Telehealth Best Practices: Dr Sean Boynes of CareQuest Institute for Oral Health On How To Best Care For Your Patients When They Are Not Physically In Front Of You

Establish and maintain a strong patient-provider relationship. When it comes to teledentistry, one of the great benefits is that it expands access to people. Because of this, there’s a chance you will be seeing and meeting many new faces via teledentistry. So, it is important to establish a strong foundation of trust and build rapport, and continue to maintain one each time you see them.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Sean G. Boynes.

Sean G. Boynes, DMD, MS, serves as Vice President, Health Improvement for CareQuest Institute for Oral Health. Sean leads the organization’s health improvement programs, partnering with public and private stakeholders across the health continuum to develop, test, and measure prevention-focused, person-centered strategies.

A dentist anesthesiologist and prolific author and speaker, Sean is a catalyst for systems change — testing ideas and identifying solutions to create a more equitable, accessible, and integrated health system, especially for historically marginalized people and communities. He spearheads several initiatives, including national programs that promote the integration and coordination of person-centered care, the development and implementation of value based oral health strategies, and the establishment of meaningful oral health measurement to evaluate success.

Sean has been recognized by a number of national organizations for his work in health policy and clinical care. Recognitions include: National Health Service Corps’ 40th Anniversary Celebration 40 Top Clinicians award, Distinguished School Services Award from the South Carolina School Nurses Association, Dentist of Distinction designation by the National Children’s Oral Health Foundation, and the National Network for Oral Health Access President’s Award.

Sean earned his doctor of dental medicine degree from the University of Pittsburgh and completed a three-year residency in anesthesiology from the University of Pittsburgh Medical Center.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

I’ve always wanted to be a dentist. I think I was so drawn to the profession because I experienced early childhood dental disease and decay. My high-risk status meant that I was frequently at the dentist office and even had to undergo sedation at a relatively young age. My childhood experiences with dental treatment weren’t great. That is what drew me to the profession. I wanted to become a dentist to help make the oral health care experience better for everyone. Fast forward to today and now I am a dentist anesthesiologist. While my experiences shaped what I do, what I am is more ingrained in family and culture. I am the son of a coal miner and grew up in a small rustbelt town in northern Appalachia, Weirton, WV. The town is home to one of the largest steel mills in the country, once dubbed the “mill of tomorrow” and featured in multiple movies like Deer Hunter, Reckless, and most recently Super 8 from JJ Abrams and Steven Spielberg. (Super 8 is a pretty good rendering of my childhood — minus the alien of course). Because of the steel boom and the prosperity that came with it, individuals from all over the world came to my town for an opportunity to get a good wage. This allowed me to grow up in a multi-cultural environment and learn different customs important to different people. It also allowed me the opportunity to understand how certain structures in society can affect people in different ways. I saw firsthand peoples’ ability to overcome adversity and create change which has inspired me in the work I do at CareQuest Institute for Oral Health.

Can you share the most interesting story that happened to you since you began your career?

Early on in my career I was an oral health provider in the rural south. One day just as I was ready to close up the clinic, a large pickup truck with a horse trailer pulls into the parking lot. Assuming it was an emergency patient, I went out to see what was going on. The gentleman explained that he was from a few counties over and that I was the nearest dentist he could find. We were in a very rural area so that made sense to me. But the next words out of his mouth took me for a loop. He continued to explain that he was not the patient. It was the horse!

His horse had chipped a tooth and it was causing enough discomfort that the horse was bucking incessantly. I’d never performed equine dentistry before but with the help of a veterinarian friend on the phone, we were able to smooth out the chipped tooth and send the horse and his happy owner on their way.

Not only was that one of the most interesting stories from my early career but it also might be one of the earliest examples of interprofessional care and telehealth in oral health!

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

Admittedly I have a rebellious streak, so I am going to bend the rules and give you two quotes.

