Technology: Real Time Virtual Collaboration

by Craig E. Wilson, B.Eng, Kenneth S. Serota, DDS, MMSc.

It requires little vision or imagination to see that some aspects of dentistry are quickly becoming digital, interactive and technology driven. Moreover, a focus on enhanced patient education is fostering increased demand for expanded health-related services. Information technologies allow dental professionals to formulate innovative solutions to clinical situations and to respond more efficiently and effectively to patient needs. Tomorrow’s clinical environment will increasingly contain interactive apparatus connected to other diagnostic, measurement and production tools, knowledge-based data centres, research institutes, and peer-to-peer forums.

One of the most exciting of these possibilities is the ‘virtual consultation’. Interdisciplinary treatment communication can now incorporate conferencing that involves and includes the patient, thereby ensuring their understanding in the planning process.

The ability to store and retrieve clinical information electronically from a digital dental record has been available for many years. As is the case with many new technologies, the impact of this digital record is only now being demonstrated as greater numbers of practices are working with them. Early in the adoption curve, digital technologies were promoted as an effective means of marketing patients and streamlining office procedures. The real benefits were not fully explained or defined.

In dentistry, some technologies like digital radiography, the Internet, email, and digital cameras, have been solutions looking for a problem to solve. While it was obvious how these inventions were of value to other industries, it seemed that the marketers were trying a little too hard to make a fit for them in dentistry. Early adopters delighted in the esoteric value of displaying a bitewing on a 21″ monitor. The profession in general, however, was not as quick to see the significance.

Digital radiography for example was initially marketed and sold by those focusing on the fact that it provided a reduced radiation dose. The true benefit of digital radiography, which is that it allows for the acquisition of a diagnostic image in a digital format, was not initially understood. The fact that a digital radiograph can be copied and distributed immediately, is mutable, and can be incorporated into a report or digital presentation program, took time to become significant. The distributed nature of a digital image takes on special importance when the coordinated involvement of multiple specialties is required.

Group practices that include specialists in the team have demonstrated the advantage of an integrated interdisciplinary environment. For most practitioners however, the luxury of that physical proximity is lacking. Geographic constraints make it difficult to create comprehensive interdisciplinary treatment plans without referring the patient to each specialty in turn, collecting and collating the data, and then presenting the material to the patient. Patients are being moved, not records, and the redundancies and inconsistencies have the potential to result in chaos. The repetition, time loss, delay, and the sheer inefficiency add to the possibility of treatment rejection. Attempting to bridge geographic gaps, many providers have relied on voice mail, snail mail and fax to correspond with team members at a distance, but these older modes of communication had their shortcomings. The inability to communicate effectively within the interdisciplinary team can result in confusion, misunderstanding, misperception and invariably treatment that is sometimes less than ideal.

Instead, consistent collaborative input from a unified team of providers can help to ensure quality control throughout the process. As many general dentists are equipping themselves to communicate digitally with their patients, we are seeing a gradual growth in the prevalence of digital communication between dentists as well. Collaborative diagnosis and treatment planning is finally becoming an integral part of the patient experience.

The following is an array of digital elements that can contribute to the restructuring of a practitioners’ approach to interdisciplinary treatment and treatment planning:

Digital radiography

As digital radiography becomes increasingly common in the dental mainstream, the value of the axiom, a picture is worth a thousand words, is being renewed. Generalist, specialist, patient, auxiliary; a digital image enables “everyone” to see structure and pathology rather than just describe it. Communicating and reporting online by incorporating imagery into a standard document type such as MSWord or Adobe Acrobat allows team members to communicate with one another regardless of the type of digital radiography implemented in each location.

This digital ‘common ground’ has resulted in an increase in electronically-generated referrals between generalists and specialists, again shrinking the diagnostic treatment timeline. Referral forms on interactive websites expedite the treatment planning process. One image can go to many end viewers. Duplication of films and reduction in quality become anachronisms. All members of a treatment team can view online radiographs simultaneously, thereby facilitating collaborative diagnosis and treatment planning. This invariably engenders a real time discussion that is impossible with reporting letters.

These images can be of use to treatment coordinators in the office for the incorporation into digital treatment plans that the patient keeps with them. The era of ‘smart cards’ in dentistry is not that far away; for now, we can make do with re-writeable CDs in various size formats. As the incidence of litigation based on ‘uninformed consent’ grows, the need for a renewable record for all parties involved in treatment, especially the patient, will invariably become mainstream.

Digital photography

Digital dental photography no longer represents a substantial investment of funds or time. While photography enthusiasts, both film based and digital, can spend significantly in the pursuit of their craft, it is also possible to get started capturing digital photos very modestly and with a limited learning curve. While technical improvements arrive literally overnight, the basic science of imaging has reached a point where a current digital camera will produce results that will be satisfactory for years to come. It is now the norm for dentists to have the ability to capture digital photos in some way. Incorporating these images into PowerPoint or Windows MovieMaker for the purposes of patient education is not nearly as common, but certainly possible for all practices. Before and after photos, customized case presentations, an CD’s burned for patients to review at home are effective marketing materials, but the ability to collaborate with a team, each with their own copy of a digital photo, may be a more compelling reason to look into digital photography.

