Conclusions. Based on recent experiences of hospitals and medical practices, dentists can expect to encounter revolutionary changes as a result of the digital transformation. The Internet, the World Wide Web and other developments of the information revolution will redefine patient care, referral relationships, practice management, quality, professional organizations and competition.

Practice Implications. To respond proactively to the digital transformation of oral health care, dentists must become familiar with its technologies and concepts. They must learn what new information technology can do for them and their patients and then develop creative applications that promote the profession and their approaches to care.

The lessons and promise of digital transformation now can be applied to dentistry, suggesting changes that are not foretold by the clinical sciences and dental technologies that have shaped the profession’s evolution. This new force is the result of tools that only recently have been perfected—networked computing and digitized information. Dentistry may have avoided most of the undesirable effects of managed care and government regulation, but it will not escape digital transformation. The good news is that dentists and patients ultimately will benefit from the two major results of this revolution: teledentistry and electronic commerce, or e-commerce.

	DIGITAL TRANSFORMATION OF DENTISTRY

TOP ABSTRACT DIGITAL TRANSFORMATION OF... TELEDENTISTRY E-COMMERCE IMPLICATIONS AND CHALLENGES CONCLUSION REFERENCES

 
Although dental science and technology made remarkable advances during the 20th century, the nonclinical aspects of day-to-day practice changed relatively little in comparison. Diagnostic images were recorded and stored on film throughout the century, even though the tools of radiology and intraoral photography constantly improved. Patient records were paper documents stored on shelves or in file cabinets. Only the method of writing changed—from fountain pen to typewriter to word processor. Business records were no different, although the medium varied from plain paper to forms to computer printouts. Integrated studies of dental practice, such as cost-effectiveness analysis, were tedious because data had to be collected from many different and unstandardized sources. Dentists spent untold hours trying to improve practice management via continuing education, but the effort was constantly hindered by the complexity of documentation and record-keeping systems.

This longstanding problem is effectively solved by the digitization of practice. Technologies to manage all dental information in a single, consistent format are starting to be marketed at an accelerated pace. Oral images now can be captured and stored in one step (that is, digital acquisition); no paper or film is required.² All financial transactions can be conducted at an easy-to-read electronic screen. Information from different sources can be retrieved and displayed on a single monitor at the same time, creating all sorts of new possibilities for improving patient care in general and the doctor-patient relationship in particular. Following are a few examples that illustrate the impressive realm of new opportunities created by digital transformation:

– The dentist and patient can jointly examine preoperative and postoperative views of dental conditions by displaying radiographs and photographs on a computer screen.

– A dentist can access all practice records from home, preventing scams like having an unfamiliar patient call late at night with a fraudulent request for narcotics.

– Legitimate prescriptions can be written at the dentist’s workstation and submitted electronically, with built-in mechanisms to detect errors and improve accuracy.

– The entire office staff can have access to necessary records at chairside terminals, eliminating the inefficiencies of retrieving and refiling paper records.

– A practitioner can study a digitized image in detail by changing its density, zooming in on an area of interest, or manipulating it to study possible interventions.

With existing digital technologies, the entire collection of a typical practice’s records can be reduced from dozens of shelves and filing cabinets to a digital storage unit smaller than a shoebox. Alternatively, the same information can be stored off-site on a server shared with other users and accessed as needed over the Internet. (Indeed, growth in the use of applications service providers and other fractionated network services is likely to be phenomenal, because dentists can rent the digital capacity they need without having to buy a complete information system.) For purposes of research or quality improvement, an entire practice’s records can be reviewed to identify all patients who have a certain condition that might be corrected by a new procedure or material.

Knowledge is power, so the benefits of digital transformation will become immediately clear to dentists who explore its potential. The digital practice of the 21st century will be better than its film-and-paper precursor because information will flow seamlessly and immediately to the place where it is needed. However, two perceptual roadblocks—concerns about security and cost—seem to hinder many dentists from seriously considering the digitization of their practices. These concerns were well-founded in the past, but recent advances in both areas suggest that digital transformation should now be a key element in practice planning for 2001 and beyond.

