CBCT Imaging for your Practice: Is Now the Time?

By Dr. Kenneth R  Webb

As I walked the exhibit floor at the AAO Annual Session in San Diego this past April, I stopped and talked to several of the company reps displaying the latest generation of CBCT scanners. Competition is good – what struck me is how far this technology has come in such a short period of time. Effective dose, image quality, and versatility are three areas where the advances are most impressive. I have witnessed these advancements first hand in my practice where we have been using CBCT since 2012 and recently upgraded a satellite office from a 2D digital Pan / Ceph to an “Ultra Low Dose” current generation CBCT scanner. I’d like to share some of my thoughts about the 2D to 3D transition.

Effective Dose
I encourage anyone interested in CBCT technology to search for studies authored by Dr. John Ludlow and his team. Dosimetry data and image quality for many CBCT scanners (both older and current generations) have been researched in great detail. Comparative data for 2D dental radiographic imaging (both intra and extra oral) is also available. By replacing our 2D Digital Pan / Ceph with a current generation CBCT scanner we have reduced the effective dose of our diagnostic records imaging by approximately 60%. (Ludlow JB, Walker C. AJO-DO, 2013;144 (6): 802-817) This is accomplished with one, approximately 5 second, ultra-low dose CBCT scan compared to the two longer duration exposures (pan then ceph) required with 2D imaging. Certainly a win-win for our patients.

Versatility
What else can we use the 3D data for? Digital models: used to assess the inter-arch and intra-arch relationship as well as aiding the determination of arch length and arch width requirements and assessing arch symmetry. Modelling labs can produce articulated 3D study models from the CBCT data (DICOM) files.

STL files of the patient’s dentition and occlusion can be uploaded into whatever software you may be using in your office for 3D model storage and viewing. Additionally, these models can be used (with appropriate software) to produce treatment simulations by “moving” individual teeth or the arches as a whole. Imagine completing your diagnostic records with Intra / Extra Oral photos and one 5-second CBCT scan!

Viewing the Diagnostic Data
The software that comes with a CBCT scanner can easily produce the customary 2D diagnostic images that we are used to evaluating (panoramic, lateral and A-P ceph). In addition – you see everything! The data can be viewed in sagittal, axial or coronal sections (slices) or as a 3D “volume rendering” which can be rotated and sliced (“clipped”) at will. So why is this additional information gained from CBCT imaging important?

Pathology
You will see pathology in the 3D data that isn’t visible with standard 2D imaging. When pathology is visible in 2D, the 3D data can more accurately ascertain location, extent, and character of the area of concern. This is beneficial to our patients.

Developmental Anomalies
One of my first revelations when we began imaging in 3D was the prevalence and extent of “individual anatomic variation”. But how much is too much? We have made referrals to medical specialists for significant developmental anomalies in the cervical spine, nasal cavity and paranasal sinuses. Patients / parents are appreciative of the thoroughness of our diagnostic process that includes 3D imaging.

Asymmetries
They get their own paragraph! Your patient smiles at you and you notice a vertical asymmetry and occlusal plane “smile” cant. Is it caused by hemimandibular hyperplasia, condylar hyperplasia, a unilateral expansive lesion in the maxilla, a growth response to unilateral progressive condylar resorption (to name a few) or a growth response to a foreign object lodged in the nasal cavity? I’ve seen them all. Similar clinical presentations – different treatment plans.

TMJ
Condylar position in centric occlusion, condylar size and shape, glenoid fossa morphology, condylar osseous morphology, joint space, findings suggestive of degenerative joint disease – both active and stable. It is hard to argue that these are not important considerations in our diagnostic process.

Airway
The value of volumetric and cross-sectional analysis of the naso – pharyngeal airway and its relationship to orthodontic diagnosis and treatment planning has, and continues to be, studied in great detail. Is the growth and development of a patient who presents with narrow arches, an anterior open bite or anterior crossbite, tongue thrust and a strong mouth breathing pattern secondary to adenoid / tonsillar hyperplasia, a deviated nasal septum, environmental allergies or restrictive airway dimensions in general? Should your imaging modality include an assessment of these areas?

