+
MODEL
Journal of the Formosan Medical Association (2014) xx, 1e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
ORIGINAL ARTICLE
Improvements in dental care using a new mobile app with cloud services Chia-Yung Lin a,b, Kang-Lin Peng c, Ji Chen c, Jui-Yuan Tsai d, Yu-Chee Tseng c, Jhih-Ren Yang a, Min-Huey Chen b,* a
Dentistry Department, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC Department of Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan, ROC c Department of Computer Science and Engineering, National Chiao Tung University, Hsinchu City, Taiwan, ROC d Information Management Office, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC b
Received 9 January 2014; received in revised form 12 February 2014; accepted 23 February 2014
KEYWORDS cloud computing service; dental care; mobile app; telemedicine
Background/Purpose: Traditional dental care, which includes long-term oral hygiene maintenance and scheduled dental appointments, requires effective communication between dentists and patients. In this study, a new system was designed to provide a platform for direct communication between dentists and patients. Methods: A new mobile app, Dental Calendar, combined with cloud services specific for dental care was created by a team constituted by dentists, computer scientists, and service scientists. This new system would remind patients about every scheduled appointment, and help them take pictures of their own oral cavity parts that require dental treatment and send them to dentists along with a symptom description. Dentists, by contrast, could confirm or change appointments easily and provide professional advice to their patients immediately. In this study, 26 dentists and 32 patients were evaluated by a questionnaire containing eight dental-service items prior to and after using this system. Paired sample t test was used for statistical analysis. Results: After using the Dental Calendar combined with cloud services, dentists were able to improve appointment arrangements significantly, taking care of the patients with sudden worse prosthesis (p < 0.05). Patients also achieved significant improvement in appointment reminder systems, rearrangement of appointments in case of sudden worse prosthesis, and establishment of a direct relationship with dentists (p < 0.05). Conclusion: Our new mobile app, Dental Calendar, in combination with cloud services, provides efficient service to both dentists and patients, and helps establish a better relationship
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Dentistry, School of Dentistry, National Taiwan University, No. 1, Changde St., Zhongzheng Dist., Taipei City 10048, Taiwan, ROC. E-mail address: [email protected] (M.-H. Chen). http://dx.doi.org/10.1016/j.jfma.2014.02.009 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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C.-Y. Lin et al. between them. It also helps dentists to arrange appointments for patients with sudden worsening of prosthesis function. Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Introduction Wide disparities in dental care and variation in dental manpower distribution exist in Taiwan.1 The National Health Insurance system adopted by the government offers a comprehensive single-payer, fee-for-service health benefits; however, this has resulted in increased utilization of dental services and uneven distribution of dentists and care.2 Some not-so-serious diseases, such as periimplantitis and full ceramic crown fracture, are associated with high morbidity and are of more concern to patients due to associated high dental expenses. Therefore, we need to minimize delays in treatment by optimizing available resources. In addition to chair-side treatment, traditional dental care processes including oral hygiene maintenance, scheduled dental appointments, a good cooperation between dentists and patients, and dental emergency treatment are very time consuming. Among these procedures, communication between patients and dentists at every scheduled appointment plays a key role, especially for patients who have received expensive dental prosthesis. Dentists require to follow up these patients regularly and sometimes call them earlier for observation, to prevent the occurrence of any unresolvable problems later; more time may also be saved if the patients receiving high-priced dental prosthesis do not face any problems. Many dentists would overbook appointments frequently to prevent idle dental chair capacity. However, this method was not very effective, and an appropriate organizational system was required to be designed for a quick diagnosis of patients’ oral condition to increase dental chair-time utilization.3 Besides, with an unhealthy tendency of dentiste patient relationship in Taiwan an easy comfortable communication platform for the autonomy claimed by patients and informed consent provided by dentists could be developed to soothe these ethical and legal issues.4 Telemedicine, including mobile technology and cloud services, is of interest because it provides an excellent system for communication between patients and dentists and referral from primary care sites to hospitals.5 However, few publications have reported experiences in dental care with telemedicine, and most reports described the use of telemedicine as broadcast directly or synchronously.6e8 A few reports described the telemedicine system as an optimal tool for diagnosis, consultation, and referral.9e12 Therefore, our group used the techniques of mobile technology combined with the cloud computing service to create a new app for making an efficient, qualified, and valuable dental care system. This new app has been discussed in detail in the Methods section. It helps avoid unnecessary travel for patients, makes dental chair-time utilization more efficient, and reduces the failure rate of dental prosthesis by providing appropriate treatment in time. The purposes of this research are to improve traditional dental care services
through an interdisciplinary collaboration and to enhance the application of mobile technology combined with cloud service in the field of dental care.
