Thank you for taking time out to join us tonight. I want to talk to you about something that I think we're all focusing on, which is trying to merge telehealth into our practices. Right now, across our country and across the globe, telehealth visits are booming as doctors and patients both embrace distancing amid the coronavirus crisis and virtual healthcare interactions are on pace right now to top one billion visits by the end of this year. Like most dentists, I was sent scrambling to try to find ways to incorporate dental health or dental sleep medicine into telehealth so that we could continue to take care of our patients. I've never been accused of being an early adapter to technology. And like many of you, the internet didn't even exist until I was in college. But it's never too late to learn a new skill. And we as dentists are creative problem solvers by nature. I'm gonna just touch on who I am and what I do. I am a prosthodontist and I've served as a Lieutenant Commander for the US Navy. And right now I work full time for Pulmonary and Sleep Medicine Department for a hospital. We fabricate between 50 to 60 appliances a month. And every day I'm learning something new. So why now? Why incorporate telehealth now? Telehealth was slowly increasing before the COVID-19 pandemic. But now with the rising cost and shrinking availability of PPE, telehealth can save you a lot of time, money and offer a way around the new social distancing restrictions. And I really think telehealth is here to stay. For example, Medicare does not have a reputation for making quick changes. But in 2020, it relaxed its position on telemedicine. So I'm sure you've all heard the saying that the only constant in life is change. And I really believe that. So let's embrace that it's time for us to learn something new and to do that to help those patients utilize new ways. Bear in mind, telemedicine is not going to be an option for every single patient. For example, the average Medicare patient in 2018 was almost 80 years old. And that led a lot of researchers to question hearing and vision problems, as well as how comfortable these patients would be with technology. And the researchers looked at what they called telemedicine unreadiness. And they looked at that as being anything from difficulty hearing, speaking, dementia, anything that might stand in the way of them being able to use telemedicine. And what they found is that over a third of Medicare beneficiaries weren't ready to use telemedicine. But on the flip side, think about how many are ready and are able to use it. What they found was that 41.4% had no desktop or laptop or even high speed internet. Others had no smartphone or wireless plan and still more had complete lack to digital access. One thing I do wanna encourage you to do as myself and my colleagues talk about telehealth tonight is remember to reach out to your malpractice provider and find out are there any type of caveats that you need to consider. Currently, they weren't seeing a large upsurge in a lot of malpractice cases due to telehealth, but what they were seeing was based on misdiagnosis. So now that that mandatory legal disclaimer is done, let's take a look at some of the objectives that I know either myself or my colleagues are gonna cover. And that includes what software, what apps to use, what type of visits in sleep medicine can telehealth apply to, and how to create a script or a template to keep you on track, how you can provide written, verbal and video suggestions of different protocols, incorporating images from the vendors and creating after visit summaries. So I think clearly we know that there's a lot of benefits to telehealth. Certainly we know it works, it's efficient, it's proven that it works, it's convenient. You can provide access to patients that otherwise would not be able to come into your office. And it's very cost effective. You can save quite a lot of money in an environment like we are finding ourselves today where PPE is so expensive and so difficult to access. And the cost savings extends well beyond what we ourselves are going to experience as the provider. There was a large hospital system that Red Quill Consulting Incorporated did a study of. And what they found was that over an 18 year period, they looked at what did patients save and patients saved a total of nine years of travel time and 5 million miles and even more savings. So there's a lot of benefit to both us and the patients. So what do you choose? Do you choose telephone or real time audio video? And this is a very important thing. Telephone is never going to give you as much benefit as the real time audio video consultation. So much can be lost when you're on the telephone. Imagine a patient trying to describe jaw pain and trying to indicate where it was hurting. Having that connection where you can see and talk to the patient in real time is very, very important. Also from a reimbursement standpoint, the telephone consults are in some cases not compensated at all. And in other cases, compensated at a much lower rate. Software, what software or app to use? And again, I think the first thing you want to ask yourself is do you want a standalone, a partial integration or a full integration? The standalone is the least expensive, but it's the least expensive for a reason. It's the least secure. It's kind of like a sidecar to the electronic healthcare record. And it's a standalone approach as the name implies. Partial integration provides the same real time audio video of the standalone, but it incorporates things like patient paperwork that can be integrated right into the patient record, which is very important. Full integration is the most expensive, but it's also the most elegant and it's very secure with a video portal. And typically it'll have a virtual waiting room built right into the electronic health record. Certainly use what you find to be the easiest and what you can afford, but remember it has to be secure. The most popular software that we've probably all heard of is Zoom. Now you need to protect personal identifiable information. This includes your patient's name, email, phone number, and address. You cannot record the session and have it be HIPAA compliant. The Health Insurance Portability and Accountability Act of 1996, or as it's more lovingly known HIPAA, was enacted to protect a patient's privacy and to ensure that they have access to their medical records. Now, healthcare providers store their patient's personal identifiable information and medical records. Anytime they do that, they're required to follow HIPAA guidelines. So you want to choose a software that is going to be compliant. So most of us are familiar with what that means in our traditional charting and record keeping, but when using software such as Zoom, HIPAA's rules apply mostly to how the patient's personal identifiable information is transmitted, stored, and of course who has the potential to gain access to it. And this brings us back to Zoom. Now you have to remember Zoom started in 2011. And when they started, they were not developing this as a healthcare application. It really has no special designed