R U E-AWARE? It is not always appreciated that these new forms of communication are required to conform to the same professional and ethical standards as the more traditional media.
Dental Councils around the world, just like their medical counterparts, have been wrestling with the regulatory implications of these forms of communication which cross national and jurisdictional boundaries.
Information and advice can now be accessed by patients in one part of the world, from healthcare professionals based and registered in another part of the world, and over whom the local regulatory body usually has no jurisdiction. When the information provided is inaccurate or misleading, or perhaps when the advice conflicts with the policy or standards of the national regulatory body, this can create a potentially difficult dilemma for any regulatory body to resolve, within the powers at its disposal.
Websites
The demand from patients wanting to learn more about healthcare choices is growing rapidly. The web is increasingly used by dental patients to obtain further information on particular treatments that they have heard about, or which have been proposed for them, as well as for general information on oral healthcare and where they might elect to receive it.
But it is important to realise that the information you provide to a patient via your website, and the expectations that this information might generate in the patient's mind, will become an integral part of the overall consent process.
A patient may well rely upon information that they have obtained from your website, unless they have been given further information which applies more specifically to their own individual circumstances. Although it is natural for dentists to want their websites to present the benefits of dentistry and the range of treatment available (and perhaps their facilities) in the best possible light, this must not be done in a way which suggests or implies superiority over other dentists, or which makes claims that cannot be substantiated, or statements which are potentially misleading or untrue. In general, comparative advertising or promotional statements are best avoided.
However, by including items such as pictures of the staff and the dental surgery, an overview of your services and perhaps a location map, you can start to convey the feel and values of your practice. By publishing examples of the range of fees charged and the payment methods accepted by the practice you can reduce the incidence of new patients who either didn't know that they might have to pay at the time of their initial consultation, or who were unaware of the sums that could be involved. This minimises the potential for complaints regarding financial matters.
Images
Once any image file has been placed on the Internet there is no control over ownership and usage. Such images could then be copied and freely distributed. It is essential, therefore, to obtain the consent of any patient or other person of whom you are contemplating to use an image from which that person could be recognised. Images should be tasteful and used with sensitivity, given the accessibility of the material to a wide audience. Avoid using images that might be misleading, or capable of raising patient expectations to an unrealistic level.
Links
Any decision to provide links to other websites should only be taken after the most careful consideration. Any such link could create problems by association; even when the content of your own website is beyond criticism, you have no day-to-day influence over the content of the remote site, the controller of which might decide to change the material it posts without you being aware of this fact.
These are relatively early days for dental websites, most of which by comparison with many other organisations are fairly undeveloped at this stage - although there are notable exceptions to this.
In the USA, the plethora of available online information has in some respects served only to create greater confusion for patients, rather than providing consumers with better quality and more reliable information. Many manufacturers have created a 'virtual' market by developing attractive, sophisticated websites that purport to be independent and providing public information, but in fact are well disguised marketing platforms promoting one of more specific products or services in order to create a demand when the patients next visit their dentist. Some such sites even direct patients to specific providers, some of whom pay a fee for the referral - all of which can cause dento-legal problems for the dentist concerned. For all these reasons, the American Accreditation Healthcare Commission (URAC) is developing an accreditation programme for healthcare sites on the Internet, and it may be that this kind of approach will, in the long-term, help to reassure patients that the information they are obtaining is from a reputable source. URAC's web address is provided on the facing page.
E-risks
A look at some of the dento-legal problems associated with websites, email and other forms of digital communication.
Email
All the personal information you accumulate about a patient by virtue of your professional relationship with them, is bound by the ethical principle of professional confidentiality, as well as by the separate legal requirements under the Data Protection Act 1998. If, in addition to providing you with their name, address, telephone number etc, your patients provide you with an email address, it is important to establish at the outset the way in which this email address will be used, and with whom it will be shared and under what circumstances. Such information forms part of your compliance with the principles as set out in the Data Protection Act.
Email addresses may or may not be secure, so when inviting a patient to supply their email address, they should be asked to indicate whether they agree to receiving all kinds of communication from you by these means, or simply (for example) a reminder for them to contact the practice to arrange a check-up.
Once you offer an email facility, both new and existing patients can contact you for information, or to make an appointment. Subject to the controls outlined above, you can then confirm appointments by email, which take only a moment to send and are simpler, quicker and cheaper than posting an appointment card.
In the same way that the quality of your website reflects directly on your dental practice, so does the speed with which you respond to your patients' emails. As a minimum, emails should at least be checked daily - you never know when something may be sent that requires your immediate action. People seem to expect a faster response to an email than to more traditional forms of communication. If a reply that takes days has the potential to frustrate your patient, then a same-day response can greatly impress them.
Informality
Face-to-face communication is partly non-verbal. It is important to remember that email lacks the range of subtlety normally supplied by body language or speech intonation.
Email exists solely as images and text viewed on screen, so think carefully about how you will use it to provide information to patients. You may, for example, be more tempted to write in light-hearted fashion or less professionally than you might in a formal letter. Such comments could be misinterpreted. As a clinician, a professional manner should be maintained when providing services or advice whether by email, telephone or in person.
Convenience
The same convenience that is one of email's great attractions, is also one of its greatest dangers. It is easier to attach new messages and replies to earlier correspondence (or to forward replies to a new group of recipients who were not privy to the original exchange(s)), than to create a new message which simply refers to the earlier material. It may not, however, be appropriate for some of these new recipients to see the earlier correspondence, and you may not have the agreement of those involved to share material which relates to them, in this way.
Tele-dentistry
A natural extension of email is dentistry's equivalent of telemedicine, in which remote consultations, second opinions, and advice can take place using electronic data interchange (EDI). The high quality of EDI which is now possible through digital x-rays and intra-oral camera images, supplemented by web cam consultations, allows dentists working in more remote areas to access top quality specialist opinion and guidance, with minimum inconvenience to themselves and their patients.
The limited penetration of these techniques into UK healthcare to date has helped to contain the urgency of any need to address the legal implications that arise when data passes across borders. The patient and referring dentist may be in the UK and the second opinion almost anywhere else in the world. With the passage of time, this situation will change, although strictly speaking the regulatory controls are identical whether one is practicing dentistry 'in the flesh' within a state or territory, or 'electronically' from outside the country.
Text messaging
This is already widely used by some dental practices, perhaps to remind patients of the fact that a periodic examination is due, and offering the facility to ring back the practice immediately to arrange the relevant appointment. More entrepreneurial practices have even been known to send text messages offering birthday greetings to patients, or to remind patients of how to reach the dentist outside normal surgery hours if they have recently undergone a procedure where they could be experiencing postoperative pain, discomfort or other problems.
Records
In seizing upon the simplicity and immediacy of these forms of communication, it is often overlooked that the patient's records, whether held in paper or electronic form - should contain details of all contacts with the patient. This includes phone calls, emails and text messages sent or received, just as much as attendance to the practice in person. It can otherwise become very difficult to piece together the complete chronology of a sequence of events which might later become the subject of a complaint or claim, or some kind of formal investigation by third parties.
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