Virtual Consultation is Here to Stay: An Interview with Dr. Mark Coreil

Dr. Mark Coreil (MC): Hi, I’m Dr. Mark Coreil, and I practice in Lafayette, Louisiana. And I practice with my wife, Katherine Coreil. And, we actually have two locations, one of them in Lafayette, and one in Houma, Louisiana.

Blu Nordgren (BN): Why are virtual consultation capabilities so important right now?

MC: So currently, when we’re not able to see patients, virtual consultations are a very essential part of maintaining contact with the patient. At every level, right? So we’re able to interact with them to the degree that we can check on their tooth movement progress, we can adjust treatment, like change elastic arrangements. Right now, we are creating an environment where we can actually check the patient, make sure the progress is going well, make sure nothing is out of place, so it allows us when we’re not able to see the patient in the office, we are actually seeing the patient while they’re at home. So, a virtual consultation for me, is being used quite extensively for our active patients, and we’re also engaging new patients. So if a new patient wants to call and have an evaluation like a new patient consultation—that’s important. But as of late, the ongoing process of taking care of existing patients has been the focus.

BN: Can you walk me through a new patient exam and the way that you do it right now?

MC: A new patient consultation or examination, in a virtual environment, for our office starts with going to our home page, and clicking on virtual consultation. That instantly launches OrthoScreening, which is a propriety software that guides them through a series of photographs that they take themselves or they take with a buddy. And it’s the same photographs that we take in the office whenever we’re doing records, right; so we get a smiling photograph, we get a frontal shot. So we get the five or six critical images that are necessary to look at the teeth, look at the malocclusion, and in addition to that, the patient fills out a questionnaire as to their primary concern, what they would like us to look at. And so it’s the same dialogue, it’s virtual, and we’re doing it like in written form. Once we complete that process, I then invite them into a live consultation with Doxy.me or Zoom. Doxy.me has been our preference lately because of the waiting room and we’re able to share a screen. So we’re able to talk to the patient, we have the still photographs to look at, which are really high quality. We don’t have to have them pulling back their cheek during the live consultation, we have the still photographs to look at. We are able to educate the patient using, what we call Braces Academy, which is a software that animates how would we take care of their chief complaint. So it’s the same thing we do in the office except it’s in a virtual environment.

BN: Could you tell me more about the hurdles you’ve faced in the recent weeks?

MC: The most difficult challenges that we have faced, you know with the office environment being closed and not able to see patients—seeing the patients has been overcome with the virtual consultation. The team members that have been asked to stay home—I mean it’s like family right—so that’s a challenge. We can’t get together anymore. We have a couple of people who get together with us to help on the administrative side. But I feel like the most difficult part is not getting our orthodontic family together to support each other, so we’ve been doing that virtually. So we get together whether it’s telephone, or whether it’s written cards, we do the best we can. I’ve personally reached out to all of my patients via phone, and then through virtual consultation. But the most difficult part as an orthodontist, is, you know, you get into this business to interact with people, and then all of a sudden you have to do it through the web, which is fine, but it’s not the same, right? We love the hugging, we love the laughing, and all the things that we enjoy on a regularly day, so we’re trying to re-create that as best as possible. But we’re anxious to get back.

BN: Can you tell me a little bit more about how you’re leveraging the tools in Cloud 9 to help you conduct your virtual consultations and new patient exams?

MC: So our decision to go to Cloud 9 has proven to be instrumental in our ability to navigate through this current moment. We had made a choice because of Cloud 9’s reputation, its inherent ability to do everything we needed it to do, but most importantly we have access to the entire patient data pool, meaning that we have their charting notes, we have their photographs, we have their radiographs. So whenever we’re doing a virtual consultation, and we’re talking to the patient, we have their photographs on one screen, and we’re talking to them on another screen. We have a reference on where they started, with OrthoScreening we have a reference on where they are. So the idea that with using Cloud 9, I don’t have to be at the office to do this. So whether I’m at home, whether it a staff member at their home, everyone has access to the office files. We’ve made an attempt in the past to use VPNs and that was extremely unsuccessful. So the contact via server-based, or client-based software was a total bomb. Cloud 9 has allowed us to be an office wherever you are and right now that is critical, and it will be critical in the future. So it’s been, it’s really been a godsend.