Methods Motivating scenario Dental Calendar is a new mobile app specifically designed for dentists and patients. Patients can install it on their smartphones or mobile devices when making appointments with dentists at clinics. One week prior to every scheduled appointment, Dental Calendar would automatically remind patients and confirm whether they would be able to visit the dental clinic or not. Patients can take photos of their oral cavity using smart phones (selfie), and through cloud services send them to dentists and confirm whether they would arrive at the clinic on time. If patients are unable to attend their scheduled appointments, dentists can arrange another appointment through cloud services, thus saving time. If patients still cannot come at the new time, then dentists can contact them directly over the phone. A flowchart of the system is shown in Fig. 1.
Architecture overview of the system Dental Calendar comprises three main elements: a phone app, a Java server, and a web server (Fig. 2). Phone app Patients can install this new app, Dental Calendar, on their smart phones easily. Dental Calendar has the following five functions (Fig. 3): (1) Individual calendar. After dental treatment, a patient makes the next appointment with the dentist at the clinic. The scheduled days on the patient’s calendars would be circled by a red tooth (Fig. 3A and B). (2) Schedule reminder. One week prior to every scheduled appointment, Dental Calendar would remind patients automatically and confirm whether they can come to the dental clinics or not (Fig. 3C and D). (3) Symptom report. In addition to conveying patients’ answers regarding visiting the dental clinics, the app would request patients to take dental pictures and write messages about their oral conditions. All this information would be sent to dentists through cloud services (Fig. 3E). (4) New appointment notification. If patients have difficulty in attending the original appointments, dentists can make new appointments and Dental Calendar would notify patients automatically (Fig. 3F and G). (5) Private messages. After examining the reported symptoms, dentists can give some instructions regarding oral hygiene care or arrange earlier appointments for patients, and patients can read these messages from the designated column (Fig. 3H).
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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Improvement in dental care with new mobile app
Figure 1
3
Flowchart of Dental Calendar combined with cloud service.
Java server The Java server supports phone app backstage. Besides controlling users’ log-in activity, Java server performs the following four primary functions (Fig. 4): (1) Schedule query service. This function helps every phone app installed on patients’ phones search for every scheduled and not
overdue appointment in the database. (2) Symptom report service. This function deals with patient replies regarding clinic visit, and pictures and messages sent by every patient; all this information is stored in a database. (3) Appointment service. This function recognizes patient replies regarding the clinic visit and help arrange patient appointments accordingly. (4) Message service. This function helps every phone app installed on patients’ phones search for dentists’ specific messages to respective patients. Web server This interface helps dentists perform all management tasks on web browsers, which are as follows (Fig. 5). (1) Management of patient data and appointment: Dentists can check up patients’ basic data and make appointments with them (Fig. 5A and B). (2) Management of report data. Dentists can make a primary diagnosis based on the symptom reports including pictures and messages (Fig. 5C and D) sent by patients and then can send required professional advises to selected patients. Dentists can even ask patients to come earlier if some problems are detected in their oral conditions. (3) Management of schedule. Dentists can rearrange scheduled appointments (Fig. 5E) if patients express their inability to attend the scheduled appointment (Fig. 5F).
Assessment
Figure 2 Architecture of Dental Calendar combined with cloud services, which has three main elements: a phone app, a Java server, and a web server. Java server and web server acquire information from the database for mutual communication. Java server is mainly supported by smartphones used by patients, whereas web server by computer web browsers is used by dentists.
Interviews and questionnaires were used to identify the efficiency and quality of Dental Calendar combined with cloud services at the end of the system developer life cycle.13 Steps of the system developer life cycle are as follows: (1) a system analysis was carried out to investigate the problems associated with existing dental clinics; (2) a cloud service system prototype was constructed based on the investigation results of the first step; (3) add-on app services were installed to mobile devices for dentists and patients; (4) trial systems were parallel to add and fix components in order to solve the occurrence of problems and reduce the failure possibility of the systems; and (5) interviews and questionnaires were used to evaluate the efficiency and quality of cloud-based dental clinic
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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Figure 3 Five main functions of Dental Calendar: individual calendar, schedule reminder, symptom report, new appointment notification, and private messages, shown on patients’ mobile devices, are demonstrated. (A) Patients can use personal identifications and passwords to start the app. (B) Scheduled appointments on personal calendars are circled by a red tooth. (C) Dental Calendar reminds patients automatically and (D) confirms whether they can come to dental clinics or not. (E) Patients can take pictures using their mobile devices and write messages about their oral conditions and send these to dentists. (F) If patients would like to change original appointments, dentists can make new appointments on their computer web browsers and (G) Dental Calendar notifies patients automatically. (H) After examining the pictures along with symptom descriptions, dentists can provide instructions on oral hygiene care or make earlier appointments for patients if required.
management systems. Eight questions in the questionnaire (Fig. 6) were designed to do a comparative prior to-andafter evaluation of experiencing this new dental care system. In this study, 26 volunteer dentists and 32 volunteer patients all of whom had already experienced traditional dental care were enrolled as participants to use our new system. Their altitudes of Dental Calendar combined with cloud services were assessed, based on the questionnaires administered prior to and after they experienced the new system, by paired sample t test. Overall experience was estimated from the differences of total mean value prior to and after using the new system. Eight items were also evaluated individually.