components for the management of patients online. And it was definitely not designed to provide for secure patient data. So all of this being said, how did Zoom make it HIPAA compliant? Well, what they did is it has a lot to do with how the video, and again, you cannot record this. It has a lot to do with how the video is being routed to your patient. It's pretty hard for a third party to gain access, but if the video is routed through a server, it gets really complicated. And the company has to follow guidelines to ensure that even their own employees who have access to the server are not snooping, even if there's encryption in place. So the way Zoom got around that was it was able to certify that its video is HIPAA compliant because its technology routes its video directly between people and not using a server. You probably see where I'm heading with this. To get around the problem, instead of developing systems to ensure privacy, Zoom just realized it was gonna be a lot easier to just turn off the ability to record for its healthcare users. So in short, you cannot record the video sessions with your patient through Zoom and still be HIPAA compliant. And the patient's video is only one of the vital components that you need to think about. So for example, if you wanted to add your patient as a contact in Zoom so that you could say, send them invitations or schedule a meeting time, and you're not using the healthcare version, you are definitely violating HIPAA because it means that you're saving their information. And another thing, the free and the regular paid versions of Zoom are not HIPAA compliant. It has to be the healthcare version. And for those of you who haven't heard or use Doximity, highly recommend. It is a great service so that if you're doing telemedicine, telehealth from a remote location, it will disguise your cell phone number and it will come up as your office number. So highly recommend that. Moving on to which visits can telehealth apply to? Well, I use basically everything but the delivery. But this depends upon your comfort level. I do new patients, 24-hour post-delivery appointments, and almost all the follow-ups. I find that scripting, especially for me, I tend to go off on tangents or forget to cover something that's really important. So pre-written templates for each visit work really well for me, and then I pre-chart each patient the day before. So I know this is really small, but here's an example of one of the new patient telemedicine visits. I write this as a guide to keep me on track. And I also like to incorporate PowerPoint presentations with patients. So I'm gonna quickly share one of those. So if I'm doing a telemedicine visit with a new patient, at some point, I'll share the video, or rather share the PowerPoint presentation. I'll go slide by slide. And the nice thing too is that you can do this in different languages. So we have an interpreter that has translated this into Spanish, for example, so that we can share this with every patient. And just remember, keep it really simple. People are either gonna listen to you or they're gonna look at your slides, but they're very rarely gonna do both at the same time. Now, in case you, like me, did not grow up using computers and you aren't really quite sure how to use Zoom and then also pull in a PowerPoint, here's a quick guide to sharing your screen. I recommend that you have your PowerPoint presentation up in the background. And then if you look, I have the picture of me here and there's the little green button down in the bottom. You wanna hit that and then you'll see your image go into the side there. Just remember, when you're done with your patient visit and you want to close that out, you have to hit stop share in order to close out the visit entirely. One of the things in my new patient template that I like to add just as an additional coverage is that the physical exam has yet to be completed. If everything based on our conversation, diagnostic sleep study, and the clinical notes from the pulmonologist appear to make it seem that the patient's a good candidate, I'll add this in just to leave that opening that you know what, upon actually examining the patient, we might find some reason not to move forward. Providing written, verbal, and video of advancements, elastics, anything that you can think of. For visits that review the home care, I like to make sure that I have copies that will include something like this PowerPoint. So this is another example. We put together a little take-home package where we put everything for the patient's delivery into one document. We put everything for the patient's delivery into one bag, one little box, if you will. And then the next day, within 24 hours, I go through slide by slide every component that was in there. And for some patients that are extremely interested in knowing every component, we even have like all the MSDS sheets that we can send them if they need. Vendor images. You will never take as good a picture as the vendors have taken. Ask your vendors. Most of them are gonna be really excited to have you share their hard work, whether it's on your website or in your notes for your patients. After visit summaries. I like to email this to the patient, but I'll also have it available on a website. Sometimes I'll mail it. Whatever you find to work best for your patient. Billing and documentation. Very, very important. Always reference whether your encounter is a telephone call, a video, and put that right into your soap notes. And document the time it started, the time it ended, how much time we spent in direct patient consultation. So my templates begin with, today's visit was completed using real-time audio and video, patient initiated consultation at, and then I put in the time. And if your call happened to be lost because the patient lost their internet connection, document that the switch was made to telephone. If the patient is unable to use Zoom or refuses to use it, make sure that you document that as well. And so this is just, you know, one of the other components I put 50% or greater. This is how I close my notes. 