And there is more…
Orthognathic surgical treatment planning, TAD placement guidance, precise localization of ectopic and supernumary teeth, and assessment of treatment progress – including evaluation of root torque. All are possible or enhanced with 3D imaging. And by managing scan parameters (field of view, scan time and voxel size) at an effective dose equal to or less than 2D imaging modalities.

So, if you haven’t brought this technology into your practice – is now the time?

At the 2017 AAO Winter Conference in Ft. Lauderdale, Mr. Chris Bentson reported on a survey of recent (2016) U.S. Orthodontic Residency graduates: 88% responded that they had used CBCT imaging for diagnosis and treatment planning during their residencies including 21% that used it on all patients.

For the 2013 graduates, the responses were 76% and 9% for the same questions.

Based on these statistics, are we that far away from 3D imaging being included in the “standard of care” discussion? Embracing new technology is not easy but the value added for the practitioner and our patients is significant. The orthodontic educators who expertly taught my generation faced a similar situation during their careers with a then relatively new technology: panoramic radiographic imaging. My generation faced the challenges of transitioning from analog imaging (film) to digital.

Change is not easy. The transition from 2D to 3D imaging in your practice will require a financial and educational commitment. The whole staff will be a part of this paradigm shift. A positive – 3D imaging will be a differentiator for your practice. If you are seeking an associate, partner or complete transition, 3D imaging will make your practice more attractive to the next generation of orthodontists.

3D imaging will benefit you and your patients. Is now the time?

What Your Email Address Says About You

By Steve McEvoy, Technology Consultant

Sending business emails ending with @Netcom.com, Aol.com, Earthlink.com and soon Yahoo.com are tell-tale signs you aren’t keeping up. People notice and may ask you if you are still driving the ‘72 Ford Pinto as well.

Using personal accounts from your Internet Service Providers (ISP) also looks old school like Comcast.net, TimeWarner.com, RoadRunner.com, SBCGlobal.net.

There is no rule making us keep up, or against driving a ‘72 Pinto, but I’d argue if you are in a marketing battle for new patients, this is just one small aspect you can easily improve.

For work, you really should have an email for your practice’s domain.   DrSmith@SmithOrtho.com or DrJones@SmileDental.com, for example. People expect this, and when they see FlyingPigs65@aol.com, you send a subtle message that isn’t positive.

You might certainly have a private, personal email account as well, but even for that, you should consider using something like BobSmith@gmail.com or JaneJones@Office.com.

This should also apply to any of your staff using email on behalf of the practice.

There may be other motivating reasons as well. Companies offering email services for free (AOL and YAHOO) that aren’t thriving financially in their core business won’t be putting development resources into keeping products current, safe and secure.  The news is full of stories about hacked email accounts and ransomware which typically makes its way into your computer via email. Companies like Google, Microsoft, and Apple have reputations to maintain and will have the resources to keep up.  If you are going to use a free email service, I might suggest you look to one of the major players.

Changing your primary email account is always a major hassle, and this is likely what has kept you from making the switch.  Setting up a new email account, and merely forwarding all the email from your old account indefinitely isn’t the right solution. Your old email account can still be hacked, and the company can still go out of business.

The steps generally are:

  • Setup your new email account – and take this opportunity to make sure the password is a hard one. I’d suggest you setup two-factor authentication with it as well.
  • Link your new account to your PC, phones, tablet, etc.
  • Using your old email, notify EVERYONE in your contact list that you are changing your email to the new one effective immediately.  You can do this in one mass email, but be smart about it and put all the recipients in the BCC list so they don’t see everyone else you emailed the list to. Make yourself the only official To:
  • Configure your old email account to forward to your new one (for a while).
  • After a month, check your old account to see if anyone you know is continuing to use the old account, then contact them directly to start using the new address.
  • After another month, turn off the forwarding from your old account and delete it at the vendors. Gone forever, but no risk of hacking.

You can also always enlist some help from your IT person, they should be well familiar with the process.

You have a Document Scanner in your Pocket

By Steve McEvoy, Technology Consultant

Many orthodontic practices strive to be paperless, and part of that equation is dealing with paper that comes into your practice from external sources.   Referral slips, insurance cards, drivers licenses, transfer cases, etc. Dealing with these typically involves using a scanner of various types.   In the old days, there were large ‘flat bed’ scanners.  More recently, there are highly effective ‘bread loaf’ and ‘wand’ style scanners that take up considerably less space.