Digital charts and records

Digital records exist in as many locations as required, and allow a team to simultaneously examine and record details of the patient’s condition. A simultaneous meeting of the digital documents, and the team members including the pivotal member the patient; results in a ‘virtual consultation’. Ownership is a key precept in treatment acceptance. Not only must a patient understand their needs, they must recognize their responsibility to the predictability of the treatment recommended. The dental consumer’s active participation in the discussion at hand makes them a part of the ‘team’ that creates a successful, maintainable and optimal end result.

Chairside computers with Internet connectivity are becoming commonplace. Comprehensive interdisciplinary dentistry has been the backbone of a quality standard of care from the beginning of modern dentistry. Technology has finally caught up with the dental timeline, at least in the realm of communication. The time taken to discuss the proceedings serve to minimize confusion, and enhance the clarity of the proposed treatment, thereby fostering heightened accepta
nce and appreciation of the full scope of the treatment plan.


Emailing images and notes between practitioners is a timely and effective way to share data on mutual clients. In addition, it affords a level of privacy not in force with standard referral forms. The annual costs to a practice are in the range of $1K.

In addition, people answer their email in a routine manner, particularly if it’s business related. Pulling someone away from a procedure to answer a telephone is simply not that easy. For that matter, it’s invariably simpler to review a case when both parties have access to the photographs and radiographs of the patient under discussion. At the very least, prior email communication can keep the amount of time required for telephone conversations to a bare minimum. At best, email eliminates the need to reproduce x-rays, mail referral forms or reports, or interfere with either office’s daily operation until all parties are available for a ‘face-to-face’.

Email peer-to-peer forums

For small groups of up to about 15 users, it’s relatively easy to copy a message to one another using a list created in an Email Client (MS Outlook, MS Outlook Express, etc.). In most situations, this is ideal for a small study group, or team of practitioners engaged in the treatment of a specific patient. For larger groups, a discussion list server will be required to broadcast the email to the membership. There are numerous peer-to-peer forums available. In Canada the site offers numerous clinical discussion groups and provides the opportunity for any group of motivated dental professionals to request the hosting of a private or public list. Provincial and federal associations have begun to request email addresses from their members and are using this modality with increasing frequency and obvious cost savings. The value was demonstrated in the most powerful way during the onset of the SARS crisis. Emailed notifications and forms were received literally on a daily basis; there is no way this type of timely information dissemination to member dentists would have been possible with Canada Post.

Microsoft NetMeeting

NetMeeting is Microsoft’s Internet conferencing solution, which allows multiple users to share text, audio, video, a whiteboard, and transfer files. It comes pre-installed on most Windows PCs, and requires no central server to enable communications. Two or more dentists, in multiple locations, can interface online and collaborate in real time, sharing all required materials digitally. The only prerequisites are Internet connected computers, and a mutually agreeable time to meet. In fact, offices are beginning to schedule online consultation sessions with other members of the treatment team. The ability to bring a patient in to the operatory, pull up their digital radiographs and images, and conference digitally with other specialists is very realistic to implement.

Increasingly, whether through NetMeeting, or the use of chairside email and a treatment room telephone, the digital exchange of information is an expected aspect of the treatment planning process. Just as all general dentists who use digital radiography expect the specialists with whom they work to have the capacity to receive a referral online, so too will it be expected that those involved in multi-disciplinary cases be equipped with at least the minimum requirements for digital collaboration. This means a high-speed Internet connection, an email account in all participating offices, and the ability to share data online in real-time.

The sophisticated consumer of today is using or experiencing digital communication in many of the avenues of their life and their workplace. They shop online, bank online, seek out medical information online, make travel plans online and download entertainment online. As they appreciate the connectivity of the world in which we live, they will be less likely to accept the fact that they need to visit several different locations and meet with several different individuals to plan their dental care when digital data conveyance of the information is readily at hand. In the past, bringing the various specialists into the office on a rotating basis obviated this problem. This is not, however, a reality for most practitioners and an alternative is required. A logical implementation of technology has a ‘leveling effect’ and allows smaller offices to create a similar experience without needing to bring the specialist physically onsite. Ultimately, communication in whatever form between members of an interdisciplinary team provides the patient with more definitive options, more optimal treatment and invariably the acceptance levels of treatment increase dramatically.

You can practice dentistry without being connected to the Internet, just as you can also practice dentistry without incorporating any of the new materials, techniques or technologies that appear literally on a monthly basis; but for how long in an world of increasingly educated consumers? The expectation of minimizing redundancy, sharing relevant clinical data, and interacting in concert regardless of the number of players is no longer an impending event in the day-to-day armamentarium of dentistry. It is here and it is now.

Technological change is a process of fits and starts, but inevitable progress promises that yesterday’s impossibilities will become today’s magic, and tomorrow’s routine. As connectivity and computerization is becoming a pervasive presence in every dental environment, a new set of exciting, and heretofore unexpected possibilities is becoming available.

Craig Wilson is the CEO of Compudent Systems Inc., an IT company specializing in customized computer installations for dental offices. Dr. Ken Serota is an endodontist practicing in Mississauga, ON.