The state of the art in computer security has advanced during the past year to the point where digital records can be safer than paper records.

Security. The state of the art in computer security has advanced during the past year to the point where digital records can be safer than paper records when systems are properly managed. Peripheral devices for retinal scanning, voice recognition, electronic signatures and fingerprinting now can authenticate the identity of the person requesting access to the file. A user’s authorization to see the data then is verified; access is denied if the person does not have the right to know the requested information. Data can be transmitted in encrypted form (that is, scrambled before transmission by a complex mathematical process and then reassembled at the authorized user’s end with use of the same secret code). Further, a properly configured system can keep complete records of every person who accesses information as well as all changes made to the data. Confidentiality and security of electronic records will receive even more attention in 2001 as the federal government begins to implement the Health Insurance Portability and Accountability Act.

Cost. The cost situation also has improved during the past few years. Prices on computer hardware have plummeted while functional capabilities have increased. As a rough rule of thumb, a system with constant specifications in terms of speed and storage probably costs half as much today as it did a year or two ago. (Conversely, a buyer often can purchase twice as much computing power today for a one-year-old price.) However, the most important economic improvement is the rapidly declining need to invest in infrastructure. The Internet, now accessible for a few dollars per month, provides data communications capabilities that required an expensive, dedicated line only a few years ago. Also, improved telecommunications engineering (for example, compression technology) has greatly increased the amount of data that can be sent over standard telephone lines. Software can even be rented over the Internet for a fixed monthly fee or a per-use charge, thus eliminating the need to buy an expensive package and install it on the office computer. As noted above, data can be stored securely on central servers, eliminating the need to buy massive hard drives for the dental office. Necessary on-site equipment—to the decreasing extent that on-site equipment is needed—can be leased.

At the bottom line, the costs of participating in the digital transformation of dentistry are falling fast. The number of available options in both hardware and software has risen just as impressively. Any dentist who recently rejected a digital investment should reevaluate the decision now, if only to communicate with patients who are incorporating the same tools into their daily lives. Given the rapid proliferation of digital communications in the United States, even more consumers will come to expect electronic interaction with their suppliers—including dentists.

	TELEDENTISTRY

TOP ABSTRACT DIGITAL TRANSFORMATION OF... TELEDENTISTRY E-COMMERCE IMPLICATIONS AND CHALLENGES CONCLUSION REFERENCES

 
Teledentistry will be the clinical dimension of the new doctor-patient relationship. Although the term has not yet entered our everyday vocabulary, it should quickly become a cornerstone of modern dental practice. A recent definition of telemedicine helps identify the emerging realm of teledentistry:

"Telemedicine is the combined use of telecommunications and computer technologies to improve the efficiency and effectiveness of health care services by liberating caregivers from traditional constraints of space and time and empowering consumers to make informed choices in a competitive marketplace."¹

The concept of teledentistry can be understood easily by substituting dentistry for medicine in this definition. Dentists, like their physician counterparts, increasingly will use networked computers to deliver care in ways that do not require face-to-face contact with patients, and consumers will approach dentistry in new ways because they will have more oral health information than ever before. The transition from the 20th- to 21st-century dental marketplace will be difficult for those who resist it, but 21st-century dentistry will be a better value in terms of both cost (efficiency) and quality (effectiveness).

Virtual-reality software will allow patients to compare potential changes in function or form.

A few examples of teledentistry’s benefits will help dentists and patients start thinking about a realm of possibilities that only a small number of people have begun to explore:

– Online health care consumers—estimated to be 30 to 35 percent of the adult population in 1999, and growing fast—will be able to complete all registration procedures and health histories from home before coming to the dental office (for example, "www.frost.com"; "www.forrester.com"; "www.eratings.com").

– Monitors in the operatory will allow patients to take real-time "guided tours" of their own mouths, allowing dentists and hygienists to personalize patients’ understanding of their oral conditions and empowering patients to assume responsibility for their own oral health.

– Patients will be able to use digital cameras, home diagnostic kits and other Internet-enabled devices to send key health status indicators (for example, blood pressure, blood glucose levels, images of swelling, use of prescribed medications) directly to the dental office and into their dental records.