What you might not realize (until now), you are probably carrying around a document scanner in your pocket.   Your smartphone, that Apple or Android phone many people carry typically has an epically good camera in it.

“Ahh, he’s going to tell us to just take pictures with the camera” might be what you’re thinking. You could, but then you have a collection of random JPEG images, probably stuck on your phone.   I’d like to direct you towards a genre of document scanning apps for your phone, ones that do more than take a picture. Microsoft Office Lens, Tiny Scanner and CamScanner are a few to mention. I use CamScanner (because someone recommended it to me) and will describe how it works in this article, but you can look at all your options as they will tend to offer the same features. You can find the CamScanner app as a feature limited free version (or splurge the $2 for the full version) in the Apple App Store or Google Play Store.

Scanning a Document

Once installed, CamScanner (CS) is simple to use. Open the app, click on the Camera icon, take a picture of the paper, ID card, or whatever you need to scan. The magic comes next.

The first super cool part is that CS will deskew the image.   When we take a picture, we are rarely perfectly centered above the document, rather we are probably at some weird angle and even the document we are scanning might be wrinkled or skewed.   CS automatically tries to find the edges of the document in the picture but allows you to quickly tweak its results by dragging the corners of the frames.

Once you tap the check mark icon, it will stretch the image back to its original real life square proportions (deskewing). Depending on your settings, you can also have it adjust the contrast and colors to make it more readable.  I use the default setting that converts the image to a high contrast black and white image, allowing it to make very small file sizes (which are good for saving and transmitting over the internet). You can, of course, change this to save in color.

Once you’ve scanned that item, you can continue and scan more that will be compiled into the same document at the end, page 1, 2, 3 etc. Obviously, you won’t want to scan 15-page documents this way, but a page or two is an ideal use.   This is a feature you can’t do with just taking photos with your camera, CS is building a multi-page document for you.

Getting the PDF from your Phone to your Computer

After you are done scanning, your next concern is how to get the document out of your phone and to where you want it. In a practice, you might want to be able to add it to a patient’s chart. At home (and this is GREAT for using at home) you might want to save receipts for tax purposes, scan those monthly bills or other filings.   CS gives you several methods for moving the document:

  • Cloud based storage like Dropbox and Google Drive
  • Sending the document to yourself as a PDF file attached to an email
  • Text, Bluetooth, and most any other file transfer technique your phone can muster

Sending the document as an email has been the best for me.   I can email it to myself, or to a colleague that is dealing with the patient. Maybe you send them all to Scans@YourPractice.com. When you choose this option, it prompts you for a file name for the PDF document.   You can add a subject line and a blurb of text to your email, but I usually just type in the most minimal info here “Steve McEvoy Signed Consent” or something like that, enough so you have a clue about what the document attached to the email is for.

A copy of the scanned documents is retained on the phone. You’ll need to eventually do some housekeeping to clear them off periodically, but that’s up to your style.

When you open your email, the document will be simply an attachment and you can save it to your computer or server like any other scanned PDF in your practice.

A Note about TWAIN

CS and these apps are not TWAIN compatible (an industry standard for software applications to operate scanners directly), meaning that your management software can’t directly start the scanner and import the result.   The Bread Loaf and Wand Scanners can typically do this (since they are attached to your computer), but the phone is an island so you’ll need to do the save and import steps noted above (which most Practice Management companies also support).

A Note about HIPAA

Keep in mind that if you are using these apps to scan patient records, it likely is PHI (protected health information) as defined by HIPAA.   As such, you’ll need to consider your risks and how you’ll keep that data protected.   It’s really easy to encrypt your smartphone (see this other CTech article on how), and you may want to consider using an email method that is encrypted as well.   If you are just emailing expense receipts and documents to yourself, there is no requirement for this.

So pull that phone out of your pocket, download an app, and get rid of that paper on your desk!

Creating Videos for Your Orthodontic Practice

Humans are visual creatures. Simply put, we process visual data better. Research shows that more than 80 percent of human learning is done visually and that humans process visuals 60,000 times faster than text.1  As such, creating compelling, easily sharable videos is one of the best ways you can choose to promote and showcase your orthodontic practice. Thankfully, creating low cost, high impact videos online has never been easier. With just a small amount of effort and know-how, you can make a lasting, positive impression on potential patients and set your practice apart from competition in your area.

