Remote Clinical Consultations in Restorative Dentistry for Primary Care

In the UK, general dental practitioners (GDPs) in primary care are supported in the patient-care decision-making process by specialist consultants in the NHS secondary care sector. The consultation takes place as an 'in-person' event in secondary care centres (E.g. Teaching or district hospitals). The primary outcome of the consultation is to provide the patient and the referring GDP with the required specialist advice and a patient-centred care plan for the management of the referred condition. The care plan is in the form of a letter-report and consists of a summary of findings, diagnoses, prognoses and a treatment strategy. This is relayed to the patient verbally during the consultation and in a written letter-report format to the referring clinician, copied to the patient and appropriate stakeholders. This model is used ubiquitously for oral health care and other medical services.

Efficiency and effectiveness are largely compromised in an in-person specialist consultation. Efficiency is compromised by the need for the patient to travel to the remote location of the specialist referral centre. Further suggested inefficiencies are the time-lag between completion of the consultation and the follow-up with the referring clinical team. Effectiveness is equally limited due to the potential for the primary care clinician to misinterpret, not be able to comprehend or be unable to carry out the suggested plan; which may in turn lead to frustration and lack of desired appropriate action.

There is a drive to deliver this service in a more patient-centred, cost-effective, efficient manner, addressing the NHS plan for a 30% reduction of OP visits (NHS Long Term Plan v1.2, August 2019), and in an environmentally sustainable manner by reducing unnecessary patient travel - 31% of NHS-Dentistry carbon foot print. Remote Clinical Consultations (RCC) have the potential to offer this service by linking both the primary care clinician and the patient (co-located in the dental practice) to a remote specialist consultant, using super-fast internet connectivity. This enables them to hold a live 3-way patient-centred discussion about the patient's care needs.

RCCs can operate using a platform of secure internet-based, high-resolution, multi-channel audio-visual streaming that enables simultaneous sharing of information and communication between primary and secondary care, leading to integrated management of patient care between the three parties (patient, doctor/GDP and consultant) at the point of specialist treatment planning , , . The concept of 'no decision made about the patient without the patient' is central to this process, so that the patient is present for all discussions and have an informed say in the decision process' . RCCs shifts the decision-making-process from a one-to-one scenario (clinician-patient or GDP-patient or clinician-GDP) to group decision making with all three stakeholders present in the dialogue in a contemporaneous manner; a care model that is in line with the need for increased patient involvement in the NHS treatments.

Tele-dentistry holds the potential for facilitating true group-decision making between the three key stakeholders; patient, GDP and specialist consultant. Studies on the factors required for effective group-decision-making have shown that doing so using remote connectivity can be at least as effective as face-to-face in person.

A collaborative system using tele-communication through the use of telemedicine, dental image tools, sharing electronic patient records and videoconference, helps to establish a cooperative diagnosis, treatment planning and professional mentoring in the field of dentistry , , .

Potential advantages of RCC

A combined system, using super-fast broadband connectivity and advanced multimedia communication technology enables the provision of RCC with the following advantages:

• Patient not required to travel to a remote location.
• A consensual treatment planning process with both the GDP and the patient present during the whole process.
• A more patient centred process, with less inconvenience to the patient.
• A shared database, as part of the bespoke system, could use smart auto-populating templates for report generation, so the report could be easily created within the appointment.
• Reduced risk of miscommunication and eliminate replication of work (x-rays, etc.).
• Potential for professional education as the GDP will be participatory to the process.
• Potential for a faster process from referral to treatment.
• Hospital overheads will be reduced with the elimination of a dedicated clinical surgery and support staff.

RCCs can operate by using a platform of secure internet-based, high-resolution, multi-channel audio-visual streaming that enables simultaneous sharing of information and active, engaged discussion between primary and secondary care, leading to integrated management of patient care between the three parties (patient, doctor/GDP and consultant) at the point of specialist treatment planning.

This initiative is at the core of the 'NHS Long Term Plan' (www.longtermplan.nhs.uk. January 2019) that emphasises a commitment to reduce face-to-face outpatient appointments by up to a third over the next five years. The director of the national Elective Care Transformation Programme highlights that the driver for this plan is "…to save patients time and money, it will allow staff to work in the most efficient and satisfying way, reduce pollution from road travel, and save the NHS more than £1 billion a year" (https://www.england.nhs.uk/blog/long-term-plan-will-be-a-game-changer/).

RCCs shifts the decision-making-process from a one-to-one scenario (GDP-patient, Consultant-patient, Consultant-GDP) to group decision-making with all three stakeholders present in the dialogue in a contemporaneous manner; a care model that is in line with the need for increased patient involvement in the NHS treatments. A collaborative system using tele-communication through the use of telemedicine, dental image tools, sharing electronic patient records and video-conference, helps to establish a cooperative diagnosis, treatment planning and professional mentoring in the field of dentistry.