
CureMD
EMIS Health
my GP
LIVI Connect
EMIS Health
LIVI Connect
MyMD
ManageMyHealth
Egton
MDLive
Patient Journey Connect
my GP
MDLive
Nye Phone
The GP Service
Push Doctor
Nye Phone
Ortus i-Health
Video Doctor
The GP Service
Ortus i-Health
Wellola
Wellola
Wellola
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.
Tool
Features
Attend Anywhere
Designed to be used alongside existing hospital systems
Used widely across NHS Scotland and many NHS Trusts in England
Patient does not need to download any software, accessed via internet link which can be pinned to practice/hospital website
Can be used on any device
Patients enter a private online waiting room whilst waiting for their consultation
Secure and patient data is not stored
Can share screens with patient
Can write notes to patient
Costs of the service are unclear
EMIS Health
Used by some NHS GP practices and some primary and secondary care providers in Scotland
Primarily an electronic healthcare records management system
Allows patient records to be linked and multiple professionals can access and contribute to patient records to ensure joined up care
Allows video consultations
Video consultations can be recorded to allow the clinician to refer back to the recording afterwards if required
Costs of the service are unclear
LIVI Connect
Platform that enables clinicians to have video consultations with patients
Video consultation is started by a secure link being sent to patient
End to end encryption of video consultations
No data is stored
Costs of the service are unclear
Nye Phone
Enables telephone and video calls to patients
Can be integrated with existing NHS systems
Accredited by NHS Digital
Widely used by many NHS GPs
Can be used on any device
Does not reveal any personal details or telephone numbers, therefore maintains patient and clinician confidentiality
Fully compliant with GDPR and information governance guidelines
Free
Ortus i-Health
Used by some NHS Trusts including Barts Health
Patients have a mobile phone app and providers have a web portal
Costs of the service are unclear
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
Clinician
Patient
Improved clinical networks
Limiting the risk and spread of infection
Increased quality of services
Minimizing travel
Develop communication with patients
Improved access to care
Reduced patient non-attendance
Reducing stress
Cost-effective and efficient
Promoting self-care and prevention
Reduced administrative workload
Enhanced communication and convenience
Good experience and satisfaction
Good experience and satisfaction
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.