As vice chair of the ADA Dental Informatics & Digital Health Committee, Dr Stephen Liew can see firsthand how the digital revolution of recent years continues to change dentistry in profound ways. By John Burfitt
2018 may only be two years ago, but in the digital landscape, that might as well be a lifetime in terms of the unrelenting shifts in direction of dentistry.
Dr Stephen Liew has been watching those unfolding changes closer than most, in his role as vice chair of the Australian Dental Association Dental Informatics & Digital Health Committee (DIDHC). Back in 2018, he noted dentistry was more accepting of rapid digital changes than most other medical fields.
“Dentistry seems to be way ahead in terms of the adoption and willingness to adapt to new eHealth measures,” he told the ADA News Bulletin. “We have a choice over whether to embrace it for the good of our profession and patients, or sit back and get left out.”
He also pinpointed three key areas of dentistry demanding focus to stay ahead of the game—the My Health Record system, ePrescriptions and secure messaging.
In an interview with Bite, Dr Liew reflected on his 2018 comments and admitted he was pleased the DIDHC had made progress on each of those points, and was now getting ready for the next round of developments.
“Among other stakeholders, we made sure to convene meetings with vendors to collate their views on implementing new eHealth programming and use those to inform our position on dentistry in the eHealth environment,” Dr Liew, a graduate of the University of Melbourne, says. “The past few years has seen the committee become one of the most important for the ADA in planning for the next decade.”
The creation of the Australian Digital Health Agency in 2016 provided an important focus to the digital future of all professions within the medical field. The ADA’s DIDHC has been represented in a variety of working groups the government agency has set up.
“The ADHA had a difficult task bringing everyone along for the ride but we are now at a stage where we have the backbone of what we want to make the eHealth environment in Australia more useful for all,” he says.
My Health Record
Of the three areas the DIDHC initially focused on, the big breakthrough was the introduction of My Health Record, so dentists can now access a patient’s complete medical records to gain a more cohesive view of their health history and regimes.
“We needed to link to those other details, so all medical practitioners are on a consistent playing field with patient data,” Dr Liew explains. “This has proven vital in the case of dentists dealing with older patients with dementia or similar conditions, who can’t recall the other drugs they’re on or who have carers who do not have access to that information.”
MHR has proven useful in how dentists can decide on procedures and treatment plans, Dr Liew adds.
“MHR has allowed us to keep our patients safe, by avoiding drug interactions and providing information that allows us to determine the best way to prescribe treatments.”
For all its many benefits, however, Dr Liew believes some streamlining of MHR is still needed, as he discovered recently when undertaking a trial at his own practice, Camberwell Dental Group in Melbourne.
“I have nine practitioners and I wanted to connect us all up to MHR,” he says. “The number of steps it required proved very time consuming, but we managed to get there. My hope for the future it that one day we can access our patients files safely and securely, but in just one click.”
The rollout of computerised prescriptions began in late 2017, with an added feature of the system being that prescriptions are automatically loaded into patients’ records.
Dr Liew says there has been a good uptake of the process in dentistry, with the next frontier being ePrescribing which will enable the uploading of prescriptions directly to the pharmacy system. The ADHA is currently working with stakeholders but dentistry will have to wait a few more years before it has this functionality.
Secure messaging, allowing the secure exchange of confidential information between healthcare providers, has remained in development over recent years, with much of the focus on ironing out various kinks. Some issues have been privacy concerns when using internet servers based outside of Australia as well as the problems of sharing information when the sender and recipient do not have the same encoding and decoding capabilities.
In May 2019, the ADHA offered $30,000 grants to software vendors to help fund the integration of new features into existing systems, to better facilitate the exchange of information across differing platforms.
Also, the ADA is continuing to monitor the Systematised Nomenclature of Dentistry (SNODENT) program, a deviation of the SNOMED system used by general practitioners and specialists.
The ADHA is now determining if both systems are necessary and the ADA is considering how the SNODENT codes should be managed. It was hoped developers would deliver enhanced secure messaging capability by earlier this year, but this was interrupted by the COVID shutdown.
Dr Liew, however, remains hopeful there will be a breakthrough within the coming months. “It would be nice if by the end of the year the medical community can communicate effectively this way,” he says optimistically. “The one thing this hangs on is deciding what procedures in dentistry are truly relevant in the context of the overall medical state of the patient, and how this can work so all parties stand to benefit from this. It’s a matter of deciding what those parameters are. For example, a fissure sealant is not really a high impact procedure that needs to be recorded in a national electronic record to make other medical providers aware.”
In a 2015 report by Lloyd Insurance and Cambridge University, Sydney and Melbourne were ranked 12th and 15th as the most at-risk cities in the world of cyber attack. Dr Liew says an increased number of digital ransom attacks on Australian practices have been reported.
“Thankfully, there is far more awareness of this risk than a few years back, with more talk about cyber insurance and safeguards needed for a practice,” he says.
“Once a hacker has your patient data and locks you out of your own system, you are crippled. The ransom that can be placed on health data is considerable, and we need to remember that the personal data we hold is considerable. A business like a dentistry practice is ripe for the picking.”
The DIDHC has a range of resources available about what to do in the case of an attack, how to prevent it and what insurance is available. Dr Liew says the approach to this issue has undergone a significant change in recent times.
“I recall talking about cyber insurance in a meeting only a few years ago and back then, it actually sounded a little ridiculous. Now, it needs to be looked into, sooner rather than later.”
One of the new frontiers on the digital horizon is the application of artificial intelligence (AI) in dentistry.
There has also been increased examination of artifical intelligence within the academic dental community as well as by the DIDHC.
“I have been approached by a university looking into AI to diagnose a range of dental issues and we also have two colleagues on the committee that provided advice to a US-listed AI start-up group,” Dr Liew says.
He predicts AI will play an important role in the future of dentistry, and all possibilities should be up for consideration.
“It would be silly not to use it where appropriate, but we do need good guidance to protect users from harm and ensure the diagnostics are correct. So, all aspects of artifical intelligence and how it can be utilised safely are on the agenda right now.”
The age of COVID-19
One of the key responses by Australian dentistry to the COVID-19 pandemic was the release of item number 919 on the Australian Schedule of Dental Services and Glossary to allow for telehealth consultations. This proved particularly useful for patients in self-isolation during the shutdown.
Accompanying the development of the teledentistry item was a Guidelines for Teledentistry, created to explain how and when to use the new item number. “This was an important step as it was fast-tracked, in order to give a lot of our patients peace of mind when they needed a dental consultation but were not allowed to leave their home,” Dr Liew says.
Lessons on limitations
The dental experience during Australia’s COVID shutdown proved to be full of lessons—not just about the reach of technology but also about some of dentistry’s core values.
While digital avenues proved ideal to bridge communication gaps for consulting in a time of limited social contact, Dr Liew believes it also proved the limited efficacy of technology in such a procedure-based profession, and highlighted that the human connection between dentist and patient cannot be replaced.
“A practitioner’s physical presence, and ability to provide treatment during the dental consultation still supersedes anything,” he says. “In dentistry, some things cannot be replaced. We can get to a stage where AI can determine dental caries, but the key thing is how do you then explain what that means to a patient with empathy, patience and caution, and perform the treatment successfully?
“When it comes to the nuance of human interaction in health, that simply can’t be achieved through technology. I’m not convinced it ever will.”