Videos that introduce yourself and your staff, feature patient testimonials and showcase your practice and the services you offer is a key way to build trust and let potential patients get to know you before actually ever stepping foot in your office. As a bonus, videos hosted on your practice website can also improve how your site appears in search engine results…meaning increased web traffic.

Videos can easily be created without a major investment in equipment or software.  Although they do take some planning and time, especially early on, the investment is well worth the effort. But, if you are trying to keep your costs low, a newer model iPhone or Android device you may currently have in your pocket offers outstanding video capabilities. (Just be sure you’re shooting in horizontal vs. vertical mode.)

Regardless of what equipment you use, following these basics.

  • Shooting a video can be intimidating at first. Just always try to focus on sound and picture quality.
  • Shoot your video in 720p or 1080p resolution.
  • Pre-plan your video. Have a goal in mind. Create and work from an outline so you don’t go off-track.
  • Be sure to add captions to your video. This is because up to 85 percent of videos watched and shared socially are viewed without.  Captions are added via a video editor’s text feature.
  • Make the first few seconds of your video visually impactful. Your goal is to capture your viewer’s attention quickly, within the first 3 seconds.
  • Give your video a compelling title or headline.
  • Brevity is key. Be efficient with words and visuals.

As you begin planning your videos, consider:

  • Stability is key. Invest in a small tripod, monopod or desk stand – your videos will be of much higher quality if you can prevent excess camera movement.
  • If you are producing a video for patient education, you may want to invest in a high quality consumer camcorder with an external microphone.
  • While professional lighting is always preferred for marketing and practice website videos, natural lighting is usually sufficient. Just film in a brightly lit room and make sure there is enough light on your subject’s face.
  • Make sure to have your interviewee or one of their parents sign a photo/video release form giving you permission to use the video you just shot. These forms are available at aaoinfo.org. Log on; then go to Practice Management > Forms and Releases. Scroll down to Practice Management Forms & Materials; then click on Photo Releases.
  • Think outside the box. Videos can be an extremely powerful communication tool for patient education and staff training.

Once you’ve captured your video, you’ll want to begin editing. Editing video means trimming and arranging your video. Video editing software is also how you can add transitions, music, captions and titles…as well as export the movie file that you’ll host on your website or social media channel. Thankfully, there are easy-to-use and affordable options available that will allow you to quickly transform your raw footage into a finalized video for your web page or social media channels.

For users on the Mac, iMovie is a solid choice for beginners. On the Windows side, Windows Movie Maker is an ideal tool to use. Some video users even use apps on their smart phones to edit footage. Apps like the iMovie app for the iPhone and CyberLink PowerDirector for Android are well worth considering for no-frills, simple video edits. For more advanced editing, you might consider options like Apple’s Final Cut Pro X or Adobe’s Premiere Pro CC.

Creation of videos goes quickly and the learning curve is shallow. Make it a goal to begin producing videos today. Fight the urge to think it’s too difficult and just get started.

REFERENCE
1. Gutierrez, Karla. “Studies Confirm the Power of Visuals in eLearning.”

Shift eLearning (8 July 2014). Retrieved from shiftelearning.com/blog/.
* For advice or encouragement on how you can easily begin shooting videos for your practice, or for any video related questions you have, please contact Burt Bollinger, AAO Multimedia Production Manager at bbollinger@aaortho.org.

Is it Time to Say Goodbye to our DSLR Cameras?

By Dr. Anthony M. Puntillo, DDS, MSD

When I first graduated from my orthodontic residency, now more than 23 years ago, a standard set of initial records included plaster models, facial and intraoral photographs taken with film, developed, then trimmed and placed into mounts and panoramic and lateral cephalometric radiographs taken with film and developed in darkrooms. The digitization of our society has made the process of gathering and storing this important diagnostic information much more efficient for most orthodontists. In fact, more than four years ago (November 2012) I wrote a Tech Blog article on digital retainers and the impressionless orthodontic practice. Since then the use of intraoral scanners and 3D printing in our profession has grown exponentially. It is now not hard to imagine a day in the near future when impressions will disappear completely from the practice of dentistry.  As I near the end of my 8 year term on the CTECH committee, I can’t help but wonder what is next.   Where else can we use technology to eliminate inefficient processes from our practices?