BN: Great. Thank you. And actually you touched on something else I want to ask, which is how do you see virtual consultations being a part of your practice in the coming months, and even years, now that the environment really has changed?

MC: So virtual consultations, we’ve discussed virtual consultations at many levels, on many different webinars. And the consensus in our office, and amongst our colleagues is that virtual consultation is here to stay. I think that everyone would agree that there are several key areas that we’ll focus on. One is observation. So we have a busy mom, a busy patient, and instead of having to come in to look at a progression of maybe a tooth being lost, growth, that sort of– we can take a look at that virtually and maybe save mom a trip, and not have her come in just to take a look and tell her that “Wait, we’re waiting on molars to erupt, we’ll see you back in six months.” So observation appointments are one. Number two is retention. We have a number of retention patients that have to come into the office on a regular day just for us to look and say “Hey, it looks great.” That’s really nice to be able to visit with the patient and to re-engage. But given the current environment, the virtual consultation allows us to see and confirm with them “It’s great,” or, “No, it’s not so great, you do need to come in but you’re going to come in at this specific time,” when we have the appropriate amount of time to take care of like a new scan, or whatever we need to do. So, observation and retention are definites. The other thing that’ll happen is that when we have the extended appointment, like let’s say we do an initial bonding, and we’re going to put the patient out 16 weeks and let the wires work their way, in between those appointments we historically have not engaged the patient. We just told mom “Everything is working, call us if there’s a problem,” but now we can engage, right? So make mom feel like hey, we’re still connected to you. We had done that in the past with, sort of, text messaging and maybe a few photographs, but now that we have an organized, systematic way of doing that, mom– they’re going to be really fluent. And, in fact, like every patient will leave now with a retractor, ready to take photographs so that they can submit those, and be taught how to take those photographs, so that the quality of the photograph is the same photograph that we take in the office and in fact, we currently use an iPhone for all of our intraoral photographs. So, the patient will be taking the exact same image that we take in the office. The clarity, the ability to check the liner fit, the ability to check wire movement, tooth movement, you know, emergencies, patient says something’s giving them trouble—we can see that very, very, very closely with the retractor, so it’ll be as if they’re in the office. So it’s a wonderful tool, it’s unfortunate how we came about to see the benefits of it, I think, but moving forward at least we discovered it.

BN: What advice would you give someone wanting to start virtual consultations at this time?

MC: Any orthodontist that’s considering doing virtual consultations and they have nothing in place, I would look at, you know, one specific aspect of it, and that is time availability. We have found that scheduling the live consultation via Zoom or via Doxy.me has been very, very challenging. It’s hard to coordinate time with the doctor and the patient. So, the reason OrthoScreening has worked so well for us is that we text them, we say “Hey, go to the website, click on virtual consultation,” and they provide us with the photographs, or they take the photographs at their leisure, right? So they’re submitted to us, and I look at it whether it’s on my iPhone, and I can be out and about. I look at it, I get a notification, “It came in,” I can scroll through those images, and then I can respond to them really quick. Our average response time with the software is maybe a minute. And then they get a response back and it’s at my leisure but it’s very, very fluid. I don’t have to be anywhere in particular, and we can provide them with the necessary information. I think flexibility is important because if you try to do live virtual consultations with everyone, you will get frustrated. We find that the number of people that, you know, you go to voicemail, that don’t actually answer the phone, is significant. So what’s practical, we like to have photo submissions, and so we do the live consultations as needed. And those aren’t very frequent, believe it or not. I think that moving forward we may be engaging some, but we really like the OrthoScreening tool because of the fact that there’s some flexibility. For both of us. One of the things that’s important about using OrthoScreening is the ability to use Braces Academy simultaneously to export the data, those videos. For instance, if a patient submits a photograph and the elastic arrangement that they currently have needs to be changed, you simply go to Braces Academy and grab the image that you need for the new elastic arrangement, and you send them that photograph, and they can change the elastic direction, virtually. You don’t have to see them in the office. And it’s the same thing with brushing, if it’s poor, or if they need to make an adjustment, we have those videos in place to show them what to do. You can animate it with your hands, but it’s really nice to be able to send video. And again, Braces Academy, the reason we love it is the fact that we engage patients constantly via text messages. We send them videos, we send them Hellos, we send them just engagement just to say “Hey, we hear from our orthodontists way beyond just the regular appointment. We hear from them all the time.” And when we really want to wow them, is when they’re in the office, and we’re in the new patient exam, a live new patient exam in the office, we’ll send them the videos to their phone while they sit on the side of us. So like in the office, and they’re getting pinged, like “There’s your video. There’s another video, There’s a third video.” And we keep pinging them with videos because we say “Now you have the whole catalog of videos, so when you get home tonight, you can show them all to dad.” And so that’s the nice part. That’s really cool.