50% or greater of the visit time was spent counseling the patient, real-time audio and video of how many minutes was spent discussing. And then I go through everything that we discussed. Documentation, I can't stress this enough. Make sure that the patient knows anybody that could be in the room. So if you're doing this from your office and your assistant is in the background, if somebody walks into the room, make sure that you document who was in there. And, you know, with respect for the patient too, if they want to bring their spouse, their bed partner into the conversation, encourage that and document it. You know, for example, Mrs. Smith wanted Mr. Smith to discuss the following concerns. There's a lot of valuable information that can be added there. And now just quickly some troubleshooting. If you have trouble talking to your patients because they, like me, were new to Zoom, try to share with them that there's a little chat button down in the very bottom of the screen and you can send messages back and forth that way. I have a sign that I have printed so that it'll come up with, you know, so the patient can read this. Just saying, you know, hey, is your sound muted? Because oftentimes they don't know, they may not be familiar. I try to have one of my assistants always reach out to them in advance, but sometimes this is still a good option to have this as well. Oh, sorry. And make sure to get the most flattering image. You want to know where your camera angles are at. So you want your camera to be just at eye level or a little bit above. And then at the very end, because I don't want to take up any more time from my colleagues, I just have two slides of recommendations that you can share with your patients. I'm just going to leave that there at the end. If you have questions for me, please put them into the I-O. I look forward to hearing what your questions are and connecting with you at future AADSM meetings. And also you can always find me on Facebook and also you can always find me on LinkedIn. Thank you so much for making time for tonight. So like Dr. Cantwell, we got started at Midwest Dental Sleep Center into telemedicine due to the coronavirus. On March 20th, we were sort of forced to shut down our practice. Governor Pritzker put in a stay at home order. The Illinois schools started to close. There was some ADA guidance that came out in regards to really only seeing patients for emergencies and the Illinois Dental Society sort of followed along suit with those guidelines. So we had decided to close our practice during the coronavirus when it initially started. And we sought some guidance and decided to launch telemedicine sort of right after we had closed. We had cleared it with our legal counsel. We wanted to start with our delivery appointments just because we had patients who couldn't get in that had started the process with us and we wanted to be able to provide that therapy to them. So we started with sort of a company-wide Microsoft Teams meeting on the 23rd and 24th. We had about two days to sort of discuss the workflow across all of our departments. And for those of you who don't know, Microsoft Teams is like a, it's another like video sharing team collaborating tool. So we discussed the workflows across our different departments and we developed templates like Dr. Cantwell was mentioning. We create a lot of policy and procedure, different documentation that would be necessary in order to get the job done, whether that be sort of editing and modifying our texts that go out to patients for reminders, different things like emails that go out to them, our release and receive documents, anything that we were gonna need to get signed off on ahead of time or that we wanted to go over with the patient and have them sign, whether that was informed consents or our financial quota benefits, those things were modified so that we could get electronic signatures. So there was a lot of work that was sort of done ahead of time from an administrative standpoint just to be able to do this. And then we tested that entire process with the team via Microsoft Teams and we were utilizing our EMR telemedicine platform to provide these services to patients. And that's been an indispensable tool. We really got into telemedicine, obviously for the patient and staff safety factor with COVID going on. We wanted to avoid furloughs, we wanted to continue to treat our existing patients who were going to need to continue to have care, whether that be through the deliveries or follow-ups or whatever services we needed to provide. We didn't know how long we'd be shut down, we didn't know if that might happen continually or whether patients would be comfortable coming into the office. So we knew we were gonna have to provide some other form of service that patients could get to without physically coming in the office. We wanted to overcome any of those barriers that patients may have or concerns physically coming into the practice. And we knew there was potential that some of our staff members could wind up with a positive diagnosis or symptoms and we needed a solution that we could offer whether some of our staff members were at home or in the office. So telemedicine was sort of a great approach to overcome those barriers. And we're continuing to provide telemedicine services for many of the same reasons that patient and staff safety factor. As Dr. Cantwell was mentioning, there's been expanded Medicare reimbursement. I'll go into that a little bit more. We wanted to provide our patients with options. We wanted increased access for patients. We wanted to improve our efficiencies and telemedicine certainly can help do that. In terms of our access, we have patients who come to us from remote locations that we're not necessarily at multiple days throughout the week. So we may be at some of our remote sites only one day a week or a couple of days a month. So this provides increased access for those patients in the sense that they can schedule and see our providers on any day. So it really doesn't matter what facility we're at. We can do a telemedicine appointment there for any patient at any location. So that provided some increased occupancy and efficiencies and it definitely improves our productivity. The efficiencies really derived from, the improvement in our efficiencies really derived from our ability to utilize our telemedicine platform in such a way that the medical history was just a lot easier for the patients to fill out. So they would get a text ahead of their appointment. They could click on that and it just walked them through sort of a virtual check-in, a touchless virtual check-in process that allowed them to immediately fill out the questionnaire and that questionnaire then dumped right into our progress note, which just really improved a lot of our efficiencies. So it reduced down the time of the appointment and we were able to take, as an example on our new patient consult appointment, we were able to take it from an hour and a half down to an hour. We separated it into two separate appointments. So the first half of the appointment being a telemedicine consult and the second half being a physically coming into the office and doing impressions, X-rays and a detailed examination with the provider. But it really did increase our productivity by breaking those two things apart. It also improved a lot of our patient satisfaction. There's sort of an enhanced perspective where the patients feel like the time between the impressions and getting the appliance is really reduced. In the past, we would see patients for consult, we would take impressions at that same time and we wouldn't obviously then deliver the device until the delivery. And so there was a sort of a prolonged process. Now, when we do the consult, we're able to gather all the documentation, submit that to the insurance company and then it takes a little bit of time for the patient to typically schedule the impression appointment. So there's usually a few days where there's a bit of a gap and that allows us then to submit everything to insurance and have it ready. So when the patient comes in for their impression appointment, everything can go