The most obvious next step for me is the elimination of intraoral photographs. All of those intraoral scanners, now used by most orthodontists, take multiple photographs of our patients’ teeth to create the 3D digital images. Several of these scanners can capture images in true, or close to true color. It can’t be long before we come to the realization that digital images taken with a good intraoral scanner are a better alternative to the standard set of 5-7 intraoral 2D photos we have been taking for decades. The 3D digital image is not only a better diagnostic record of the patient’s current dental state, it also is more versatile in that it can also be used to create and fabricate appliances (i.e. clear aligners, indirect bonding setups, retainers, etc.). If a good intraoral scan can consistently be completed in less than 10 minutes, aren’t we wasting our time and that of our patients’ taking 2D photos. I concede that we are all very accustomed to diagnosing our patients with these 2D photographic images. However, it was not that long ago when most thought that multiple radiographic exposures were necessary on the majority of our patients.   Now most of our patients are diagnosed with a single, quick radiograph taken on a CBCT machine and from that single exposure we derive a much higher level of diagnostic information.

To be honest, I am not yet ready to mothball our cameras. For starters, I still think that facial 2D photos are necessary. I know that there are 3D cameras available that will someday eliminate the need for our extraoral series of facial photos. However, for whatever reason (I believe primarily cost) these have not yet caught on. So for now we will still be taking a series of three 2D digital photos of our patients’ faces. Additionally, 2D intraoral pictures still play a significant role in our new patient consultations. We have not yet found the best way to display and share the captured 3D dental images (STL files) to educate our patients. I anticipate that this last hurdle will be overcome in 2017 and when that happens our DSLRs are going to see much less action and our IOSs are going to play an even larger role in our new patient process.

Reevaluating Your Password Management

By Dr. Matthew Larson

We live in an amazing age where the world is at our fingertips… if only we could remember our password.

It’s no surprise that passwords can be a frustrating part of our digital lives. Websites can have different requirements for passwords and then have to be changed at different intervals. In theory, there are clearly good reasons to have high standards for strong passwords. However, in real life this often means the same password is used for multiple websites and are frequently saved in other locations to remember them.

Here are a few questions to ask yourself about how you handle passwords in your office:

  1. Do you use strong passwords when needed?
  2. Do you have UNIQUE passwords for different sites?
  3. Do you change passwords when you have changes in staff?
  4. Do you keep important passwords private? (This means not posted in plain sight! In many practices the private WiFi password or Invisalign login can be easily found by opening the drawer or cabinet near the computer.)

If you answered no to most of the questions above you may want to consider a password manager app. (If you answered yes to all the questions and do NOT use some form of password manager, I would love to have your memory.) There are many good password manager programs – some are built into web browsers (Internet Explorer, Google Chrome, and Safari all have password managers) while some are 3rd party programs (some of the more popular ones are LastPass, Dashlane, 1Password, and Password Safe). These programs and apps can help manage your existing passwords and help create strong new passwords.

Here are my personal thoughts when selecting a password manager program:

  • Select a program that requires a strong master password to open the app. This rules out most default password managers within web browsers, although there are browser extensions available for many of the 3rd party programs which do require a separate logon. This master password unlocks all your other passwords, so carefully create a unique and very strong.
  • Select a company that has a strong history with good reviews. You want a company with a strong reputation that will continue to maintain high security.
  • Expect to pay a small fee for a high quality company. These programs are inexpensive overall (most range from free to about $5 for the app), so don’t get too caught up trying to find a bargain. A bargain price typically means they are either trying to grow (and then will likely increase fees later) or they are making money through other venues (and the priority may not be the password management program).
  • Use a program that works on mobile devices, Windows computers, and Macs so you can utilize it on all your devices. Additionally, make sure you can sync your database files easily in the cloud between devices.

Related to the database files, ensure the program you choose maintains an encrypted database file. This requires that you have the program and the master password to open the database. All the 3rd party programs mentioned about are encrypted with AES-256 encryption (which is much better than a word document on dropbox).

