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Dental Articles
Why Every Office Needs to Be Digital
The latest buzzword to enter the dental lexicon is
“paperless”. Most offices agree that developing a paperless practice is an
ideal goal. However, this goal is very challenging to achieve. While I’m not a
huge fan of that term, since all offices still require paper, I do think that
developing a “chartless” practice is much more obtainable and realistic. The
challenge for any office is to understand which systems can be changed into a
digital format, what the advantages of digital system are over the older
systems, and how to go about choosing the best digital systems for the office. This
article will address all of those issues.
One key that appears to be very important is to develop a
set plan, a “treatment plan” if you like, of how to approach this paradigm
shift. I have developed my six point plan that I believe every dentist should
follow these six points as they start to digitize their practice:
Practice
Management Software
For most offices, the best
feature of practice management software is the concept of decentralization. Speak with any dental office receptionist, and the concept
of decentralization will make them smile! Imagine an office where patients
don’t have to wait for other patients to check out of the office, where the
assistant doesn’t mishear the doctor’s instructions to the receptionist, and
where every practitioner, whether it’s a dentist or hygienist, has access to
all patient data from any room in the office. This is the idea behind
decentralization. In order for decentralization to happen, there needs to be
three components in place: an electronic scheduler, computers in the treatment
rooms, and a computer network
The electronic scheduler is a must
for the modern office. Among the many advantages of electronic scheduling, it
allows for a rapid means of finding patient appointments, easy methods of
changing appointments, and scheduling to achieve production goals for the day.
However, contrary to popular belief, the scheduling is best handled from the
operatory. The doctor and assistant often require that a patient’s next visit
be longer or shorter than is normally required. In a typical dental office, the
assistant walks the patient up front and relates specific instructions to the
office manager or receptionist. However, if that person is busy or has another
patient to handle or is on the phone, those instructions are often not heard
and the patient is improperly scheduled. This doesn’t happen if the assistant
schedules the next visit right from the treatment room. In many offices I’ve
seen, the assistants are trained to collect payments and process insurance
claims right from the operatory
The practice management software is, far and away, the most
important component in this process. It is the glue that ties everything together.
There are certain features that are crucial to the practice management software
that allows it to function in a chartless environment. The software must be
able to handle daily treatment notes. Many of the less-expensive and older
practice management programs were never designed to work in this type of
environment, so many practices will have to evaluate whether they need to
purchase a more advanced program.
Image Management
Software
Probably the most difficult decision that the dentist faces is whether to purchase image management software that is sold by the practice management software company, or to invest in a third-party product. Both have their pros and cons. Most of the major PMS companies have incorporated imaging
suites into their offerings. On the plus side, these programs are tightly
integrated with the PMS software; the dentist will feel that they are still in
the same program even though the databases are usually separate. This is
actually preferred. With the constant consolidation that is occurring in the
dental technology field, it makes sense to have image stored in a separate
database in case the dentist chooses to switch to another program at some point
in the future. Also, with the complexity of these various packages, it’s
comforting to have the same company responsible for all aspects of the
software. In a few cases, it is possible to have the patient chart and
thumbnail-sized images all on the same screen; this is not possible when using
a third-party program. Also, since three major companies currently dominate the
market, dentists can be relatively secure that the company will not go out of
business or stop supporting their software. Finally, there’s no doubt that
having the image software integrated with the practice management software
makes it far easier to send e-claims with image attachments.
However, this option may not always be the best. In most
cases, the image software is significantly more costly than the third-party
programs. Many of the image programs sold by the PMS programs are modular: a
dentist would have to purchase separate modules in order to be able to images
from digital radiography, intraoral cameras, digital cameras, and scanners. The
cost of the fully-loaded image suite from the PMS company is often more than
the PMS program itself! Another concern is that some programs will only capture
images in a proprietary format, requiring time-consuming conversion utilities
if standardized format, such as JPEG, are needed. Finally, the compatibility of
the software with digital radiography systems is more limited with the PMS
systems. Most are compatible with 8-10 different sensors, while average for the
third-party programs is 23-25. Finally, some of the image suites from the major
vendors use a word processor that is unique to that software rather than being
able to work with Microsoft Word.
One thing that’s nice about working with a program like
Dentrix is that you have two options for imaging: an integrated solution using
Dentrix Image, or a stand-alone program called Clarity (used to be Vipersoft)
for non-Dentrix customers.
As dentists move towards the chartless practice, there are many systems that must be evaluated to find the best choice for that practice. While most offices will spend most of their time evaluating the hardware choices on the market, the software is often the most important component and dentists should not overlook this factor when choosing their imaging systems.
Operatory Design
In most cases, the dentist should attempt to place the
computer where it will be unseen by patients. Most offices use either a
side-delivery or rear-delivery cabinet for storing dental supplies and
handpieces, and this is often the ideal location for the computer system.