The first is attributed to Socrates and becomes increasingly relevant as I age. “The secret of change is to focus all of your energy, not on fighting the old, but on building the new.” To me it means some things are not meant for changing and that’s quite all right. Instead of focusing on the things we can’t change, we should focus on the future and the new things we can create.

The second is from the one and only, George Carlin. “I put a dollar in the change machine, and nothing changed.” The work of transforming health care to improve peoples’ lives can be incredibly difficult work that requires a lot of piloting, testing and redesigning. It is good to have a sense of humor about it when it is time to go back to the drawing board. This Carlin quote reminds me of that.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

There have been so many mentors, colleagues, students, friends, and family who have helped me grow and evolve throughout my career. But I always go back to the very beginning. My grandma was a great influential figure in my life right from the start. She taught me the importance of a purposeful life and introduced me to philosophy. She encouraged me to explore the concepts of right and wrong and bought me books of quotes arranged by topics that shaped my world view in a way that I did not fully appreciate as a kid. I learned to never accept the status quo without true consideration and interrogation of the facts. Her influence led me to a career focused on continual improvement and the betterment of people’s lives in meaningful ways.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

As health professionals, one of our favorite parts of the job is interacting with patients face-to-face. Beyond treating and caring for patients, I’ve always loved getting to know the people I serve to build lasting, trusting relationships.

While teledentistry allows for face-to-face interactions virtually with video conferencing, in-person interactions will always be an important part of dentistry. In-person interactions allow dental team members to build rapport, understanding and ultimately trust with patients. It gives us the opportunity to connect on a more emotional level. For example, we can better celebrate with those who have just gotten their braces off or empathize with a patient who may be nervous about a particular procedure or circumstance.

In-person interaction can be especially beneficial when talking about important health issues. As the provider, the personal touch can help ensure our patients understand us clearly and vice versa. We can more easily clear up any confusion, questions or miscommunication.

Another benefit of having patients in front of us is that we are able to immediately provide them with a full range of services — from preventative care to emergency care. After all, dentistry is still a hands-on profession with the majority of treatment requiring direct contact with an individual.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

Teledentistry has enabled dental teams to expand access to needed services and treat more patients at lower costs. Integrating more telehealth-enabled care into dentistry is the future, but today, there is still a need to ensure that patients have a dental home and can access care for more comprehensive treatments in a physical setting.

One challenge with virtual care is ensuring that patients can access in-person follow-up care when needed. For example, if a dentist performs a virtual evaluation and determines additional treatment is needed at a dental office, there is no guarantee the patient will be able to take time off work or have access to transportation — or that there is even a dental office within a reasonable distance from the patient’s home. Without in-person visits, we can’t provide certain services critical to good oral health. Additionally, it can be more difficult to gather all of the sufficient information needed to ensure the best possible health outcome. Teledentistry, especially during COVID-19, has worked great to prescribe medications, conduct a visual exam, provide hygiene instructions or triage/evaluate for risk, but being in-person enables us to more adequately and holistically diagnose and provide any needed surgical care like fillings, crowns or tooth extractions.

Another challenge can be technology and broadband. Accessibility is an issue. Many families, particularly low-income families and those in rural areas — two population groups who we are most concerned with improving access to care — still lack access to basic broadband. And those that do have access — particularly our seniors — may not be as comfortable or savvy with technology. This presents communication barriers to our dentists that we must work to improve training and education.

While many dental offices have invested in teledentistry technologies, our policies are still catching up. Teledentistry and telehealth policies differ from state to state. It is broadly allowed in most states, but some have stricter laws limiting its use or don’t yet have reimbursement policies in place. Government investment in broadband can make a big difference in ensuring that everyone has access to care when they need it.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)

1 . Establish and maintain a strong patient-provider relationship. When it comes to teledentistry, one of the great benefits is that it expands access to people. Because of this, there’s a chance you will be seeing and meeting many new faces via teledentistry. So, it is important to establish a strong foundation of trust and build rapport, and continue to maintain one each time you see them.