Currently, I personally use 1Password (https://1password.com/ ), mainly because I like the “Teams” option that allows you to share passwords between team members. You do this using shared “Vaults” as shown below. They charge per user so currently I only have one account for my personal use and one account that the staff uses for ordering and insurance. The program also allows you to save credit card information and profiles, so entering information on a new website goes much quicker. It is also a great way to organize NPI and license numbers for you and your team.

Another nice benefit of these managers is that you can actually load the sites and passwords very quickly and efficiently. I found myself actually saving time going through and paying bills after switching to a password manager because loading every site basically just takes a couple clicks of the mouse. A couple screenshots of how this looks on a mobile device are shown below. (I use this as quick access to my office Facebook account, since the app on my phone has my personal account saved.)

Some may have security concerns by having all your passwords stored in one spot. However, keep in mind that this is the focus of the company and they likely can manage it better than most people can with the little time they realistically devote to it. The first step to deciding if this type of program is right for you and your practice is an honest look at the security and efficiency of your current systems. If managing these passwords is stressful or they are not being stored securely, take a look into what current password manager programs can add to your practice.

2017 Winter Conference – Technology: Balancing Profit, Lifestyle & Patient Care

By Dr. Doug Depew

The 2017 AAO Winter Conference is quickly approaching. Our theme of this year’s meeting Technology: Balancing Profit, Lifestyle and Patient Care.  It promises to be a meeting filled with information for both newer and established practices to help make those tough decisions on what technology is important to use in our practices and when we may wish to invest in it.

The meeting will begin with keynote speaker Jack Shaw.   Mr. Shaw is a world- renowned technology futurist who will be discussing how cutting edge and disrupting technologies will change the way we do business and run our practices in the coming years.

IT guru Steve McEvoy will be answering some of those pesky questions we all have about computer hardware, effective and cost-efficient data backup, and security.   In the ever changing world of computers, what you hear at this meeting will certainly be different than what Mr. McEvoy would have talked about even a couple of years ago.

On Friday afternoon we’ll have a lively discussion by Drs. Greg Jorgensen and Neil Kravitz regarding building our practices through social media, websites, and Internet marketing. Their success in these areas has been paramount in growing their thriving practices.

Saturday morning will begin with Dr. Aaron Molen sharing his experience and thoughts on bringing emerging technology into our practices to help create more efficient and more comfortable patient care.

We’re excited to have Drs. Ed Lin and Christian Groth discussing how to integrate some of the latest technology hardware into our orthodontic practices. This includes workflows for using CBCT, Scanners and 3D Printing.

The conference will conclude with Chris Bentson and Charles Loretto with a discussion on how technology can affect the value and profitability in our practices. This should help answer the question about at what stage of practice a doctor might consider investing in advanced technology.

The location for the meeting is at the gorgeous Marriott Harbor Beach Resort and Spa in Ft. Lauderdale, Florida. The dates are February 10-11, 2017. The schedule is organized in a way to allow some time for afternoon recreation.

There will be plenty of time allotted for attendees to ask questions of the speakers to be sure all bases are covered.   To learn more and to register, visit https://www.aaoinfo.org/meetings/2017-winter-conference-technology-balancing-profit-lifestyle-patient-care

How Can Patients Contact You During an Office Relocation?

By Dr. Dan Grauer

member_on-phoneMoving your office to a new location is a tedious process involving many tasks and some headaches. A critical moment during the move is the transfer of your main phone number to the new location. Unfortunately not all numbers can be transferred to certain areas. Phone carriers have rules regarding the assignment of specific numbers to defined geographical areas that are beyond the purpose of this blog. Luckily there are solutions to this problem.

One way of transferring your number in an undetectable way is using a cell phone as a proxy. You will need to call your old office phone carrier a few days before the transfer and assign your old office number to a cell phone. This process could take from 3 to 5 days. Once your number has been assigned to a cell phone it automatically disconnects from the physical location of your old office. The last step is to forward your calls from the cell phone to the new office number. This is done through the setting menu of the cell phone, and it can be activated or deactivated on demand. The cost of this transaction will depend on the cell phone plan and the cell phone purchased. Advantages of this solution include that your patients will automatically reach the new office and you will maintain your old number regardless of your new geographical location.  Another advantage is that by deactivating the call forwarding function on the cell phone, it becomes an emergency phone for your new office.