right out to the lab and it improves that time to delivery, which has definitely improved the patient satisfaction that tends to be the number one complaint is just the amount of time to get a device delivered. So that's been a huge enhancement. I think some of the keys to success, we're our Office 365 platform, that ability to collaborate with our team members regardless of what office they are in. We've got five locations throughout Chicago. So we've been working on that platform for a long time due to the fact that we have many remote locations and a central headquarters. And so we're not with our team members at all times. So that really set the stage for us being able to communicate while we were all in different locations, whether that be at different offices or at home. Adobe Sign was a HIPAA compliant platform for receiving patient signatures that we used to send these documents out ahead of time, get them signed off on and back to us so we could start some of the process of gathering documentation and so forth before the patient had even arrived into our practice. We used that in the past and we've used that even more so now with the telemedicine appointments. We also leveraged our accounts with UPS to deliver some of these devices. We utilize Comcast Business VoiceEdge as a voiceover IP solution for our phones. So that really allowed our providers to really be anywhere in terms of communicating with our team members or having any sort of conversations that we need to have amongst the various team members. We leverage our patient portal and we also have an app that allows patients to get into the telemedicine appointment. And those tools also allow us to do many other things, take payments, send out e-patient statements. We can send after visit summaries through those portals and the app as well. So patients are very familiar with what went on in the appointment and then what the next steps and so forth are. And then we're always leveraging some of the best lab partners that are providing 3D CAD CAM based devices. So we're able to take digital intraoral scans, send that to the lab, have them make the device and that time to treatment tends to be reduced. And with the accuracy of the CAD CAM appliances, we typically have first time fitting devices which is extremely important when you're trying to deliver something via telemedicine. If you have any issues with respect to fit, it can become a very big problem. And I don't, I certainly understand why Dr. Cantwell wouldn't prefer to do a teledelivery. That was something that we really beat up internally within the practice. And we sort of have a specific workflow for that. So I think what to consider when doing this or if you're gonna do it within your practice, you really need to look at some of the licensing requirements. We do have patients who come from border states and you need to be cautious about making sure that you're practicing within your state. So if you're seeing patients from, let's say Indiana in our example, because we have many patients coming from there, that's something where we're not doing telemedicine appointments in Indiana because of the licensing requirements, we would need to be licensed there to do that. And are moving forward with doing that here in the future. So we can do telemedicine appointments in Indiana. Scope of practice issues, the reimbursement, as I said, there's expanded reimbursement with respect to telemedicine appointments with COVID. And I'll go into that a little bit more. And then there are some specific informed consents that need to be signed off on to do telemedicine appointments. And the AADSM has a great template for that that you can find on their website under practice management tools, they have a link to it. And just the technical expertise of your practice, I think needs to be at the forefront, whether you have some pretty tech savvy team members and your patient base specifically, if you're really having Medicare, that may be something that you wanna consider and whether or not you're going to launch these types of services. We do have some great guidance with respect to telemedicine. In Illinois and many other states, there is a telehealth act. We have the state dental boards and the dental practice acts within the states to look at for guidance. The AADSM has a telehealth for dental sleep medicine practices document and it has a lot of great resources in it. The ADA has a teledentistry guidance and the ADA also has a policy on teledentistry as well as some COVID-19 coding and billing in term guidance for virtual visits, which is more geared really towards the dental side of things. But it is a reference for those of you who may also be doing general dentistry. And there's a great site, the Center for Connected Health Policy has some great references on their website regarding state rules, regulations and some of the federal rules and regulations and reimbursement as well. That's a great reference. But in the wake of COVID-19, a lot of things changed that really propelled telemedicine into a whole new level. So the Department of Health and Human Services Secretary declared a public health emergency and that allowed CMS to have authority under their 1135 waiver to broaden access to Medicare telehealth services. It waived some of the originating site requirements that used to be in place that required patients to be at an office or a particular site in order to have these services be covered. Now they can be done from the patient's home. They waived the prior relationship requirements so you can see new patients that you haven't previously seen for telemedicine appointments. They waived the state licensure requirements for Medicare, Medicaid and CHIP specific plans. So there's some relaxed licensure guidelines if you're seeing patients from different regions. They've provided increased reimbursement for telehealth services in which those services are being paid at the same rate as a typical office visit, which is a big change and a huge increase in pay. And most states sort of follow suit with those sort of laxed licensure issues. And then the DEA also came along and allowed prescribing for controlled substances without prior in-person exams. So just to name a few. There's also a lot of, about a lot of different services in terms of like the CPT codes for office visits, like the 99201s and the 9920, through the 99205s that used to be a GT modifier and a place of service too. And we're talking about synchronous, you know, video, audio, real-time video, audio. So those modifiers were different pre-COVID than they are now. Now you use a modifier of 95 with a place of service of 11. Same thing with the follow-up visits and the coverage for these particular services. You know, it used to depend on the payer and now they're typically covered regardless of the payer. All the major carriers are providing payment for these services. And the payment level used to depend on the parity laws of the state and so forth as to whether or not they would cover it at the same rate as in-person appointments. And now most of them are in fact covering them at the same rate as in-person