Results Results of assessments through interviews and questionnaires indicated a significant increase (p < 0.05) in both dentists’ and patients’ overall experiences (Table 1). Not only dentists gave positive ratings to and reported high satisfaction with our new system, but also patients’ user experience scores increased by 16% after using this system. Detailed analyses also indicated differences between dentists’ and patients’ ratings. From dentists’ viewpoints, the app provided significant help (p < 0.05), especially in one service item (appointments can be rearranged for patients with sudden worse prosthesis; Table 2). Further interviews
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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Figure 4 Java server, developed at the National Chiao Tung University, supports phone app backstage. This figure demonstrates that we used Eclipse 4.3.1 (Eclipse Foundation, Ottawa, Ontario, Canada) to implement the Java server. Communication between the Java server and Dental Calendar is displayed in the Consoles column.
Figure 5 For convenience and to maintain privacy, dentists can perform all management tasks on browsers of theirs own computers, without any other manpower assistance. (A) Dentists need to log in. (B) Besides checking up every patient’s basic data and appointments, (C and D) dentists can also see pictures along with symptom descriptions sent by patients. (E) Dentists can ask patients to come earlier if some problems are detected or (F) rearrange scheduled appointments directly over the phone if patients express their inability to come on the first scheduled appointment.
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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Figure 6 Eight questions in the questionnaire designed for (A) dentists and (B) patients to carry out a comparative prior to-andafter evaluation.
of dentists revealed that they felt very confident about their initial relationships with patients. Some experienced dentists gave high scores to five service items (following of scheduled appointments by patients, easy rearrangement of patient appointments, patients’ trust in dentists, dentists’ consideration for patients, and dental service quality). The dentists that participated in this survey mostly work for the National Taiwan University Hospital. Dental emergency services provided by the hospital emergency room were the reason why this new system made no significant improvement on this service item. From patients’ viewpoints, significant differences (p < 0.05) were observed in three service items (appointment reminders, appointment rearrangements for sudden worse prosthesis, and dentistepatient relationship; Table 2). By contrast, no Table 1
significant differences were observed for five service items (appointment rearrangements during daily life, dental emergency help, trust in dentists, dentists’ consideration for patients, and dental service quality); this was because patients trusted their earlier dentists and further interviews revealed that the new system did not decrease either the service quality or the patients reliance.
Discussion The status of the oral condition and patients’ satisfaction with their dentition can have definitive impacts on patients’ daily living and quality of life, regardless of their age, gender, and level of education.14 Population growth
Paired sample t-test of overall evaluation. Difference of paired variables Mean
Standard deviation
Standard error of the mean
t
Difference
Significance
3.556
7
0.009*
8.947
7
0.000*
95% confidence interval Lower bound
Upper bound
(a) Total mean increment in aftereprior-to test for dentists, from questionnaires Paired After-Before 5.875 4.673 1.652 1.968 9.782 (b) Total mean increment aftereprior-to test for patients, from questionnaires Paired After-Before 18.500 5.831 2.062 13.625 23.375 *Significant difference (p < 0.05).
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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Improvement in dental care with new mobile app Table 2
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Paired sample t-test of detail evaluation.
Paired After-Before
Difference of paired variables
t
Difference Significance
Mean Standard Standard error 95% confidence interval deviation of the mean Lower bound Upper bound (a) Significant different item from questioners for dentists Patients can be rearranged 0.385 0.752 0.148 appointments for sudden worse prosthesis (b) Significant different items from questioners for patients Appointments reminding 0.844 1.668 0.295 Appointments rearrangement 0.781 1.601 0.283 for sudden worse prosthesis Dentist-patient relationship 0.500 1.368 0.242
0.081
0.689
2.606 25
0.015*
0.242 0.204
1.445 1.359
2.862 31 2.760 31
0.007* 0.010*
0.007
0.993
2.068 31
0.047*
*Significance (p < 0.05).
and economic development during the past 50 years in Taiwan demand an increase in the dental workforce.15 However, in the Second Consensus Conference on the Dental Workforce held by the National Health Research Institutes (NHRI) in 2010, all experts agreed to limit the increase in the number of dentists because of the dramatic decrease in birth rates. An imbalance indeed exists between supply and demand of dental services in Taiwan; especially more exquisite services should be created to improve this dilemma.16,17 Therefore, we developed a new dental care system based on telemedicine technology to help reduce dentists’ workload. By introducing the basic concept of updating service quality,18,19 our Dental Calendar combined with cloud service can not only remind patients to come to dental clinics for follow-up on a scheduled time, but also help them capture their dental images and
send these to dentists for making an early diagnosis. First, the user interface confirmed patient schedules; second, the service management server assessed and allocated medical resources for dentists’ requirements, and then exchanged with picture achieving and communication system (PACS) and database in hospital information system (HIS); third, accessed PACS and HIS database through hospital Virtual Private Network (VPN) for further request; and fourth, the service management server helped establish communications between dentists and patients (Fig. 7). According to questionnaires and further interviews, this new system significantly changed volunteers’ overall dental experiences. This new system gained very high appreciations from both dentists and patients, who confirmed its usefulness in the dental services field. However, its importance varies from dentists to patients. This system helped dentists
Figure 7 Our cloud dental care system can not only remind patients to come for dental follow-up on time, but also advise them to capture images of their own oral conditions for further diagnosis.