Am I legally responsible if I receive a patient referral from another dentist and it is sent to me unsecured?

By: Charlie Frayer, JD, MS, HCISPP, CIPP, CIPM

DISCLAIMER: Protected Trust cannot and does not provide legal advice, and the following question(s) and response(s)—like everything else we publish—are not intended as legal advice or opinion. If you need legal assistance, you should contact an attorney licensed to practice law in your jurisdiction.

For the purpose of this answer, we assume that “sent” means “emailed.” Yes, it is possible that you could be responsible if something bad happens to the patient’s electronic protected health information (ePHI) contained in the email referral, but only if it happens after you receive it.

Under HIPAA, a health care provider is called a “covered entity”. The HIPAA Privacy Rule defines “treatment” to include, “…the referral of a patient for health care from one health care provider to another.” The Privacy Rule also states that, “A covered entity is permitted to use or disclose protected health information…[f]or treatment…”. Therefore, under the scenario you describe, neither the referring dentist nor you are violating HIPAA by merely sending (disclosing) or receiving a patient’s ePHI as part of a referral. Given this good news, the core question now becomes, “Does a covered entity violate HIPAA by sending (or receiving) ePHI in an “unsecured” manner?” Again, the answer is mostly good news, but BE VERY CAREFUL AND READ THE REST OF THIS RESPONSE!!!

First, we have to know what makes ePHI “unsecured” vs. “secured”. Then, we need to know whether HIPAA requires ePHI to be secured (seems like a silly question, but you’ll probably be surprised). And, lastly, if HIPAA does not require ePHI to be secured, then what risks do you have if you face by choosing to leave it unsecured?

Unsecured vs. Secured ePHI
The HIPAA Breach Notification Rule states that, “Unsecured protected health information means protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary [of HHS] in the guidance issued…”. The HHS guidance emphasizes the use of encryption to make ePHI secure. So, technical details aside, the simple answer is that “unsecured” means unencrypted, and “secured” means encrypted.

HIPAA: Encryption Is NOT Required…What?!?
That’s the title of one of our blog posts from Feb.-Mar. 2016—republished by AAO, which we highly recommend that you read immediately (here or here). Although you would be crazy to not use encryption when emailing ePHI—because the risks are enormous, it is true that HIPAA does not literally require encryption (again, read our blog post here or here right now). Rather, what the federal government decided to do was strongly encourage the use of encryption by making it a get-out-of-jail-free card (apologies to Parker Bros.). Under the HIPAA Breach Notification Rule, you must notify certain persons and/or entities whenever you have a breach (e.g., a loss or theft) of unsecured (unencrypted) ePHI. For example, depending on the breach details, HIPAA requires notifying not only the affected patients, but also the federal government (HHS) and prominent members of the media. But—and here’s the GREAT NEWS—if you have a breach of secured (encrypted) ePHI, you do not have to notify anyone. Why? Because the loss or theft of encrypted ePHI—which cannot be read without the key(s)—is not considered a breach at all. So, encryption=no breach=no notifications=no problems for you.

Risks of NOT Encrypting ePHI Emails
If you’ve already read the above-mentioned blog post—and, if you haven’t, stop now and do so immediately (here or here), then you already know the frightening list of risks you face for not using encryption. In summary, in the event of a breach of ePHI:

No Encryption = Notification(s)

Notification(s) = Investigations, Fines, Lawsuits, PR Disaster, and Lost Business

Investigations, Fines, Lawsuits, PR Disaster, and Lost Business = Wasted $,$$$,$$$.

Our Recommendations

  1. Never email ePHI without using Protected Trust Healthcare Email Encryption.
  1. Require all of your fellow covered entities (e.g., health care providers and insurers), other business associates, and patients to use Protected Trust Healthcare Email Encryption.

IMPORTANT REMINDER: As a Protected Trust client, all of these third-party persons and entities can communicate securely with you, free of charge, and forever. No catch!

  1. To comply with HIPAA, make sure everyone in your office has their own Protected Trust Healthcare Email Encryption account (shared accounts are not permitted by HIPAA).