BN: What’s a common myth you would say of virtual consultations, and can you debunk it?

MC: One of the myths of virtual consultations. I was talking to a surgeon recently and he said that virtual consultations like for his patients, for head and neck patients, is very difficult because they need to palpate. In orthodontics, what’s unique is that it’s so visual. You would think that virtual consultations have a very limited capacity in orthodontics. They would have a limited capacity maybe in dentistry because you have to see so up close. But in orthodontics it’s actually like a real appointment. I mean, a really high quality photograph you can make the decisions that you need to make, and you can inform the patient as to the quality of the progress or what needs to be changed, or “Hey, you need to come in, you really need to come in now.” I’ll give you an example. I had a patient submit photographs last week, she was wearing elastics and trying to close the space. And I saw a little kink in the wire, and I knew that the tooth couldn’t move because of the kink, right, it wasn’t straight, so the tooth couldn’t slide across, and so I said “Hey, we need to change your wire.” Now the prior ten patients that I saw that were doing something similar, the wire was perfectly flat so there was no need to come in, just continue the elastics. So, you can determine via the virtual consultation the necessity of bringing the patient in.

So as we extend appointments out there’s no question that the virtual consultation will be that tool. And so I would say that orthodontics is probably the most applicable place for a high quality… you know, if the images are of a high quality, to get the information that you need to make a decision. Same thing we do with aligners: instead of having some proprietary software we use OrthoScreening. And we just have the patient get really close and really focused with the iPhone, and we can see if the aligner is seated just as well if we had them in the chair. So we know that the aligners are working, and it’s just simply a high quality photograph.

BN: Wow. So I’m personally curious about the piece the, the mouthpiece that goes with the camera?

MC: So in order to get exceptional quality with the patient photographs, the ones that they take of themselves, we either mail out this retractor, but now we will be giving them out to every patient that walks in. So, 50 cents each on Amazon. It’s a “Speak Out” retractor, and “Speak Out” is just a game you play, when you put this in and you try to articulate it’s kind of funny, but it’s so simple because once you insert it [Dr. Coreil inserts retractor] you can’t talk anyways. That’s the “Speak Out” game, you can’t articulate. [Dr. Coreil removes retractor] But, with this retractor, once the patient puts it in you really get a nice visual of the teeth, and if you pull it to one side you really get a nice side shot, for us, as orthodontists, it’s called a buccal shot. So you get these really get these really high quality images, whether it’s open or closed. So instead of using your fingers you can use spoons, but this is the retractor we’re talking about.

Starting yesterday, what we’re doing is when a patient contacts us via the web or via phone for a consultation, what we’ll do is we’ll immediately mail this out (if they can wait, like 24 hours), we’ll get the retractor to them so that our quality of images goes up significantly, so we can make a very good diagnosis. And obviously, that diagnosis, I want to emphasize one very important point: It will not totally replace the clinical examination, so at some point we will see the patient in person, and we will take a radiograph and do a thorough diagnosis. However, in the meantime, the patient gets very good feedback from the doctor as to, “I have a complaint, what will that entail, how long will it take, and about how much will that cost?” I think that we have to be reasonable as orthodontists considering that there are alternative methods, or alternative ways, that they can access this care. It’s out there in society and commerce and so, this is our way of allowing the patient to find out “What can we do?” you know. But being supervised by a doctor, a specialist, and it’s actually fun. So that’s the way we’re going do it. We’re going to use this retractor right here.

BN: Nice, well thank you, that’s actually a great demonstration! Ok, so moving along here, are there (this actually ties in really well with that, but), are there any resources that have really helped you along your journey toward virtual consultations?

