Choosing the Right Computer System
by Barry Freydberg, D.D.S., F.A.G.D., F.I.C.D.
Barry K. Freydberg, DDS, is a full-time practicing dentist in Skokie, Illinois, a Fellow of the AGD, the International College of Dentists, and the International Academy of Dental-Facial Esthetics. Dr. Freydberg is the future program chairman for the Chicago Midwinter Meeting in 2002 and a consultant to the ADA Council on Dental Practice. Dr. Freydberg’s speaking engagements on the use of technology and the Internet in the dental practice have received critical acclaim, and he has authored many articles published throughout the world.
Steve M. Seltzer, president of Seltzer Institute, is an internationally recognized expert on dental technology and practice management. He has been lecturing to dentists and staff for 12 years at every major dental meeting in the United States. His integrated technology management research has been published in several industry journals. For more than 5 years, Mr. Seltzer was a high-tech dentistry instructor at Boston University, Tufts University, and New York University dental schools. He currently teaches at a high-tech marketing course at the Las Vegas Institute for Advanced Studies and is a consultant to the ADA Council on Dental Practice.
Bradley Walker has assisted hundreds of dental professionals to integrate state-of-the-art clinical systems into their practices. His expertise covers software application development and implementation, technology management strategies, dental office and ergodynamic design, transitional process planning. As early as 1991, he was the architect for the development of the first fully integrated clinical software for dentists. He has since led innovative projects in the areas of voice recognition, electronic document management, and cross-platform software development. Mr. Walker currently serves as Executive Vice President of Unident, LLC.
We are living in a world where virtually any information you desire can be acquired in a matter of moments with the click of a mouse. The computer is a ubiquitous fixture in elementary schools, universities, small companies, large companies, and homes. Many dental offices have incorporated computers as an integral part of their management systems. However, the role of the computer is expanding in the dental office as new hardware and software advancements emerge. The growing popularity of digital radiography and photography is making the possibility of a completely digital patient record more desirable. The trend for expanding the role of dental office computer systems is reflected in the increased number of companies that offer computer packages. The purchase of one of these new systems represents a significant commitment on the part of the dentist and the staff. Not only do the systems have a substantial price tag, but they require a great deal of time and effort to become fully integrated into the daily office routine. To help the reader gain some clarity on the blur of new hardware and software available, I have enlisted the help of three recognized authorities on the subject of office organization and computer systems. This article is not intended to provide a ranking of features and shortcomings of specific products that are available, but rather to present a process by which the reader might be able to make better choices when selecting or upgrading a computer system.
Mr. Steve Seltzer sees the role of the computer in the dental office systematically changing. With the advent of faster, more powerful hardware and the development of sophisticated, user-friendly software, computers have been transformed from being just a front desk appliance to being a completely integrated tool for all aspects of the dental practice. Traditionally, the computer was used for insurance, billing, and recall. Before computers were commonplace in the dental office, the dentist typically would delegate these office tasks to a staff person. The advent of computers did not change this model: a staff person was still designated as the individual to perform those tasks, but instead of doing it by hand, it was done with a computer. The dentist rarely worked with the computer, did not understand the software, and did not become proficient in using it. This hands-off model of the dentist is rapidly changing. As a result, the role of all office personnel, including the dentist, is changing as well.
Computers Today
Computer systems today provide chairside check-out, charting capabilities, treatment planning options, educational modules, photographic and radiographic image storage, and total office organization modules to streamline every aspect of dental health care. Today’s systems can rapidly become the backbone of an office and everyone, including the dentist, must become intimately involved with the computer to gain the maximum benefits that these tools have to offer. Dr. Barry Freydberg feels that the modern computer system has taken on a mission-critical role in many offices, in much the same way as an air turbine and vacuum system are critical elements that must be working for the office to function every day.
If an office decides to integrate the computer system to its maximum capability today, performance and reliability become crucial. If it were to fail, access to records, radiographs, and scheduled appointments would bring the office to a halt just as quickly as if the vacuum system broke down. This is why Dr. Freydberg places an emphasis on choosing the right hardware, software, and back-up systems. It is also critical that all records be archived and protected from accidental damage. In a traditional office, fire, flood, and theft can compromise the integrity of the chart records, but when they are stored digitally, they can be easily duplicated and stored off-site in a fraction of the space (Figure 1).