appointments. Additionally, there are some payers that are willing to waive some of the patient co-pay and so forth. And that was never the case in the past. And all that sort of changed as a result of COVID. And there are temporary changes. So I do expect that they will only last for a period of time. I don't know what will continue, but I do expect it to change a bit. You know, when we started, just to give you a sense of sort of our delivery workflow, we wanted to establish whether or not patients were willing and able. We wanted to then schedule the tele-delivery appointment. The DDS or our dentists would review the case and approve it for whether or not it was okay to be delivered via telemedicine. They would make any adjustments that were necessary on the appliance, just based on their clinical experience and what they've seen in the past in terms of some of the sticking points with various devices. We would create an order in our EMR and document the lot numbers and any sort of adjustments that we made on the device. And then we would contact the patient to verify the telemedicine setup and receive any sort of payment for the services. We create a UPS shipment with a delivery confirmation and signature. We then emailed that delivery ticket and the DME packet and consent with e-signatures and we shipped everything to the patient. This is a shot of our team and the first delivery that we did on March 25th and all went well. Everybody was working together to make that happen. And I definitely recommend starting small. You know, our first schedule with telemedicine really only had about seven appointments on it. And then we worked our way up from there. The, at this point we've completed about 864 different telemedicine appointments with 303 new patient consults via telemedicine, 151 follow-ups, new patient follow-ups, 74 existing patient follow-ups after that 90 day period. We've done 108 deliveries via telemedicine, 89 annuals. So quite a few appointments. So just to reiterate, this definitely can be done via telemedicine and does work. And, you know, we see a variety of different demographics. 57% of the visits that we did were male, 43% female, and really at all age ranges, as you can see below, quite a few over the age of, you know, 50. In terms of our team and the responsibilities of the various departments, we've sort of broken up our practice into a patient care coordination department that comprises of a patient care coordinator who's in charge of scheduling inbound referral coordination and a clinical care coordinator that focuses more on clinical related Q and A and then outbound referrals to our various providers for follow-up sleep studies and so forth. Those folks are responsible for assessing the patient for telemedicine appointments, whether or not they are really capable of doing a telemedicine appointment in terms of their hearing, how technically savvy they are, whether or not they have the proper equipment to do it. They do patient intake and web-enabled patients. So they get them set up, you know, with a user ID and password and make sure we have an email and file so that they can actually take part in our portal and our app to do the telemedicine appointments. They, you know, explain how to connect and, you know, and sort of lay down some expectations for the links that they're going to need to click on in order to connect, which are done via text and email to patients ahead of the appointment. Where they're going to connect, they explain the portal and our app. They advise patients to log in 15 minutes ahead of time to complete any sort of medical history and then explain that they'll wait in a virtual waiting room after that history is completed. Our insurance department is comprised of an insurance supervisor, benefits coordinator, and medical necessity coordinator. The supervisor is responsible for claims, patient accounts receivable, insurance accounts receivable, and so forth. And the benefits coordinator handles all of our benefits eligibility and HMO authorizations while the medical necessity coordinator handles the patient medical necessity documentation that supports the claim for the oral appliance, PSCs, diagnostic sleep studies, orders, et cetera, that are needed to be gathered before the appointment. So that department has really been responsible for requesting electronic signatures on the releases received prior to the teleconsult so we can get all that documentation from the various providers that refer to us. You know, they're responsible for the electronic signature on our quota benefits. So the patient knows what their out-of-pocket costs are going to be after the telemedicine appointment. They handle the submission of any prior authorizations post that teleconsult. They obtain a card-on-file agreement, which has been sort of an imperative with things that are happening with COVID so that we can just charge that card after we deliver the device. And if any additional follow-up comes up that needs to be done via telemedicine, it's just easier for us to charge the card that's on file rather than potentially getting hit with a significant amount of patient AR. And then we utilize some electronic patient statements that help in the workflow for any outstanding balance that might be there after things go out to the insurance. We also have our clinical department, obviously the dental director, who's overseeing everything in terms of the clinic and doing the telemedicine appointment himself. We have a clinical supervisor that oversees all of our clinical assistants, and they're responsible for sort of this virtual check-in, check-out process, the patient paperwork, documenting all of that, and then some of the patient payments they'll collect after the appointment and they assist the dental director with anything that's necessary. And that's about all I have. Well, thanks everyone. And Michelle and Scott, great job. I don't know if the dinosaur in the background is applied to me because I'm going extinct, but hopefully not. Anyway, it's great to be part of this presentation today. And I have to disclose, I am the medical director of ProSomnus Sleep Solutions and the medical director of Better Night, which is a telemedicine company. So, you know, what do I see as the problem? About two years ago, I started my own telemedicine company. And the reason why I started it is because I realized that we have this condition, obstructive sleep apnea, that's a medical disorder. And really, I think the majority of the patients, those are the mild and moderate ones, can be treated with oral appliance therapy. Yet, we all know this, that sleep physicians continue to preach that the gold standard is CPAP treatment. And really, in most states, dentists can't diagnose obstructive sleep apnea or order an HST without being liable for practicing outside the scope of their license, and that they need referrals from sleep physicians and prescriptions for the oral appliances. So I wanted to examine this and say, how can you help dentists treat their patients? And what can be done to bridge the gap between medicine and dentistry, which we all know can be difficult to do? And