What dentists should know about the Virtual Dental Home

In recent months, several policyholders have called the TDIC Advice line asking about the virtual dental home (VDH) model and the risks associated with participating in one. The following information may be helpful for dentists who are considering practicing in such a model.

The term "virtual dental home" describes a dental care model in which a dentist utilizes teledentistry by connecting electronically to specially trained allied dental team members to deliver dental care to underserved populations.

The VDH was authorized in California in 2015 after a large-scale demonstration project proved successful at safely and effectively providing diagnostic, preventive and early intervention services in community-based sites (e.g., schools, Head Start sites and nursing homes) by allied dental team members who are connected to a dentist at an off-site location (e.g., office or clinic) using teledentistry.

Within the VDH model, a specially trained registered dental assistant in extended function (RDAEF), registered dental hygienist (RDH) or registered dental hygienist in alternative practice (RDHAP) collects electronic dental records such as radiographs, photographs, charts of dental findings, dental and medical histories with portable imaging equipment and an Internet-based dental record system. He or she then uploads the information to a secure Internet website where a supervising dentist reviews and establishes a diagnosis and treatment plan for the hygienist or assistant to carry out. Patients who need care that is more complex are referred to the dentist to provide those services.

TDIC recognizes emerging trends in dental care delivery and recommends dentists use specific protocols if they want to participate in a VDH program. If a dentist employs a dental team member to work in a VDH community setting, that dentist is subject to the same requirements and regulations as a practice owner who employs dental team members to work in a traditional practice setting. This includes adding the auxiliary to  payroll reporting for workers' compensation insurance coverage. Similar to a traditional setting, TDIC's professional liability policy may extend to dental auxiliary staff. As with any coverage interpretation, the scope of coverage is subject to the policy provisions.

"Dentists and dental team members must practice to the same standard of care regardless of the setting," said a senior risk management analyst with TDIC. "Informed consent, record collection, diagnosis, care, documentation, referral and follow-up are all essential to providing appropriate care in a traditional practice as well as the VDH setting." Additionally, if the dentist is working with an RDHAP, there is an option to establish a working relationship other than employer-employee because of the RDHAP's license statues, which allows this opportunity. "If a California dentist is working with an RDHAP in a VDH under a contracted arrangement, a written agreement with the RDHAP that addresses the items listed above, as well as the RDHAP's proof of separate liability coverage is a must," said the analyst.

As the time of this article being written, the VDH model is legal in California only. If a dentist practices in California and is interested in participating in such a delivery model, or if they are in another state and the VDH model becomes a practice option, please consider the following recommendations:

  1. Know the dental team you are working with before entering any VDH agreement. Make sure these employees are skilled individuals with similar treatment philosophies to yours. Whenever possible, work with auxiliary team members directly before remotely. Trust and good communication are vital to successful patient care. The dentist is responsible to ensure all participating dental professionals have a current license in good standing with the state licensing agency.

  2. The location your staff person uses must have the appropriate dental equipment for the services being offered and abide by CalOSHA standards for employees.

  3. Establish clear parameters for your VDH working arrangements. You likely will need to speak with a labor attorney who is familiar with dental practices and specifically the VDH delivery model. At a minimum, your employment arrangement should address:

    • Method(s), timeliness and expectations for communication.
    • Quality assurance requirements.
    • Equipment (ownership, maintenance, property insurance).
    • Use of electronic records system and documentation expectations.
    • Radiographic protocol.
    • Emergency management.
    • Compensation method.

Dentists, who are accustomed to making diagnoses during in-person visits using an explorer, often ask about the accuracy of making diagnoses from records alone. The VDH demonstration project investigated this and found:

"Based on patient information collected in the field that includes intra- and extraoral radiographs, photographs and charting collected by an [allied dental team member], a dentist can, with a great degree of certainty, decide on the best next action for that patient. In this study, individual dentists were consistent in their decisions about a specific patient whether the examination was in person or virtual."

Another common inquiry relates to interim therapeutic restorations (ITRs), one of the new duties that hygienists and RDAEFs who complete the required training program can perform in a VDH. California law specifies that ITRs can be placed after the diagnosis and direction of the supervising dentist to stabilize a tooth with a cavitated lesion until the dentist determines that additional treatment is required. ITRs provided by allied dental professionals must be completed with hand instrumentation only and must not require dental anesthesia to complete. For more information about the virtual dental home or interim therapeutic restorations, see the July 2012 and October 2013 issues of the Journal of the California Dental Association.

A decision to participate in this type of practice model is one that each dentist should make on his or her own. Participating in the VDH model can be rewarding and provides a different vantage point not offered by the traditional practice model. Prior to starting such an arrangement, please notify your professional liability carrier.

For more information about this and other non-traditional practice models, contact Gayle Mathe, CDA director of community programs at gayle.mathe@cda.org.

This article was published in the California Dental Association Journal, Oct. 2015.

Related Items

CDA co-sponsored legislation that would provide key funding for the virtual dental home (VDH) model of dental care has passed unanimously on the Assembly floor. AB 648, authored by Assemblyman Evan Low (D-San Jose), would create a grant program under the direction of the state dental director to expand the VDH model into the state’s areas of greatest need. Public and private funds would be used for training, equipment, technical assistance and other support for VDH implementation. The bill passed in the Assembly Health Committee on a 79-0 vote.

October 2013
October 2013 issue of the Journal of the California Dental Association
The October 2013 issue of the Journal of the California Dental Association covers a variety of topics including a review of interim therapeutic restoration in the virtual dental home; a dentigerous cyst associated with a supernumerary tooth; CO2 laser vaporization treatment for gingival leukoplakia and a case of coronoid hyperplasia in a pediatric patient.

July 2012
July 2012 issue of the Journal of the California Dental Association
Discussion of “health homes” and the use of telehealth technologies to connect geographically distributed providers and the development of effective prevention and early intervention techniques; using telehealth technologies to improve oral health for vulnerable and underserved populations; the differences between an in-person examination versus a “virtual” one; community-based prevention and early intervention strategies; and implications and strategies.