Another method that is often employed is to use a special mounting bracket and
to mount the computer flush on one of the walls. I’ve often found that a
computer that is mounted just below the arm of the x-ray head will be
unobtrusive and will not detract greatly from the esthetics of the operatory
room. The important point to remember is that the computer will need to be
accessed to load programs, and in some cases, will need to be situated close to
other devices. For example, offices that use certain types of digital x-ray
systems must position those systems no more than 6 feet from a computer due to
limitations in the length of the connecting cable.
The placement of computer monitors is probably the most
important aspect of technology integration in the operatory. Placement will
depend on a number of factors, such as whether there will be a monitor designed
for patient viewing, cost considerations, type of existing lighting (pole vs.
ceiling mounted), and viewing considerations. While flat panel monitors were
once priced very high, they are now available for less than $300 on average and
are an excellent choice. Besides being much lighter, they have a small
footprint (take up very little space) and can easily be mounted from a ceiling,
light pole, or floor-based command console. In an ideal world, there would be
two monitors in the operatory; one placed in front of the patient that can be
used to show patients digital x-rays, intra- and extraoral images, or patient
education DVDs. The other monitor would ideally be placed behind the patient’s
head where it is easily viewed by the doctor and assistant. This monitor would
be used to access the practice management software and any other relevant data
that the doctor doesn’t necessarily want the patient to see. While a monitor
can be placed near a ceiling for patient’s who wish to watch a video, it will
have little value in that position as a diagnostic aid for the patient. Close
to 80% of the offices we have installed since 2004 have elected to use dual
monitors.
The positioning of keyboards and mice is very important
since it will affect the way that both the doctor and the assistant work. A
keyboard that is placed behind the doctor’s back will be uncomfortable to use
and will require constant swiveling of the chair. Also, this would prevent the
assistant from having access to the keyboard. Ideally, the keyboard would be
placed behind the patient’s head on a rear-unit, so that both doctor and
assistant could access it. A wireless keyboard would also be an excellent
option to consider. When it comes to mice, there are more options since more
than one can be hooked to the computer at the same time. I often recommend that
the doctor use a light pen, which will allow them to point out areas of
interest on the patient screen, and the assistant could then use a traditional
mouse or trackball to enter data for charting, scheduling, etc.
While technology has greatly aided
the modern dentist in providing care and involving the patient in co-diagnosis,
care must be taken to properly plan for the ideal positioning of these devices.
Computers and Networking
For the office that wishes to move towards the “paperless” or chartless concept that is all the rage right now, computers in the treatment rooms are mandatory. Images that are captured, whether they are intraoral camera, digital camera, or digital x-rays, must be saved for future reference and should also be visible to the patient to assist in co-diagnosis, and this is simply not feasible without a computer in the operatory. Many practitioners, however, find it difficult to choose the right computer, so the purpose of this article is to review the specifications that should be chosen for an operatory computer. We will focus only on desktop-style computers; the argument of desktop vs. a laptop or Tablet will be left for another article. Also keep in mind that this is being written in January, 2006: the technology is changing rapidly and may be slightly outdated by the time you read this. Computer Case Design
Most of us are familiar with the older desktop or upright mini-tower designs. In the operatory, however, space is often at a premium and in many cases, a small-form-factor computer makes the most sense. These computers come in multiple designs. Some are very thin and long are look like two laptops stacked on top of each other, such as the Dell GX 620 SFF. Others, like the Shuttle and FIC IceCube, look more like a toaster. One of the decisions that must be made is the need for regular PCI cards. The Shuttle-style computers can usually allow use of one PCI Express and one PCI card, where the thinner models do not. This is becoming less of an issue as most devices that are used in a dental operatory can be used with USB connections. However, certain programs, like Dentrix Image, require use of a full-sized PCI card if the office wants to use an older analog intraoral camera. Processor
Recently, Intel has decided to forgo their nomenclature based on chip speed, and instead, are now using a “series” designation. Celeron processors will become the 3 Series, Pentium 4 processors will be called the 5 Series and Centrino or Pentium 4M chipsets will become the 7 Series. While anyone who has shopped for a BMW will be familiar with this, it is expected to create some confusion in the marketplace. The rationale is that while processor speed is important, the size of the cache and the functionality is also a factor. So, a chip like the Centrino, which is used almost exclusively for laptops and has built-in wireless networking, will have a higher series designation than a Pentium 4, even though the Pentium will have much faster processor speed. Memory
When discussing memory, there are two types of memory that are occasionally mixed-up: RAM (Random Access Memory) and Hard Drive capacity. The confusion lies in the fact that hard drive sizes are expressed in gigabytes of RAM. Usually, when we are talking about memory, we refer to the RAM, the internal memory that loses all information when the computer is turned off. For a dental operatory, we recommend a minimum of 512 MB of RAM. Some digital radiography companies are starting to suggest that dentists use 1 GB of RAM, but we have yet to see any major performance boosts with this extra memory. For the hard drive, 40 GB is more than adequate. In almost all offices, the workstations will not be storing any practice management or image data on their hard drives, and this data will instead be stored on the server, so there’s little reason to pay extra for an 80 or 120 GB hard drive for an operatory workstation. Operating System
