Internet-Based Treatment Planning and Communications

In our last column (JCO, May 2006), Charles Lewis presented one company's approach to Internet-based orthodontic program delivery. Here is another alternative. Dr. Claude Boutin of Calgary, Alberta, reports on an innovative, Internet-based program suite developed by ICE Dental Systems. ICE uses animation and high-quality sound to build customized, online educational programs that can help patients understand informed consent and also provide content for multidisciplinary discussions. Availability on the company's website facilitates applications ranging from at home viewing by patients and parents to web-conference meetings among dental colleagues. The possibilities are limitless.

A unique feature of the informed-consentanimations is the ability to record the amount of time the patient spends viewing each segment. I believe this will be a valuable tool for liability protection in our increasingly litigious society.

Please read this month's Cutting Edge article; I'm sure you will take away as much from it as I have.

W. RONALD REDMOND, DDS, MS

Internet-Based Treatment Planning and Communications

One of the most basic things we do with computer programs is to communicate. When we see a patient for the first time, many of us now enter the examination findings on a computer work station, then take digital photographs of the patient's face and dentition, perhaps supplementing these with digital radiographs and models. In my office, we have used Dolphin Imaging^*** to show our patients and their parents the orthodontic problems we have found, and then used IACT CasePresenter^† to further explain the problems and the potential treatment solutions. We merged the Dolphin photos into templates we set up in our Ortho II^‡ correspondence system, and we gave the patient and parents a printout of our initial findings and recommendations for them to take home. Technology really does allow for powerful communication of complicated information.

A couple of years ago, Essentialtalk, a company that specializes in Internet communications, created an Internet program suite that allows us to do all this over the Web. Now, by logging into its Internet Communications Enterprises (ICE) Dental Systems^††, we can perform all the steps described in the previous paragraph (and more) at any Internet-connected location, without loading the images or programs onto our computers (Fig. 1). We don't need access to our office network, and everything we do on the system is securely encrypted and stored on ICE servers, which are located in major cities across North America. If we want even more backup redundancy, ICE can supply copies of our data on DVD every month.

Animations

ICE initially built a three-dimensional model of a primary dentition, then animated the tooth development process, to prove that it could deliver animations over the Internet. Samples of these are available on the ICE home page. We went further, and asked ICE to animate the most common procedures we do in our office. By logging into the system, we are now able show these short, but highly detailed, animations to our patients to illustrate proposed treatments (Fig. 2).

Each animation takes only a few moments to load and five to 10 seconds to play, although the program allows the user to slow down the playing speed. We can stitch a number of these animations together to illustrate multiple steps in treatment. For instance, one animation shows how we open spaces for replacement of missing maxillary lateral incisors (Fig. 3), and another shows how dental implants are placed after orthodontic treatment is complete (Fig. 4).

The ICE animation player is flexible enough to allow a subscriber to edit out any part of an animation with a few clicks of the mouse. In addition, multiple computers connected to the Internet can access the site simultaneously under a given subscriber's password. When the subscriber saves a set of animations, the patient can be given an access code to view it at home or to show the parent who was not able to come to the consultation appointment (Fig. 5). Patients don't have to have broadband Internet access, because this system even works over a dial-up connection. Referring dentists can be given access to the saved animations as well. With secure password access, it all remains confidential, ensuring that this sensitive private information is HIPAA-compliant.

ICE is building a comprehensive library of animations that will be useful and responsive to all dentists. Because the animations are stored on the company servers, any additions are immediately available, without having to wait for update disks that have to be loaded onto individual office computers.

The image manager handles all common image formats, from bitmaps to JPEGs to TIFF files. In our user-defined diagnostic exam, we can then click through our list of diagnostic findings and generate a diagnostic summary letter that includes the images we just loaded (Fig. 7). We can define our own library of treatment-planning letters, or select a letter from a library that ICE is building with subscriber input.

An ICE user can either print out all this information or make it available to patients electronically over the secure ICE website. A referring dentist version is created simultaneously, since more and more referring offices seem to prefer this kind of electronic communication. The patients or referring dentists can print the documentation from their own computers. In our office, the savings in color printing costs alone would cover the monthly ICE subscription fee.

Informed Consent and Automatic Tracking

When we generate the ICE diagnosis and treatment letter, we have the patient or parent sign the letter on screen using a digital signature tablet. We can also automatically link our treatment-plan letters or animations to various ICE educational presentations that patients can view in the office or at home (Fig. 8). The orthodontic topics include growth, compliance, and oral hygiene. These interactive presentations use synchronized audio with still illustrations from the animation sequences. The patient or parent can click a button to pause the presentation, which brings up a text box for entering a question to be forwarded to the doctor.

The real key to making the informed consent work is that the ICE system tracks how long patients access each slide in the presentations (Fig. 9). You can bring up a report for any of your patients to see whether he or she has viewed the informed-consent sequence, and at what time. Patients or parents can be required to use identification codes, such as the last four digits of their Social Security numbers, so you can be sure the right people were accessing the information. They can also be asked to sign the report digitally the next time they come to the office, confirming that they viewed the presentation, that they were given an opportunity to ask questions, and that they received satisfactory answers (Fig. 10). Most of this process is automated and behind the scenes, but accessible any time the subscriber needs it.

Collaboration System

The same kind of tracking is available when you use ICE's collaboration program (Fig. 11). Any images, treatment letters, or animations you put into the system can be made accessible to a colleague with a few clicks of the mouse, and each of these elements can be accompanied by a recording of your voice (or a typed comment if you prefer). You can attach images or other files from any other source and record voice comments for each of these as well.

Recipients of ICE collaborations, after viewing the files and listening to your recorded comments, can answer back in the same fashion, even if they are not subscribers. As with the other elements in the system, the information is secure and encrypted, and access to the collaboration is tracked automatically. Not only can you can see at a glance if and when the recipient looked at it, but the system alerts you when a recipient has submitted a response. This is especially useful in multidisciplinary cases where a collaboration is addressed to all the practitioners involved; you can tell from one screen that the periodontist and the surgeon have responded, for example, and that you are still waiting for the endodontist's input on the case (Fig. 12).

A surgeon in my area who is using this product is planning to phase out many of his standard letters; he feels the voice recording accompanying the clinical photos or radiographs is sufficient for most of his communications, and the tracking tells him whether the referring dentists have looked at them. We use the collaboration product to refer patients for extractions, but it can also be helpful in communicating with outside laboratories. The collaboration feature can even be used to send before-and-after pictures to a patient, complete with a recording of a congratulatory message from you or your staff.

The most significant marketing aspect of this program is that it becomes a referral tool for the dentists who send you patients. You can have the ICE referral product linked to your website, so that dentists can send you their patient referral information and supporting documentation, such as radiographs or photos, more securely via a special version of the collaboration product. We are now asking the dentists who send us e-mail queries with attached patient photos to use the secure ICE referral system so we can assure better compliance with privacy legislation.

The voice-recording capability of the system can also be used to record critical conversations with patients and parents in cases of poor oral hygiene or inadequate cooperation. Some offices already record such exchanges as MP3 files and store them in their computers for liability management. ICE makes it even easier to record this information, store it, archive it, and retrieve it.