MC: Well I think, I think the resources that are necessary, that have helped me along with virtual consultation, is the fact that you just become accustomed to being in front of a camera, and being able to talk to a patient very comfortably and engage them, you know, through a screen. And I think, everyone I think in the world probably has had some kind of practice with that over the last two months. But without question, the students, I mean all the kids have at least experienced it. And I think most parents have too. So that the fear that we had, or I would say, we considered it not significant, or not important, “You don’t need that.” And now, what’s helped me, is just to practice, and do it over and over. And after you do a few it becomes very comfortable, and you really find out that just like in the office, you spend more time talking to the patient and the parent as a person. So we’ve been emphasizing that whether it’s the phone call, phone calls are great, right, but this is better, this is the phone call with the face. And again, I think that, in our philosophy, we’re taking care of the person. The teeth are secondary. I think that most people come to us for a relationship. And we’ll give them great teeth, but we’re able to give them what they came for, right. An actual contact relationship, touch points, all those things that are relevant, and in today’s world they may be really seeking that, right? How many people do they contact that are really interested, “What’d you do today? Is your family well? What’s going on?” So, we’re touching a patient the same way we did in the office with the same amount of concern. And I think that that’s most important.

And, you know, to finish that off, I think our goal is to give hope. And it’s been a constant theme in our office, ever since we started. Laughter, hope, fun, but right now when there’s so much concern we have to give hope. And it’s not just about orthodontics it’s about “Hey guys, this is going to be great, look at what we’ve discovered,” right? And, “We’ll be in the office one day but right now, this is the best we can do, but it’s still fine.” And what’s cool is that they feel comfortable reaching out to you to do this so that we can engage each other, and get those questions answered.

BN: What are some specific roadblocks that people who are dipping their toe into virtual consultations should look out for, in your opinion?

MC: If you’re going to do, if you’re going to just start with virtual consultations, I think that there are so many out there, and I really think that you need to, although it is not necessary at this moment—those laws have been relaxed with regards to HIPAA—it’s extremely important that you invest in a HIPAA-compliant platform. And you can pick anyone you want. You know, we have chosen Zoom, Doxy.me is HIPAA-compliant, OrthoScreening is HIPAA-compliant. Because when that is brought back into place, you need to be compliant. It’s the same thing as if you were on Cloud 9, and you send email out, you want to be HIPAA-compliant. So that’s important because as the world migrates to tele-medicine, tele-dentistry, I think that there’s, there’s an inherent risk in it for people to intercept critical data. So I think HIPAA is very, very important.

The second thing I would say is that from a technical standpoint, the important components for the virtual consultation are: Quality of audio—you need to make sure your mic is of sufficient quality, you need to make sure that the room you’re in does not echo. It needs to have carpet, it needs to be…or curtains, whatever. And you just… What you do is establish a meeting, and you ask the person on the other side, “Does that echo?” Your background should be sufficient, and you know, just be aware of what do you want it to look like behind you. The same thing with the video cast, it needs to be of high quality. You want it to represent your practice. And you… in my opinion, I tend to use my hands a little bit more, instead of just try to speak, because I want it to feel like I’m next to you, right? And so, feel comfortable just talking to the camera and reaching out, and I think that that goes a long way as to making them feel comfortable. And reassure the patient that it’s okay to call back.

And lastly what I would say is that there are certain platforms that are much easier for the patient to connect to, like if you send a link out, all they have to do is click on it. And I would recommend that your team do a trial run with the patient, connect with them to make sure that if it’s a live consultation, that that connection is sufficient. The patient feels comfortable, you don’t want them frustrated with the connection, and you can’t get across to them.

So one of the reasons we go with OrthoScreening is that we give them written feedback immediately. But establishing a live feed like this, we would want to practice it so that there’s no frustration. We want everyone comfortable so that it is a successful meeting. We don’t want anyone, anyone, you know, worried about the technology, we just want to enjoy the moment.

BN: Exactly, that’s great. Yea, it’s customer service in the age of virtual meetings.

MC: That’s right. You can’t send an IT person out, but what you can do is your team is well-versed in coaching them through that, you know, over the phone or whatever, and just say “Be patient, be patient, we’ll get this through, and let’s get this connected. So now that you’ve done it once, the software is all installed, so it’s easy to get done a second time.”

BN: What’s been the biggest surprise to you in the last few weeks and why?