Figure1- Zip disk used to transfer and back up office data
Mr. Seltzer is quick to point out that the computer is just a tool and it is the human factor that makes it work. He feels that many dentists are investing in the cost of the "tools", but they are not investing enough in training personnel how to use the tools efficiently. Mr. Bradley Walker agrees that "technology leadership" within a practice is critical to the success of group management. He says, "Practitioners need to ensure that their staff is trained on the tools that they can monitor the team’s success in using them." But Mr. Walker also believes that the dentist must always provide overall leadership to set the road map for the big picture issues, goals, and objectives. The computer systems alone will not improve practice productivity or efficiency.
Technology may fundamentally change the way in which dentistry is provided in a practice. Therefore, someone in the office must be familiar enough with the technology (software and hardware) and the style of the practice to make sensible operational decisions in relationship to computers and their integration. Usually, that person is the dentist, but it can be a staff person or office manager. One pitfall that Dr. Freydberg says dentists should never fall prey to is "the critical employee" situation. If only one or two employees understand the computer system, then the dentist relies on them completely for the system to function properly. In contrast, if all the staff members, including the dentist, are cross-trained on the computer system, then the entire office can be managed by any individual at any computer terminal. It can even be managed from a remote location. If, for example, an employee goes on family leave, it is still possible for that employee to contribute to the office via modem. The dentist can also easily access charts and radiographs from home if the system has modem access capability.
Computers in the Treatment Room
Our experts agree that dentists need to bring the computer terminal into the treatment room to see the greatest gains in efficiency, but they report that only 10% to 15% of dentists currently do so. The panelists feel that the basic computer functions in the dental office should include the management issues: scheduling, patient billing, insurance billing, and recall. Mr. Seltzer relates these elements to human physiology and refers to them as the basic autonomic functions of respiration, pulse, blood pressure, and body temperature. The human body has these functions under control at lower brain levels, leaving the higher levels available for critical, creative thinking. Mr. Seltzer says that many dental practices are "chained" to performing these basic functions manually and it takes valuable office time, leaving little time for more creative tasks, such as marketing and patient education.
According to Dr. Freydberg, immediate management benefits are realized when computers are moved into the treatment rooms. The entire staff shares the duties typically delegated to one or two employees at the front desk. This reduces the front desk bottleneck, enhancing office productivity. Mr. Seltzer says that the expanded use of technology throughout the dental practice changes the fundamental role of every person who works in the office, because information is distributed to every employee, not just the select individuals who are in the closest proximity to the front desk computer. More important, everyone in the practice becomes more knowledgeable, capable, and efficient by having patient and management information wherever they are. They perform their traditional roles and, when they are properly cross-trained, they assume more responsibility for meeting the needs of the entire team. This creates a more efficient, productive work environment with increased teamwork and reduced interpersonal stress.
Productivity
One of the concerns that dentists express about expansive computer systems is that these machines "do not produce the dentistry" and therefore may not provide an adequate return on investment. However, with terminals in the treatment rooms, there are many more opportunities to be productive in what Mr. Seltzer refers to as "quiet spaces" of time. Examples of these are the few minutes it takes for anesthesia onset and the minutes waiting for an impression to set. These moments can be turned into valuable productivity by posting charges, finishing chart notes, checking on schedule changes, reviewing account information, sending a welcome letter, or answering e-mail. If a terminal is in the room, these productive tasks are just a chair swivel away (Figure 2). If not, they pile up and become a mountain of work at the end of the day or during the weekend. That is why Mr. Seltzer teaches his clients that the technology is empowering.
Fig2- Dental auxilary reviewing patient treatment plan in operatory
Mr. Walker points out that "the empowerment of staff members through the use of computers can both increase overall performance and add to the career path options within the practice." He used the analogy of the growing segment of medical records specialists in the health care industry. "By assigning responsibility for the electronic information systems to key staff members, you can develop you own 'enhanced positions' for a dental records or information systems specialist as a way of advancing key team players."