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
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8 significantly to rearrange patient appointments, especially for those with sudden worse prosthesis. Regardless of whether dentists work in hospitals or private clinics, highprice dental prosthesis always significantly contributes to their salary. If dentists can monitor patients receiving expensive dental prosthesis regularly, the occurrence of many unpredictable or unsolvable problems can be reduced.20,21 Besides, these patients can also be more loyal to their initial dentists. From patients’ viewpoints, with high scores for service times, volunteers undoubtedly agreed that they could get a better dental care. Although no significant changes were observed in five items of dental service, with some modifications such as a better art design, a friendly user interface, and mutual communication between dentists and patients, this new system would be of much help. People with unmet dental needs and those who express a lack of trust and confidence in their dentists are more likely to experience poor oral health-related quality of life.22 Based on the results of this survey, we can state that cloud services installed on personal mobile devices would be useful in improving dental care. More corrections and modifications, based on dentists’ and patients’ advices, can be carried out on our new system to build a better product. Moreover, the large amount of patients’ oral pictures stored in PACS and HIS database may help in carrying out further dental researches quickly and easily. Our Dental Calendar combined with cloud service, the first product in related fields, can automate routine, time-consuming, manual tasks, which would benefit dentists and patients. An obvious gap between telemedicine and dentists was closed by this interdisciplinary cooperation. Direct apply in the clinical situation could be worthy of expect.
C.-Y. Lin et al.
6.
7.
8.
9.
10.
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12.
13. 14.
15.
16.
Acknowledgments 17.
The authors would like to thank the Hsin-Chu Branch of the National Taiwan University Hospital (HCH102-13) and the National Chiao Tung University (102W970), for funding this work and the National Science Council Taiwan (NSC1012314B002097MY3) for providing grant support.
References 1. Cher TL, Lai EH, Huang CS, Lin CP. Field survey of dental manpower in Taiwan’s hospitals. J Formos Med Assoc 2012; 111:305e14. 2. Lin C, Chao H. Use of selected ambulatory dental services in Taiwan before and after global budgeting: a longitudinal study to identify trends in hospital and clinic-based services. BMC Health Serv Res 2012;12:339. 3. Holtshousen WS, Coetzee E. The effect of overbooking on idle dental chair capacity in the Pretoria region of the Gauteng Oral Health Services. SADJ 2012;67:460e4. 4. Naidoo S. Ethical and legal issues of HIV testing in the dental setting. J Forensic Odontostomatol 2013;31:164e5. 5. Ferrandiz L, Moreno-Ramirez D, Nieto-Garcia A, Carrasco R, Moreno-Alvarez P, Galdeano R, et al. Teledermatology-based
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presurgical management for nonmelanoma skin cancer: a pilot study. Dermatol Surg 2007;33:1092e8. Jacobs MJ, Edmondson MJ, Lowry JC. Accuracy of diagnosis of fractures by maxillofacial and accident and emergency doctors using plain radiography compared with a telemedicine system: a prospective study. Br J Oral Maxillofac Surg 2002;40:156e62. Ewers R, Schicho K, Wagner A, Undt G, Seemann R, Figl M, et al. Seven years of clinical experience with teleconsultation in craniomaxillofacial surgery. J Oral Maxillofac Surg 2005;63: 1447e54. Roccia F, Spada MC, Milani B, Berrone S. Telemedicine in maxillofacial trauma: a 2-year clinical experience. J Oral Maxillofac Surg 2005;63:1101e5. Herce J, Lozano R, Salazar CI, Rollon A, Mayorga F, Gallana S. Management of impacted third molars based on telemedicine: a pilot study. J Oral Maxillofac Surg 2011;69:471e5. Duka M, Mihailovic B, Miladinovic M, Jankovic A, Vujicic B. Evaluation of telemedicine systems for impacted third molars diagnosis. Vojnosanit Pregl 2009;66:985e91. Wagner A, Undt G, Schicho K, Wanschitz F, Watzinger F, Murakami K, et al. Interactive stereotaxic teleassistance of remote experts during arthroscopic procedures. Arthroscopy 2002;18:1034e9. Eraso FE, Scarfe WC, Hayakawa Y, Goldsmith J, Farman AG. Teledentistry: protocols for the transmission of digitized radiographs of the temporomandibular joint. J Telemed Telecare 1996;2:217e23. Paul P, Maglio JS. Fundamentals of service science. J Acad Market Sci 2008;36:18e20. Karasneh J, Al-Omiri MK, Al-Hamad KQ, Al Quran FA. Relationship between patients’ oral health-related quality of life, satisfaction with dentition, and personality profiles. J Contemp Dent Pract 2009;10:E049e56. Shiau YY, Chang CS, Chiou CH, Chi LY, Liu S. Manpower