When online, it can be easy to jump from appointment to appointment without really getting to know your patient. So, it’s important to remember to go into each teledentistry appointment with the mindset of creating a positive experience for the patient — one that is engaging, informational and fun. For new patients in particular, be mindful of their environment and past experience with oral health care.

It’s important to let patients know they are in good hands and that even online their privacy is secured. Be thoughtful of how you engage and your body language — sometimes enhanced body language is needed to create an engaging environment. Be on time and be sure to schedule necessary follow-ups.

2. Clear communication. As mentioned, communication can sometimes be a bit more difficult virtually. When using the phone or video conferencing, it’s important to be clear in your directions or instructions. Medical jargon can already be intimidating and confusing to patients and adding a layer of distance between the two of you can make it even more so. Be sure to talk clearly, slowly and in simple terms, especially when giving important advice or information on things like prescriptions, hygiene or anything critical. Use visual aids when possible. Be sure to ask if they have any questions and clarify anything they may not understand.

3. Advocate for telehealth technologies and policies. In order to best care for your patients remotely, you need to be an advocate for policies and technologies that best enable you to do so. The pandemic served as jumper cables for telehealth broadly and teledentistry specifically. With support from the federal government, states and state boards of dentistry eliminated a number of barriers to teledentistry overnight. With greater flexibility and ease of reimbursement, we saw an increase in the adoption of teledentistry but challenges remain. The reality is that telehealth policy varies widely from state to state which greatly impacts access for high-need patients. As an oral health community, we need to continue to work with state legislators and regulators to evolve policies to give us the tools necessary to meet patient needs and an increasingly digitally enabled and interconnected world.

We should be advocating for the extension of the reimbursement rates for teledentistry well beyond the pandemic. And broadband technology is now our issue as well. We should encourage our state and federal partners to make broadband accessible to all. This will not only help historically marginalized populations access care but it will benefit the entire health system.

4. Engage other medical providers and information. Another great benefit of teledentistry is its ability to easily connect with other providers and develop a more integrated, holistic care approach. Oral health is directly linked to overall health, with ties to chronic illnesses and mental health diseases. It’s more important than ever to ensure medical and dental care are truly integrated. With teledentistry, you can seamlessly connect with patients’ other health care providers and share information to ensure you are giving the best possible diagnosis and outcomes. We have care sites through our health improvement initiatives that provide a holistic care experience where patients can first meet with their medical or behavioral health provider and then visit with their dentist via teledentistry to address any urgent issues or engage in oral health counseling or screening.

5. Reimagine your business model. Today, when most dentists think about teledentistry they think about how they can use technology to triage patients, provide oral hygiene counseling, and perform basic evaluations. But as we look to the future, teledentistry can be leveraged to expand dental care teams beyond the brick and mortar dental office and into community settings to dramatically expand a dental office’s patient panel. Consider this scenario. A private practice dentist with two dental chairs employs a hygienist and a dental assistant. Because the team needs to provide both preventive and surgical dental services (cleanings and filings for example), they become limited in the number of patients they can serve and are faced with choosing between preventing disease from occurring or taking care of the disease already present. Teledentistry eliminates both of these challenges. With teledentistry, the dental practice can dedicate their chairs in the office to higher-paying surgical treatment and leverage teledentistry to extend preventive care into the community and home settings.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Teledentistry creates numerous opportunities and benefits that traditional in-office visits cannot. Most importantly, it allows dentists to reach more patients in more convenient ways for the patient. This is especially true for historically marginalized populations for which there are significant structural barriers to traditional oral health care access, such as lack of paid-time off, transportation, or sufficient numbers of providers within a reasonable distance.

For instance, Black adults are 22% less likely than white adults to have had a routine dental visit in the past year and 68% more likely than white adults to have unmet dental needs. One of the reasons for this is because communities of color often lack easy access to a dentist. Telehealth can shift that paradigm, tearing down a barrier that once hindered patients from receiving care. It is very similar for rural communities, where the number of health care professionals is often limited compared to densely populated areas. Teledentistry can help close the stark access gap, a gap that has only been exacerbated by the pandemic.