– Virtual-reality software will allow patients to compare potential changes in function or form based on different clinical interventions, such as observing how facial appearance might be changed by oral surgery.

– General dentists will send multimedia patient records (that is, including images, text and sounds) to dental specialists, often enabling the specialist to make a diagnosis and develop a treatment plan without having to see the patient in person.³

– Dental specialists will be able to provide remote support for physicians who are addressing problems with oral dimensions (for example, an oral surgeon using a video link from his or her home can help a plastic and reconstructive surgeon decide which teeth to keep during a middle-of-the-night emergency operation on a patient with serious head trauma).

– Interprofessional communications will improve dentistry’s integration into the larger health care delivery system and give dentists an unprecedented opportunity to enhance dentistry’s reputation with other health care professionals, such as radiologists, other physicians, psychologists, pharmacists and nutritionists.

– Second opinions, preauthorization and other insurance requirements will be met almost instantaneously online, with the use of real images of dental problems rather than tooth charts and written descriptions.

Patients will go to the World Wide Web to obtain personalized information about their own oral health or to find a dentist who is prepared to meet their needs in terms of such criteria as practice philosophy, financial arrangements, location, hours and Web presence.

These examples of emerging clinician-patient relationships in dentistry all are possible now; none requires a technology yet to be developed. However, some surprising extensions of teledentistry are likely to develop. For example, telepresence surgery someday may allow a remote specialist to manipulate operative instruments in a primary care dentist’s office via computer commands so that the patient gets immediate specialty care and does not have to go elsewhere for surgery. Dentists also will be able to participate in large-scale clinical trials of new materials and procedures (for example, online hypothesis generation and patient recruitment), as Internet-based research companies—already established in medicine and pharmacology—extend their reach to dentistry. Indeed, the ultimate breadth and depth of teledentistry are more likely to be limited by imagination than by technology. Teledentistry quickly will become much more than a mechanism to facilitate interactions between generalists and specialists.

Teledentistry also will improve the skills and knowledge of dental professionals. For example, Internet-based continuing education started to blossom in the late 1990s, and online testing methods are being developed to test practitioners’ competency on a regular basis. Instruction can be tailored to the way that individual dentists learn most effectively. Special-interest chat rooms, online journal discussions—even online journals—will be used to keep dentists up-to-date at little or no cost. Also, dentists with special teaching skills but limited ability to travel (because of such factors as family obligations, physical disabilities and remote practice locations) will be able to establish a virtual presence in continuing dental education, creating some competition for the established gurus who have dominated the field in recent years. In other words, it is a whole new ballgame.

	E-COMMERCE

TOP ABSTRACT DIGITAL TRANSFORMATION OF... TELEDENTISTRY E-COMMERCE IMPLICATIONS AND CHALLENGES CONCLUSION REFERENCES

 
Although dentist-patient interactions (generically called business-to-consumer, or B2C) will develop substantially during the coming years, most e-commerce in health care has been business-to-business, or B2B. Dentists already can participate in the B2B marketplace by ordering equipment, processing claims, buying supplies, registering for continuing education courses, making travel arrangements, consulting library resources, placing advertisements and participating in auctions. Many more B2B services will be developed because entrepreneurial doctors and venture capitalists are forming joint ventures on a regular basis.

The development of e-commerce in oral health care can be understood and followed in at least five product dimensions:

– connections—the telecommunications linkages that connect dentists to the World Wide Web and the Internet;

– applications—the software that organizes defined business functions;

– goods—disposables and other supplies needed to operate the buyer’s business;

– services—records maintenance, advertising, transactions clearing and other business support activities;

– information—direct access to databases, publications, educational resources, insurance eligibility and benefits, and credit reports.

Dentists should look for some unfamiliar benefits as e-commerce matures because the Web and the Internet are much more than new tools that do old jobs. They also create possibilities for doing new things. For example, buying supplies electronically will not necessarily be much different from making the same purchases by telephone using an 800 number, but buying through a dental auction site will be a much different experience. Dental practices also will be able to develop their own customized Web sites, allowing dentists to add a new dimension of service for the growing number of patients who are managing their lives with the help of the online world. Finally, dentists will be able to create and join electronic communities formed around shared practice philosophies, specific clinical interests and identifiable approaches to patient relations.