so we know that physicians have certain concerns about oral appliances. One is they often preach that CPAP is the better treatment. And what I would ask you, is it really the better treatment when you look at mean disease alleviation? And that's something we all should be very familiar with. And physicians may say, how do I know the dentist is qualified to deliver the oral device? And I'm sure you've seen this many times, that efficacy studies show residual events, and the sleep physician says, well, the sleep appliance really didn't work. And then there are insurance issues, as outlined here as well. So when we look at physician acceptance, efficacy studies are important. We know that patient comfort and compliance are marketing points that dentists can do to grow their dental sleep medicine practice. And I think you need to have open discussions of the side effects of oral appliance therapy. I really look at that as a way to embrace the treatment of it, because I think there's a lot of misinformation on really what the side effects are. And so you really wanna embrace all these things. And as more and more oral appliances are delivered, sleep physicians are gonna generate more efficacy studies. And now we're gonna turn into the telemedicine approach, because really what I've thought, and I've been working on this for several years, is that it really is a viable alternative treatment paradigm, which... Sleep physicians, and it's gonna empower the dentist to treat more of their patients. Now, when we look at the protocols of the AASM and the AADSM, what we see is a very complex process. And you can read through this slide on your own, but you all know the steps, the assessment, the referral, the steps back and forth, the paperwork, whether it's automated or not. The problem is, it's a complicated system. So what I've looked at, you have to understand, I'm both a dentist and a physician. So I keep my foot on both sides of the fence, so to speak, looking at how can we make this system better? Well, you know, the protocols that we have, cures complicated and burdensome, treatment takes too long, as to compliance with CPAP, has it really improved since 1981? If you look at a lot of the articles that have come out, the long-term compliance or adherence really hasn't changed. And yet oral appliance therapy has been available since the 1980s. Dentists are unable to diagnose obstructive sleep apnea in order in HST, and they must network with physicians for referrals. So when you look at this, you say, what's wrong? And this is one of the most important things that we have to embrace, I think, right now, is how do you change the mindset? How do you change your mindset in your practice? How do you change the mindset of your patients? And I put these icons of these four companies up here because they're a shell of themselves right now. And these were great, great companies that did not embrace change and are struggling to survive, including IBM. And so let's look at telemedicine now. And this slide is a little bit old, it should be updated. Scott mentioned this and maybe Michelle as well. Prior to COVID, the telemedicine consultation with a Medicare patient was a issue. And of course, during the CARES Act, the regulations have been relaxed. But really what we wanna do is we wanna have a system where you can have a telemedicine consultation with a sleep physician followed by an HST. So this will allow dentists to screen and test their patients without the patient having the inconvenience of time and effort to see a sleep physician. But the problem is, when you look at this, is building a national network is challenging because the sleep physician must be licensed in the state where the patient resides. And Scott alluded to this, being licensed in multiple states is a huge chore. I know it very well because I'm going through it right now. And what's the American Academy of Sleep Medicine's position on telemedicine? Well, they support efforts to expand telemedicine. They're committed to increasing the adoption of this technology to improve access. And their position paper, which came out several years ago, details the key features, standards, and processes for a sleep specialist. So let's look at dental sleep medicine and telemedicine. While dentists are really uniquely positioned to take care of telemedicine, as you know, in October of 2017, the ADA recommended that dentists screen all their patients for sleep-related breathing disorders. But what really happened, you know this because you go through it in your practice, if you do exclusively dental sleep medicine, it's a little bit different. But if you're a general dentist, you screen your patients, you send them to a sleep physician, it takes too much time, it takes too much effort, and very often the patient is lost to you. So we have these barriers that prevent patients from getting the oral appliance in an efficient and cost-effective manner. And, you know, of course there's lack of ability of sleep physicians in certain areas where telemedicine can be helpful in that regard. So let's look at the telemedicine and dental sleep medicine workflow. How does this work? Well, the dentist or dental office is gonna screen the patient for the sleep-related breathing disorder. Positive screening, the telemedicine consultation can actually be scheduled at the checkout. The telemedicine consultation is obtained via HIPAA-compliant web-based platform. And now the use of disposable home sleep studies can be mailed to the patient. I think this has been a huge change in the way things are done, because now we don't have to worry about sterilization and we don't have to worry about the unit being sent back. So this certainly saves time. So the disposable HST is downloaded to the cloud, reviewed the next day, and then a follow-up consultation is obtained to discuss treatment recommendations. And after that, assuming the patient is a candidate for a oral appliance, then a prescription for the oral appliance can be emailed or faxed to the dentist. The problem in this model has been if a dentist screens their patient and they're using a virtual sleep medicine physician, what happens to the severe patients or the patients who are candidates for a CPAP treatment? Well, then the telemedicine workflow allows you to be linked to a DME company who can provide that CPAP. And ideally, the way that it works is this is being monitored because in fact, if the patient fails CPAP or is non-compliant, it's gonna default back to the dentist to provide oral appliance therapy when indicated. The dentist is gonna go through the steps that you're well aware of, fabricating the appliance, adjusting, titrating it, and then an efficacy study can follow through the telemedicine company. And the follow-up efficacy study consultation is obtained and a telemedicine consultation to discuss results with the patient. You know, it's interesting, it's all the same steps. We're just using digital technology. And in the fact of what Michelle and Scott presented, this can be done obviously on your end as well in terms of the insertion and other steps that you can automate. This is a