and education of dentists in Taiwan. J Med Educ 2001;5:3e12 [In Chinese]. Huang CS, Cher TL, Lin CP, Wu KM. Projection of the dental workforce from 2011 to 2020, based on the actual workload of 6762 dentists in 2010 in Taiwan. J Formos Med Assoc 2013;112: 527e36. Yang CH, Huang YT, Hsueh YS. Redistributive effects of the National Health Insurance on physicians in Taiwan: a natural experiment time series study. Int J Equity Health 2013;12:13. http://dx.doi.org/10.1186/47592761213. Hsiao SL, Yang HL. A service experience engineering (SEE) method for developing new services. IJM 2010;27:437e47. Meyer Goldstein S, Johnston R, Duffy JA, Rao J. The service concept: the missing link in service design research? JOM 2002; 20:121e34. Mijiritsky E, Lorean A, Mazor Z, Levin L. Implant toothsupported removable partial denture with at least 15-year long-term follow-up. Clin Implant Dent Relat Res 2013;16(1). http://dx.doi.org/10.1111/12190. Krennmair G, Krainhofner M, Waldenberger O, Piehslinger E. Dental implants as strategic supplementary abutments for implant-tooth-supported telescopic crown-retained maxillary dentures: a retrospective follow-up study for up to 9 years. Int J Prosthodont 2007;20:617e22. Muirhead VE, Marcenes W, Wright D. Do health providerpatient relationships matter? Exploring dentist-patient relationships and oral health-related quality of life in older people. Age Ageing 2013;25:25. Available from: http://ageing. oxfordjournals.org/content/early/2013/11/25/ageing.aft183. short.
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
MODEL
Journal of the Formosan Medical Association (2014) xx, 1e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
ORIGINAL ARTICLE
Improvements in dental care using a new mobile app with cloud services Chia-Yung Lin a,b, Kang-Lin Peng c, Ji Chen c, Jui-Yuan Tsai d, Yu-Chee Tseng c, Jhih-Ren Yang a, Min-Huey Chen b,* a
Dentistry Department, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC Department of Dentistry, School of Dentistry, National Taiwan University, Taipei, Taiwan, ROC c Department of Computer Science and Engineering, National Chiao Tung University, Hsinchu City, Taiwan, ROC d Information Management Office, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC b
Received 9 January 2014; received in revised form 12 February 2014; accepted 23 February 2014
KEYWORDS cloud computing service; dental care; mobile app; telemedicine
Background/Purpose: Traditional dental care, which includes long-term oral hygiene maintenance and scheduled dental appointments, requires effective communication between dentists and patients. In this study, a new system was designed to provide a platform for direct communication between dentists and patients. Methods: A new mobile app, Dental Calendar, combined with cloud services specific for dental care was created by a team constituted by dentists, computer scientists, and service scientists. This new system would remind patients about every scheduled appointment, and help them take pictures of their own oral cavity parts that require dental treatment and send them to dentists along with a symptom description. Dentists, by contrast, could confirm or change appointments easily and provide professional advice to their patients immediately. In this study, 26 dentists and 32 patients were evaluated by a questionnaire containing eight dental-service items prior to and after using this system. Paired sample t test was used for statistical analysis. Results: After using the Dental Calendar combined with cloud services, dentists were able to improve appointment arrangements significantly, taking care of the patients with sudden worse prosthesis (p < 0.05). Patients also achieved significant improvement in appointment reminder systems, rearrangement of appointments in case of sudden worse prosthesis, and establishment of a direct relationship with dentists (p < 0.05). Conclusion: Our new mobile app, Dental Calendar, in combination with cloud services, provides efficient service to both dentists and patients, and helps establish a better relationship
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Dentistry, School of Dentistry, National Taiwan University, No. 1, Changde St., Zhongzheng Dist., Taipei City 10048, Taiwan, ROC. E-mail address: [email protected] (M.-H. Chen). http://dx.doi.org/10.1016/j.jfma.2014.02.009 0929-6646/Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Please cite this article in press as: Lin C-Y, et al., Improvements in dental care using a new mobile app with cloud services, Journal of the Formosan Medical Association (2014), http://dx.doi.org/10.1016/j.jfma.2014.02.009
+
MODEL
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C.-Y. Lin et al. between them. It also helps dentists to arrange appointments for patients with sudden worsening of prosthesis function. Copyright ª 2014, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.