	IMPLICATIONS AND CHALLENGES

TOP ABSTRACT DIGITAL TRANSFORMATION OF... TELEDENTISTRY E-COMMERCE IMPLICATIONS AND CHALLENGES CONCLUSION REFERENCES

 
The digital transformation of oral health care promises many exciting changes during the next few years. However, like any revolution, it will not be easy or painless. Initially, there will be several skeptics for every true believer. Some traditionalists will oppose teledentistry openly—refusing to believe that its initial problems can be solved. Many people and organizations will struggle to cope with learning to use a keyboard or mastering the new vocabulary of the electronic age. Nevertheless, dentistry cannot seek a long-term exemption from the Internet-based world of 21st-century health care, and the speed and success of its transformation can be affected positively by the right professional leadership.

This leadership should come soon from organized dentistry. In particular, national and state dental societies must develop and implement plans for their own digital transformation—including state-of-the-art capabilities to provide public information about dentistry, electronic journals, Web-accessible libraries, fully automated records, research management, continuing dental education and other online membership services.⁴

Dental associations are still in the best position to provide meaningful guidance and to lead by example, but the advantage could be quickly lost. Marginal costs are extremely low for a for-profit Web business that already has developed the infrastructure to offer services traditionally provided by voluntary (that is, dues-supported) organizations. In other words, new information technologies dramatically increase professional associations’ vulnerability to competition from for-profit ventures.

Therefore, to maintain their relevance, voluntary dental organizations must expeditiously launch services that will help their members deal with this dynamic revolution. Meaningful programs would teach skills such as how to manage an effective dental practice Web site, how to conduct a financial analysis of alternative technologies and e-business arrangements, how to address legal and ethical issues of teledentistry⁵ and how to use the new tools for better practice management and continuing dental education.⁶

Dentists must take initiative by becoming comfortable in the electronic world. They must begin by understanding not only how their practices will be affected by the digital transformation of health care, but also how they and their patients can benefit from appropriate development of teledentistry. Any dental practitioner who aspires to be successful at the end of this decade should learn how to use e-mail on a daily basis, surf the Web, obtain online information, make online purchases and conduct basic business electronically. Also, dentists should start learning how to develop a Web site for the practice. A "dot-com" presence is probably not essential for survival in 2001, but being in business without one much beyond 2005 is hard to imagine.

Last, but definitely not least, the patient perspective merits serious attention because the ultimate result of digital transformation will be consumer empowerment. People who care about their oral health will have unprecedented access to electronic information about dental disease, alternative approaches to therapy, cosmetic interventions, comparative fee structures, different payment arrangements, dentists’ qualifications, office hours, appointment procedures and just about every other imaginable aspect of dental practice.

	CONCLUSION

TOP ABSTRACT DIGITAL TRANSFORMATION OF... TELEDENTISTRY E-COMMERCE IMPLICATIONS AND CHALLENGES CONCLUSION REFERENCES

 
Anyone who questions the likelihood of such outcomes should study existing health care Web sites (Box, "Health Care Information on the Web: Sample Sites"). He or she will see that many services commonly associated with the future are already here. The good news is that the digital transformation of oral health care is in its early stages of development, and now is not too late to join the revolution. Visionary leaders still have a chance to shape its progress from within the profession if they act sooner rather than later.

View larger version (142K): [in this window] [in a new window]   Dr. Bauer is senior vice president, Superior Consultant Company Inc., Southfield, Mich., a provider of digital business transformation services to the health care industry. Address reprint requests to Dr. Bauer, P.O. Box 7, 34088 Road X, Hillrose, Colo. 80733, e-mail "Jeff_Bauer{at}superiorconsultant.com".

View larger version (127K): [in this window] [in a new window]   Dr. Brown is president, Brown Dental Group, P.C., Des Moines, Iowa.