MC: So what’s exciting for me is the positive feedback that we have received, especially yesterday. We begin seeing patients again next week, on a very limited basis, here in Louisiana. So yesterday we began calling active patients to see them one at a time, we’re putting them like every 30 minutes. And the very, very positive feedback from the patient. We walked them through the process: What is it going to be like this first appointment when they come back. You know, they’ll have to fill out a second sort of informed consent, they have to go through a questionnaire, we’re going to meet them at the core, we’re going to walk through—so you have to go through all the steps, I won’t go through all the details, but they are extremely positive! They’re like, “I’m so excited that Johnny’s coming back, I trust you guys.” You know, no question about it, most of them are choosing to stay in the car, that’s cool, but they’re trusting us.

As opposed to some colleagues that I spoke to yesterday who are dentists. And when they began calling routine cleaning appointment patients, right? They were calling patients in, they were scheduled to be seen for regular cleanings, the response was very different. And the response was “I’m not sure yet. Can’t we postpone this a few months? I’d rather wait.” So, you know, the whole litany of reasons. So when I talked to a couple colleagues yesterday, trusted colleagues, I think there’s, like a common denominator. Number one: Orthodontic offices are amazing, right? The staff is amazing, the patients trust us, they love us, it’s a fun environment, it’s not as intimidating, and I think that as orthodontists we have a much better chance of bringing our practices back to life than maybe other professionals do. And dentistry may be a little bit more challenged than orthodontics is because of the nature of what we do. So, in one day, I hate to make, you know, big conclusions from that, but in one day, that’s monumental. That patients are, you know, willing to come back without even any hesitation. Not a single patient said “I’d rather wait. I’m concerned.” No, “we trust you guys.” So that, that’s really good news for us.

BN: That’s phenomenal. What a positive way to kind of wrap up this week and launch into next week before reopening.
MC: Absolutely. Moving forward, every single patient that we have, that we are seeing, you know, physically seeing, and there’s an opportunity to do a virtual consultation for the next appointment, that may be prolonging the next physical appointment, that’ll be offered. And I think that the parent, whether it’s schedule or whether it’s just “Hey that’s wonderful, we’ve already experienced it once, I think we’re going to go ahead and do that.” So we’re going to be offering it to a lot more patients as an alternative, and it’s totally legit with regards to when we do the photographs, it’s stored in the cloud. And we are actually bringing those photographs into Cloud 9 so that it’s part of the patient record. So we actually just copy the questionnaire, copy the response, copy the photographs. So the whole virtual appointment was put into Cloud 9, and so everything we do is cloud-based. We don’t have any local software. And so Cloud 9 gives us that flexibility to do that. So it’s as if you saw them, right? And it’s well-documented. It’s actually better documented because we take a lot of photographs here, but we don’t take photographs at every appointment. So it’s really nice.

I think it’s well accepted that the future is “cloud-based,” right? I don’t think anyone will question that, and the reason that we went to Cloud 9 is its capabilities, its reliability, and it’s cloud-based. Now, the ability to integrate those support software, those apps that you have, it’s very helpful. But moving forward for a practice I think that everyone needs to seriously consider moving away from a client-based server in their office to cloud-based. Specifically Cloud 9 because it’s the only, in my opinion, the only truly cloud-based software out there. Because integration as we move into a more virtual world of treatment, integration will not become, or will not remain optional, it’ll become necessary. So in the coming years, what… we’re using this as a stop-gap measure, and it’s working really, really well. I think that regulatory and other means, I think that, it’ll be mandatory. So you seriously need to consider to budget into that, that this is where you’re headed. And the one thing you need to do, it’s technology. And it’s not necessarily technology in the clinical area as much as it is technology and how you’re going to manage patients using, you know, this virtual world, this virtual environment. So, all of a sudden we find ourselves at a moment when you need to make those big steps. So, that’s important. For me, that’s the way I see the world.

BN: Great, thank you so much. I really appreciate you taking the time to talk to me today, and thank you for being patient with my, with my little friends here.

MC: Oh no that was, that was a pleasure. Thank you.

BN: Would you be comfortable with us sharing any of your contact information with current customers, if they have…

MC: Anybody. Yea. All of it. I really enjoy working with practices one-on-one, and answering questions that they may have. We specialize in acknowledging a challenge, right? So the office calls, and they might have a, a frustration point. You acknowledge that it’s there, and then we work through it and solve it. And so, the team and I work together to make that happen. So absolutely. We would highly encourage phone calls and emails.