Introduction Wide disparities in dental care and variation in dental manpower distribution exist in Taiwan.1 The National Health Insurance system adopted by the government offers a comprehensive single-payer, fee-for-service health benefits; however, this has resulted in increased utilization of dental services and uneven distribution of dentists and care.2 Some not-so-serious diseases, such as periimplantitis and full ceramic crown fracture, are associated with high morbidity and are of more concern to patients due to associated high dental expenses. Therefore, we need to minimize delays in treatment by optimizing available resources. In addition to chair-side treatment, traditional dental care processes including oral hygiene maintenance, scheduled dental appointments, a good cooperation between dentists and patients, and dental emergency treatment are very time consuming. Among these procedures, communication between patients and dentists at every scheduled appointment plays a key role, especially for patients who have received expensive dental prosthesis. Dentists require to follow up these patients regularly and sometimes call them earlier for observation, to prevent the occurrence of any unresolvable problems later; more time may also be saved if the patients receiving high-priced dental prosthesis do not face any problems. Many dentists would overbook appointments frequently to prevent idle dental chair capacity. However, this method was not very effective, and an appropriate organizational system was required to be designed for a quick diagnosis of patients’ oral condition to increase dental chair-time utilization.3 Besides, with an unhealthy tendency of dentiste patient relationship in Taiwan an easy comfortable communication platform for the autonomy claimed by patients and informed consent provided by dentists could be developed to soothe these ethical and legal issues.4 Telemedicine, including mobile technology and cloud services, is of interest because it provides an excellent system for communication between patients and dentists and referral from primary care sites to hospitals.5 However, few publications have reported experiences in dental care with telemedicine, and most reports described the use of telemedicine as broadcast directly or synchronously.6e8 A few reports described the telemedicine system as an optimal tool for diagnosis, consultation, and referral.9e12 Therefore, our group used the techniques of mobile technology combined with the cloud computing service to create a new app for making an efficient, qualified, and valuable dental care system. This new app has been discussed in detail in the Methods section. It helps avoid unnecessary travel for patients, makes dental chair-time utilization more efficient, and reduces the failure rate of dental prosthesis by providing appropriate treatment in time. The purposes of this research are to improve traditional dental care services
through an interdisciplinary collaboration and to enhance the application of mobile technology combined with cloud service in the field of dental care.
Methods Motivating scenario Dental Calendar is a new mobile app specifically designed for dentists and patients. Patients can install it on their smartphones or mobile devices when making appointments with dentists at clinics. One week prior to every scheduled appointment, Dental Calendar would automatically remind patients and confirm whether they would be able to visit the dental clinic or not. Patients can take photos of their oral cavity using smart phones (selfie), and through cloud services send them to dentists and confirm whether they would arrive at the clinic on time. If patients are unable to attend their scheduled appointments, dentists can arrange another appointment through cloud services, thus saving time. If patients still cannot come at the new time, then dentists can contact them directly over the phone. A flowchart of the system is shown in Fig. 1.
Architecture overview of the system Dental Calendar comprises three main elements: a phone app, a Java server, and a web server (Fig. 2). Phone app Patients can install this new app, Dental Calendar, on their smart phones easily. Dental Calendar has the following five functions (Fig. 3): (1) Individual calendar. After dental treatment, a patient makes the next appointment with the dentist at the clinic. The scheduled days on the patient’s calendars would be circled by a red tooth (Fig. 3A and B). (2) Schedule reminder. One week prior to every scheduled appointment, Dental Calendar would remind patients automatically and confirm whether they can come to the dental clinics or not (Fig. 3C and D). (3) Symptom report. In addition to conveying patients’ answers regarding visiting the dental clinics, the app would request patients to take dental pictures and write messages about their oral conditions. All this information would be sent to dentists through cloud services (Fig. 3E). (4) New appointment notification. If patients have difficulty in attending the original appointments, dentists can make new appointments and Dental Calendar would notify patients automatically (Fig. 3F and G). (5) Private messages. After examining the reported symptoms, dentists can give some instructions regarding oral hygiene care or arrange earlier appointments for patients, and patients can read these messages from the designated column (Fig. 3H).
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Improvement in dental care with new mobile app
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Flowchart of Dental Calendar combined with cloud service.