slide that I think really is the essence of what we're trying to accomplish. We have the standard workflow and the telemedicine workflow. So in my opinion, the telemedicine workflow, the standard workflow is cumbersome. The telemedicine workflow is efficient. The standard workflow requires multiple visits. We can do minimal visits with the telemedicine workflow. And one is lengthy, one is streamlined. One is costly and waste resources. The other is economical and it preserves resources. The standard workflow, I believe, is physician-centric and the telemedicine workflow, particularly when the referral is generated from the dentist is both dentist and physician-centric, excuse me, it's dentist and patient-centric. The standard workflow has a relatively high chance of failure and high chance of success as seen with the telemedicine workflow. And what do we want? We want high patient satisfaction. And this is really what telemedicine, when done properly, can achieve. Let's look at it from the dentist's perspective, the physician's perspective and the patient's perspective. Well, from the dentist's perspective, the telemedicine utilizing HST is efficient. It may be scheduled right at the checkout, that day that you identify the patient as a candidate for an HST. Consultations and reports can be available to review. There's easy communication between the dentist and the physician. Documentation of claim submission is immediately accessible online. And it really allows for accurate diagnosis. And also, other sleep disorders can be considered other than OSA and managed by the sleep physician if they are diagnosed. What about the physician's perspective? Well, the telemedicine expands their reach and allows them to selectively schedule more complex patients. Telemedicine visits in a clinical setting, like a dental office, are usually covered by the patient's insurer. This, again, was an older slide prior to COVID. And home sleep testing is a covered benefit when sleep apnea is clinically suspected and the study has been ordered after appropriate clinical evaluation, which is really the key. Patient perspective. Well, telemedicine reduces the time traveling back and forth to various sleep centers. It's less expensive, and there's increased access to high-quality specialty consultations. So really, telemedicine and dental sleep medicine, it may be the ideal option for patients who are starting out in the field of dental sleep medicine and would like to treat their patients. They identify efficiently and safely. And it's also a useful option for dentists who have established sleep practice, but whose patients travel long distances or want a less expensive, but high-quality path to treatment. The bottom line is it's patient-centric and empowers the dentist. And really what we're doing is using a digital platform for a great experience. The patients may complete the treatment within six to eight weeks of initial consultation with high chance of success and satisfaction. Really, this is what it's all about. People want things yesterday. They don't want them today. They want them yesterday. I have somebody who comes to me for surgery. They've had the problem for years. And what do you mean I gotta wait two months to have the surgery done? This is the way people are in our society right now. And I think, you know, I launched a business two years ago prior to COVID. And what I'm showing in this last slide can be done in three or four weeks. You really can, from the time the patient is identified to the time they have an appliance in their mouth, there's no reason why it can't be done in three or four weeks. The biggest snag usually is insurance issues, getting authorizations, things of that nature. But I'm certainly happy to answer any questions further on what really is a proven model. Thank you. Thank you, Dr. Saul. That was great. So now it's seven o'clock exactly, but these questions are too good. So we have to go a little longer. And I'm gonna start with Scott. And I'm gonna combine two questions for you, Scott. One is, how has telemedicine changed the practice of dental sleep medicine? You know, you could almost say like how has COVID changed the practice of dental sleep medicine? And then the other one is, is your new patient conversion rate better, worse, different when doing a telemedicine consult versus an in-person consult? Those are great questions. I think, you know, the biggest thing that I've seen in terms of the change of our practice with telemedicine is that improved patient experience. The reduced patient costs with respect to transportation, you know, just their personal time, parking costs, et cetera, those are all improved. The reduced perceived time to delivery, I think is a huge, huge component that shouldn't be undervalued. You know, we split up those appointments between the teleconsult and then when the patient has to physically come in for the impressions to get started with the process, and that gives us enough time to submit everything to insurance and get their approval before they come in for that impression appointment. Then when we do the impression appointment, those impressions can immediately go out to the lab rather than sort of waiting for the insurance process to be approved, because you never really know who is going to get approved or denied. So, I mean, that efficiency, plus it just in the mindset of the patient, the process hasn't started until they take the impressions. So that's when the clock starts ticking and it really reduces down these complaints about the time to get the device delivered. So I think that's been a huge win with respect to telemedicine and the ability to break those appointments into two different appointments, rather. And then just, you know, increased access for our remote offices, that's huge. You know, there are patients that are geographically dispersed that this is a huge advantage for, and having additional options for our high-risk patients and our patients who are, you know, experiencing symptoms and so forth, just to keep our staff safe. Those are all big wins in the telemedicine cap, you know. Increased medical history, efficiency that we're experiencing with our particular EMR, that is really saving a lot of time. And it's allowed us to reduce down the time for the appointments, which then has improved our productivity and it's improved our scheduling. We used to allow, basically, the new patient appointment was an hour and a half, and that's moved into two half-hour appointments. Now we can schedule our telemedicine consultations anywhere within the schedule. And there used to be very specific spots within the schedule that a new patient appointment would have to go into, and now they can go anywhere. So it's just made us much more efficient. We've really improved our capacity. It's like having a whole nother op, the ability to do telemedicine. So, you know, if you're at max capacity, this is a way of really improving your ability to see more patients, and obviously that improves productivity. So those are all big wins. I think, you know, the second question is this concern over conversion, and we're looking at that like