Windows XP Professional is the ideal choice for the office environment. It contains many features not found in XP Home, such as the ability to automatically log into certain types of networks, and Remote Desktop, which allows you to log into the computer from home or anywhere else in the world. However, the core of Professional and Home are identical, so any program that runs on Professional should run identically on Home as well. Warranty
Ideally, you should purchase a computer with a warranty that
is equal to the amount of time that you plan on owning the computer. With the
ever-changing nature of technology, most offices will find that three years is
the expected life-span of these computers. The computers will still run beyond
three years, but will have trouble keeping up with the applications available
at that time. Digital Systems
While the discussion of digital systems can be an entire article in itself, I will limit my discussions primarily to digital radiography, since this is the hot topic right now. Scanners
Although it is certainly not a “digital radiography” system in the purest sense of the term, many offices use scanners to digitize their existing x-rays. Even offices who have elected to purchase a true digital system must deal with the issue of having thousands and thousands of film x-rays that ideally should be part of the patient’s digital record. Scanners are also an excellent option for the office which desires some of the advantages of digital, but finds the costs to be prohibitive. In this scenario, films are developed in their usual fashion and are then scanned into software. Many scanners come with their own software, although I would recommend using dental image management software. The key feature when choosing a scanner is the Transparency Unit Adapter (TPU), which is a light source that is in the lid of the scanner rather than the base. Many mid-priced scanners only have a 4” X 5” TPU, and while it’s fine for bitewings or a few Pas, would not be adequate for a pano or full mouth series in its mount. In these cases, a full sized TPU is needed, and there are only a few scanners that meet this requirement. The Epson 1680 Professional is the industry-standard, and the Microtek i800 is also a good choice. Phosphor Plates
While some people consider phosphor plates to be positioned between scanners and direct sensors, these systems are actually very highly developed and produce diagnostic quality images. The plates are “scanned” in a special machine which is basically a laser which reads the phosphor plates. The system must be attached to a computer which is running software compatible it. The main advantages of phosphor plates are their similarity to film. They are as thin, and often thinner, than film packets. The staff can take images with the same RINN kits and methods that they use for film, they take the plates to a centralized “processor” to “develop” them, and they mount the images afterwards. The one difference is that the mounting occurs in software templates, not cardboard or plastic mounts. Also, unlike direct sensors, the plates are relatively inexpensive, which is wise since they typically must be replaced after 300-400 uses. On the downside, the plates are easy to scratch and while they theoretically can last through those 500 uses, damage will normally require that they be replaced more frequently. Phosphor plates have less resolution, in line pairs/mm, then sensors. While this would not make a difference when viewing images on a typical 15” or 17” monitor, it can make a difference if you are magnifying the image to a great degree or printing out images that are larger than 8” X 10”. Also, because of the steps needed to get an image, the time needed to take phosphor plate images is very close to the time needed for film. Direct Sensors
Direct sensors are silicon-based receptors, often encased in protective coating, that mimic the size and shape of PA film. These sensors, which are either CMOS or CCD are connected to a thin cable which runs from the sensor to some device that would then connect to the computer. The sensors range in size from about 3 to 8 mm. The main advantages of sensors are speed and image quality. Images taken with a sensor appear almost immediately on the screen, making them the ideal choice for office who do a lot of endo or implant procedures. They are comfortable, sturdy, and have excellent resolution; many can produce a highly diagnostic image when used with the proper software. On the downside, they are thicker than film and have cables running off the sensors, which some patients don’t tolerate well. Also, they are not inexpensive, as a #2 sensor can range in price from about $5000 to $14000. Data Backup
In the past, the choice of which type of media to use was fairly easy to make. Back in the days of DOS, 1.44 MB floppy drives were more than adequate and all the data could be stored on a single disc. As servers became a part of smaller offices, many computer technicians were installing the systems that they were familiar with in the corporate world: tape drives. A large number of practices are still using these drives. Unfortunately, I do not feel that these systems are appropriate for the majority of offices. First off, the software and methods for verifying the backup are confusing to many dentists and staff. It is all too common to have a server fail and then the office discovers that their backups have not been properly run for months, and in some cases, the tapes have become corrupted. Secondly, I have yet to see an office that has more than one computer (the server) with a tape drive. One of the goals of the backup is to have a quick and easy method to restore the practice’s data and get the office running with minimal downtime. If the server crashes, and the only backup is on a tape, that tape will have minimal value since there is no other computer in the office that is capable of reading the tape. Recommended
Protocol
To effectively backup the practice’s important information, there are a number of factors that need to be taken into account:
As practice’s continue to digitize data that was once part of a paper-based system, it is vital to have a well-designed system to not only backup this important information, but is easy to implement and verify on a daily basis. Tying it All Together
There’s no doubt that most offices require guidance in choosing and implementing these systems. One of the best resources for this is your local Sullivan-Schein rep, as they have a complete understanding of not only the different systems, but which ones will work well together. They will gladly work with any office to properly sequence the addition of the various systems to minimize your downtime and make the transition as smooth as possible.
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