Teledentistry has been a welcomed addition to many rural providers with our recent research finding that, during the pandemic, rural providers were more likely than those in urban/suburban environments to use it to triage patients in order to prioritize care, prescribe needed medications and visually examine the teeth and mouth. Seventy-seven percent of rural providers using teledentistry platforms said they expect the volume of encounters to increase or stay the same over the next year.

Another benefit of teledentistry is that it allows providers to continue preventive, personalized care while prioritizing in-person care for those with more urgent health issues. While many conditions first handled via telehealth will require a subsequent visit in the clinic, some can be fully managed in a virtual setting. This reduces the burdens on an already strained dental and health system and maximizes the best possible care for all.

Teledentistry in many ways also allows for even more effective community-care. Dentists are able to more readily review patient data captured by another provider — such as a dental hygienist delivering care in a remote community setting — and create an ongoing treatment plan based on that data. It’s these kinds of models that will allow us to expand access and improve quality at the same time. It is why I’m so excited about the future of teledentistry.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

Systems that provide the ability to connect via video in real-time while also allowing for the sharing of visual information like radiographs or chart information create better and more personalized experiences for the provider and patient. There are a number of technology vendors providing these kinds of tools.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

It would contain the ability to engage in three ways:

1. Synchronous 24/7 emergency coverage;
2. Synchronous prevention to engage on patients’ wellness and address things more pertinent to their day-to day health;
3. Asynchronous ability to connect with a health team from home and track labs/results through phone applications, etc.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Be open with your dentist about what you are experiencing and what oral health support you may need. Most people know that brushing and flossing are important, but it takes more than that to stave off dental disease. Diet and nutrition, for example, are incredibly important to oral health. Staying physically healthy and managing chronic diseases are all just as vital to a healthy mouth. Be open to conversations with your dental provider about all of these areas.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

The remote patient experience will continue to evolve and improve. In fact, I believe patients will demand it over time as patient demands evolve. I am excited about the improvement in analytics and health information technology like AI that will allow us to become more predictive in diagnosis and enable us to extend intervention to even earlier. This improvement in diagnostics or the ability to diagnose disease earlier with technology will make telehealth encounters in dentistry even more beneficial and convenient.

Is there a part of this future vision that concerns you? Can you explain?

While technology allows us to advance, it also requires us to change — which can mean slow adoption if people are resistant to change. My hope is that our oral health community quickly realizes the benefits of telehealth as a tool that can extend the reach of care and embraces this positive change, rather than seeing it as a disruption or burden to their traditional ways of working.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.

The WHY NOT Initiative. It is a movement about creating more compassion in the world. One that builds empathy and provides a better environment for people to be vulnerable and experience life in a way that brings a bit more joy and happiness. The mission and vision would be shaped by three lyrics:

• “Maybe it’s not too late to learn how to love and forget how to hate” by Ozzy Osbourne
• “I have just one life, and I know what’s right” by Tom Petty Tom
• “In the end, the love you take, is equal to the love you make” by John Lennon and Paul McCartney

How can our readers further follow your work online?

You can check out CareQuest.com or follow along on social media. We actually just launched last month and have some really big plans over the next few months, especially when it comes to telehealth. The CareQuest Institute is a one-of-a-kind non-profit organization with resources to make change across all aspects of health care — from research and grants to care delivery and benefits programs to impact investing and innovation advancement. Our CEO is a national leader in addressing health disparities, Dr. Myechia Minter-Jordan, who is former CEO of the Dimock Center in Roxbury and the DentaQuest Partnership — she is great and always willing to chat if you are interested in learning more about what we do and why we do it.

In the coming weeks and months, we have some really interesting research that we will be publishing regarding the use of teledentistry and its short-term and long-term impacts, along with other aspects of the oral health community. You can find all of our research at https://www.carequest.org/research. You can find all of our grantmaking, improvement programs and advocacy efforts on the website as well.

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.