a hawk. The reality is that we do think there are some concerns with respect to our conversion. Our rates are lower right now than they used to be by a fairly significant margin, you know, over 10 to 15% at the moment. I think that we will improve here long-term with that. We're learning from some of our mistakes. And I think, you know, some keys to improving that is, you know, specifically to have that patient scheduled for the impression appointment before they're done with that initial teleconsult, if you're gonna break it into two sections, which, you know, you have to. So that's a huge piece, because that's where you're gonna see your fall off. You're gonna see patients, you know, who just, they're excited at first, we go through the whole process, and then that excitement wanes, and, you know, they don't come in for the next stage. So we're really keeping an eye on that. And ultimately, that could be, you know, a deal killer for us. You know, we have to have patients convert. So we'll be keeping an eye on it. That's a great question. Dr. Cantwell, I'm gonna combine two questions for you as well. The first is, a patient may have some computer challenges once you start the call. How do you troubleshoot these issues, such as like maybe being, having an old computer with no camera? That's the first question. And it kind of dovetails a little bit into this, which is, what percentage of each telemedicine visit is conducted by staff versus the dentist? Okay, I love those. I love those questions. What we do is before the patient ever has their telemedicine visit, and I didn't go into this, but I do, I love that someone brought this point up, is we actually have a staff member reach out to them a couple of days before their scheduled telemedicine visit, and they'll do a trial run. So the patient will have a chance to test out the equipment. Do they understand how to use it? And thankfully, this team member is a lot more technically savvy than I am. And so they walk them through it. And sometimes it's on an iPad. Sometimes it's on a computer. You know, sometimes it's on a phone. Sometimes it's on a phone. And even with them walking through and explaining how to do everything, they still, we still will have times where at the last minute, we have to convert to, you know, a telephone visit. So that does happen, but I highly recommend that. If you have a person on your staff that you can have kind of looking ahead on the schedule and saying, okay, we're gonna walk this person through. And then, you know, the first time they do it, after that, it becomes kind of second nature. I have patients that have taught me quite a lot about how to do the Zoom meetings. So, and they're a lot, you know, older than I am. So I, anybody can do this. But now something else that I did want to touch on that I forgot to mention as a benefit to the telemedicine is also that, you know, that feeling that I got the first time I had a patient who otherwise would have driven close to an hour to come in, you know, to our facility, only for me to tell them in the first five minutes, okay, well, you know, you're going through active orthodontics or you've got active periodontal issues or you're in complete dentures. You know, things that might have been a deal breaker for me personally, you know, to be able to save them that trip, at least to be able to change the guidelines for them, like, hey, this might be a concern for you. Is a really nice added benefit of telemedicine. And Trish, what was the second part to? Oh, let's see. It was what, maybe you answered it already. What percentage is staff and what percentage is doctor? Did you answer that part? We do both. We do both. Every patient that I see as telemedicine before I see them, a staff member has reached out to them. I used to initially have staff members kind of room the patient, you know, they would get on the call first and they would go through things, you know, just updating medical history, updating medications. Let's review the up worth or the stop bang, whatever we were using at that point. But, you know, that wasn't as important to me as having the staff member do the pre-visit phone call to prepare them for the telemedicine. Thank you. Thank you very much. So Dr. Saul, so we're gonna conclude with some questions that are really best answered by you. And I'm gonna combine these questions a little bit too, because it seems like they kind of fold into each other. So can you kind of describe what a telemedicine conference between the dentist and the sleep physician would look like and how the dentist could prepare to be the most efficient during that kind of physician interface beforehand? And then also like say the consultation is with regards to a dentist administered home sleep apnea test, most states allow that, you know, the dentist to dispense an HSAT for titration purposes, not for diagnostic purposes, but like how could we, what would that look like too? Like say the dentist has advanced the device, they've taken an HSAT and now they wanna have a consult with the physician because the physician needs to decide, do we need to bring this patient in and get an official HSAT or do we need to bring this patient in and get a PSG with this device in place? Well, those are interesting questions. I'm just looking them over right now. You know, it's kind of interesting with respect to telemedicine, I did not really think of telemedicine between the physician and the dentist. What my approach, so to speak, has been to be that have the telemedicine consultation between the patient and the sleep physician. That generates the HST, which generates the diagnostic test, which generates the diagnosis, which generates ultimately the prescription for the oral appliance. And there may be companies that do that, that I don't know. You know, I think certainly the issue there is gonna be people's time and reimbursement and whether or not they're willing to do it. So I don't really have an answer for that. I know of no current service that has telemedicine between the dentist and the physician. Certainly that's something that could be added, but again, there would be issues such as time reimbursement and who's willing to do that, I think, of course. And with respect to the second question, I think if a dentist dispenses an HST and wants a consultation with the physician via telemedicine, again, you're gonna come down to the same issues. Is the physician willing to do that? Are they gonna do this without any coding or compensation? That I don't know. You know, I've not seen that in the industry yet, but certainly that's something that could be looked into. I'm afraid I can't answer because I've not seen that particular workflow. The whole new world, though. This COVID is a big disruptor and telehealth is a big disruptor in arguably a good way. Little silver lining there. So thank you all, our panelists. You really brought a lot of really good information in a very short period of time.

telehealth

dental practices

dental sleep medicine

COVID-19 pandemic

cost-saving

HIPAA compliance

patient experience

access to care

telemedicine consultations

treatment options