Java server The Java server supports phone app backstage. Besides controlling users’ log-in activity, Java server performs the following four primary functions (Fig. 4): (1) Schedule query service. This function helps every phone app installed on patients’ phones search for every scheduled and not
overdue appointment in the database. (2) Symptom report service. This function deals with patient replies regarding clinic visit, and pictures and messages sent by every patient; all this information is stored in a database. (3) Appointment service. This function recognizes patient replies regarding the clinic visit and help arrange patient appointments accordingly. (4) Message service. This function helps every phone app installed on patients’ phones search for dentists’ specific messages to respective patients. Web server This interface helps dentists perform all management tasks on web browsers, which are as follows (Fig. 5). (1) Management of patient data and appointment: Dentists can check up patients’ basic data and make appointments with them (Fig. 5A and B). (2) Management of report data. Dentists can make a primary diagnosis based on the symptom reports including pictures and messages (Fig. 5C and D) sent by patients and then can send required professional advises to selected patients. Dentists can even ask patients to come earlier if some problems are detected in their oral conditions. (3) Management of schedule. Dentists can rearrange scheduled appointments (Fig. 5E) if patients express their inability to attend the scheduled appointment (Fig. 5F).
Assessment
Figure 2 Architecture of Dental Calendar combined with cloud services, which has three main elements: a phone app, a Java server, and a web server. Java server and web server acquire information from the database for mutual communication. Java server is mainly supported by smartphones used by patients, whereas web server by computer web browsers is used by dentists.
Interviews and questionnaires were used to identify the efficiency and quality of Dental Calendar combined with cloud services at the end of the system developer life cycle.13 Steps of the system developer life cycle are as follows: (1) a system analysis was carried out to investigate the problems associated with existing dental clinics; (2) a cloud service system prototype was constructed based on the investigation results of the first step; (3) add-on app services were installed to mobile devices for dentists and patients; (4) trial systems were parallel to add and fix components in order to solve the occurrence of problems and reduce the failure possibility of the systems; and (5) interviews and questionnaires were used to evaluate the efficiency and quality of cloud-based dental clinic
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Figure 3 Five main functions of Dental Calendar: individual calendar, schedule reminder, symptom report, new appointment notification, and private messages, shown on patients’ mobile devices, are demonstrated. (A) Patients can use personal identifications and passwords to start the app. (B) Scheduled appointments on personal calendars are circled by a red tooth. (C) Dental Calendar reminds patients automatically and (D) confirms whether they can come to dental clinics or not. (E) Patients can take pictures using their mobile devices and write messages about their oral conditions and send these to dentists. (F) If patients would like to change original appointments, dentists can make new appointments on their computer web browsers and (G) Dental Calendar notifies patients automatically. (H) After examining the pictures along with symptom descriptions, dentists can provide instructions on oral hygiene care or make earlier appointments for patients if required.
management systems. Eight questions in the questionnaire (Fig. 6) were designed to do a comparative prior to-andafter evaluation of experiencing this new dental care system. In this study, 26 volunteer dentists and 32 volunteer patients all of whom had already experienced traditional dental care were enrolled as participants to use our new system. Their altitudes of Dental Calendar combined with cloud services were assessed, based on the questionnaires administered prior to and after they experienced the new system, by paired sample t test. Overall experience was estimated from the differences of total mean value prior to and after using the new system. Eight items were also evaluated individually.
Results Results of assessments through interviews and questionnaires indicated a significant increase (p < 0.05) in both dentists’ and patients’ overall experiences (Table 1). Not only dentists gave positive ratings to and reported high satisfaction with our new system, but also patients’ user experience scores increased by 16% after using this system. Detailed analyses also indicated differences between dentists’ and patients’ ratings. From dentists’ viewpoints, the app provided significant help (p < 0.05), especially in one service item (appointments can be rearranged for patients with sudden worse prosthesis; Table 2). Further interviews
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Figure 4 Java server, developed at the National Chiao Tung University, supports phone app backstage. This figure demonstrates that we used Eclipse 4.3.1 (Eclipse Foundation, Ottawa, Ontario, Canada) to implement the Java server. Communication between the Java server and Dental Calendar is displayed in the Consoles column.
Figure 5 For convenience and to maintain privacy, dentists can perform all management tasks on browsers of theirs own computers, without any other manpower assistance. (A) Dentists need to log in. (B) Besides checking up every patient’s basic data and appointments, (C and D) dentists can also see pictures along with symptom descriptions sent by patients. (E) Dentists can ask patients to come earlier if some problems are detected or (F) rearrange scheduled appointments directly over the phone if patients express their inability to come on the first scheduled appointment.
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Figure 6 Eight questions in the questionnaire designed for (A) dentists and (B) patients to carry out a comparative prior to-andafter evaluation.
of dentists revealed that they felt very confident about their initial relationships with patients. Some experienced dentists gave high scores to five service items (following of scheduled appointments by patients, easy rearrangement of patient appointments, patients’ trust in dentists, dentists’ consideration for patients, and dental service quality). The dentists that participated in this survey mostly work for the National Taiwan University Hospital. Dental emergency services provided by the hospital emergency room were the reason why this new system made no significant improvement on this service item. From patients’ viewpoints, significant differences (p < 0.05) were observed in three service items (appointment reminders, appointment rearrangements for sudden worse prosthesis, and dentistepatient relationship; Table 2). By contrast, no Table 1
significant differences were observed for five service items (appointment rearrangements during daily life, dental emergency help, trust in dentists, dentists’ consideration for patients, and dental service quality); this was because patients trusted their earlier dentists and further interviews revealed that the new system did not decrease either the service quality or the patients reliance.
Discussion The status of the oral condition and patients’ satisfaction with their dentition can have definitive impacts on patients’ daily living and quality of life, regardless of their age, gender, and level of education.14 Population growth
Paired sample t-test of overall evaluation. Difference of paired variables Mean
Standard deviation
Standard error of the mean
t
Difference
Significance
3.556
7
0.009*
8.947
7
0.000*
95% confidence interval Lower bound
Upper bound
(a) Total mean increment in aftereprior-to test for dentists, from questionnaires Paired After-Before 5.875 4.673 1.652 1.968 9.782 (b) Total mean increment aftereprior-to test for patients, from questionnaires Paired After-Before 18.500 5.831 2.062 13.625 23.375 *Significant difference (p < 0.05).
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Improvement in dental care with new mobile app Table 2
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Paired sample t-test of detail evaluation.
Paired After-Before
Difference of paired variables
t
Difference Significance
Mean Standard Standard error 95% confidence interval deviation of the mean Lower bound Upper bound (a) Significant different item from questioners for dentists Patients can be rearranged 0.385 0.752 0.148 appointments for sudden worse prosthesis (b) Significant different items from questioners for patients Appointments reminding 0.844 1.668 0.295 Appointments rearrangement 0.781 1.601 0.283 for sudden worse prosthesis Dentist-patient relationship 0.500 1.368 0.242
0.081
0.689
2.606 25
0.015*
0.242 0.204
1.445 1.359
2.862 31 2.760 31
0.007* 0.010*
0.007
0.993
2.068 31
0.047*
*Significance (p < 0.05).
and economic development during the past 50 years in Taiwan demand an increase in the dental workforce.15 However, in the Second Consensus Conference on the Dental Workforce held by the National Health Research Institutes (NHRI) in 2010, all experts agreed to limit the increase in the number of dentists because of the dramatic decrease in birth rates. An imbalance indeed exists between supply and demand of dental services in Taiwan; especially more exquisite services should be created to improve this dilemma.16,17 Therefore, we developed a new dental care system based on telemedicine technology to help reduce dentists’ workload. By introducing the basic concept of updating service quality,18,19 our Dental Calendar combined with cloud service can not only remind patients to come to dental clinics for follow-up on a scheduled time, but also help them capture their dental images and
send these to dentists for making an early diagnosis. First, the user interface confirmed patient schedules; second, the service management server assessed and allocated medical resources for dentists’ requirements, and then exchanged with picture achieving and communication system (PACS) and database in hospital information system (HIS); third, accessed PACS and HIS database through hospital Virtual Private Network (VPN) for further request; and fourth, the service management server helped establish communications between dentists and patients (Fig. 7). According to questionnaires and further interviews, this new system significantly changed volunteers’ overall dental experiences. This new system gained very high appreciations from both dentists and patients, who confirmed its usefulness in the dental services field. However, its importance varies from dentists to patients. This system helped dentists
Figure 7 Our cloud dental care system can not only remind patients to come for dental follow-up on time, but also advise them to capture images of their own oral conditions for further diagnosis.
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8 significantly to rearrange patient appointments, especially for those with sudden worse prosthesis. Regardless of whether dentists work in hospitals or private clinics, highprice dental prosthesis always significantly contributes to their salary. If dentists can monitor patients receiving expensive dental prosthesis regularly, the occurrence of many unpredictable or unsolvable problems can be reduced.20,21 Besides, these patients can also be more loyal to their initial dentists. From patients’ viewpoints, with high scores for service times, volunteers undoubtedly agreed that they could get a better dental care. Although no significant changes were observed in five items of dental service, with some modifications such as a better art design, a friendly user interface, and mutual communication between dentists and patients, this new system would be of much help. People with unmet dental needs and those who express a lack of trust and confidence in their dentists are more likely to experience poor oral health-related quality of life.22 Based on the results of this survey, we can state that cloud services installed on personal mobile devices would be useful in improving dental care. More corrections and modifications, based on dentists’ and patients’ advices, can be carried out on our new system to build a better product. Moreover, the large amount of patients’ oral pictures stored in PACS and HIS database may help in carrying out further dental researches quickly and easily. Our Dental Calendar combined with cloud service, the first product in related fields, can automate routine, time-consuming, manual tasks, which would benefit dentists and patients. An obvious gap between telemedicine and dentists was closed by this interdisciplinary cooperation. Direct apply in the clinical situation could be worthy of expect.
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The authors would like to thank the Hsin-Chu Branch of the National Taiwan University Hospital (HCH102-13) and the National Chiao Tung University (102W970), for funding this work and the National Science Council Taiwan (NSC1012314B002097MY3) for providing grant support.
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