Dr. Freydberg agrees and provides an excellent example of increased productivity. When the dentist leaves the treatment room to check on a hygiene patient or take a call from a colleague, the patient is usually left waiting alone or reading a magazine. With a terminal in place, the auxiliary can immediately review the account, discuss with the patient a family member who might be overdue for an appointment, use a CD-ROM educational module, or just ensure that the address, phone, and medical history information is up to date. Mr. Walker says that the key point in this example is access. The terminals need to be conveniently accessed by all office personnel. If there is only one terminal at the front desk, then none of this productive interaction can take place.
Scheduling
According to Dr. Freydberg, the dentist’s appointment schedule is another area that can benefit immediately from using computers in the treatment room. He notes that certain patients often have particular needs, irrespective of the usual and customary time requirements for a particular procedure. One example would be the patient who takes longer to anesthetize than usual. The dentist and his or her assistant are obviously aware of this and recognize that some extra time should be allotted for anesthesia. However, this may not have been communicated clearly to the front desk. As a result, when the patient’s next appointment is scheduled, his or her "normal’ appointment time may result in the dentist running late at the next appointment. If, on the other hand, the patient’s special needs are documented and the next appointment is scheduled by the auxiliary or the dentist in the treatment room, the extra time needed for the difficult anesthesia will be factored into the appointment schedule.
Education
Patient education is another advantage of having terminals in the treatment room. If a patient is waiting for the dentist to start a procedure, an auxiliary can initiate dental education using CD-ROMs, digital video disc (DVD) technology, electronic photographs, or radiographs of the patient’s dentition.
The tools available in today’s digital age are more sophisticated than the flip-chart or slide show material from the past. Mr. Walker points out that computer-based education systems allow better targeting and adaptation of this important information to different types of patients. "Not only does it allow the dentist to focus in on the specific treatment needs of the patient, but it also can be used to give different types of patients different information," says Mr. Walker. "For patients who have good oral hygiene habits and high trust in your care recommendations, it is perceived as a ‘value-added’ service. However, it can also give a technical-minded patient a break down of the exact steps that their treatment will take and reinforce their confidence in the dentist’s skills."
This type of communication can contribute to treatment acceptance, but the real benefit can be felt in other areas. It facilitates better involvement of patients in their oral health and offers the protection afforded by a systematic and documented approach to informed patient consent. According to Mr. Walker, "The computer tools currently available allow dentists to empower every member of their team to contribute to delivering valuable information to their patients." He adds that "the computer can also be used to combine information from graphic illustrations, clinical images, and narrative descriptions into a more powerful approach than the linear orientation of earlier education techniques."
Eliminating "Drop Outs"
One problem identified by Mr. Seltzer from his client surveys suggests that in a traditional office environment, where the back office communicates to the front desk about the procedures provided, mistakes can be made. He determined that an average of 3% of gross production can be lost due to communication "drop outs" and other mistakes. If the primary providers (dentists, hygienists, or auxiliaries involved with the procedures) are entering the services and charges as they are generated, these "drop outs" are eliminated. The annual cost savings alone from this "lost" production would fund the capital expenditures for the computer system.
Perceived Disadvantages
The advantages of terminals in the treatment rooms may seem logical enough, but what are the disadvantages? Mr. Seltzer identifies four perceived disadvantages of bringing computers into the treatment rooms. The first is a space problem. Initially, retrofitting a treatment room for a terminal may seem imposing, but the availability of flat panel displays and the compact size of some terminals should not pose a major obstacle, even in the most cramped spaces. Some dentists use laptop computers to help conserve space (Figure 3).
Fig3- Compact size of laptop computer requires minimal space in the treatment room.
The second perceived obstacle is infection control. This can be managed with plastic wrap or flexible plastic keyboard skins, which can be easily cleaned with surface disinfectants. Some systems use touch screen input while others have voice recognition. The easiest solution is to remove gloves or use overgloves when working at the computer, which is the proper protocol for handling a traditional chart. The third and fourth perceived disadvantages are the initial cost of the systems and the short life cycle of the equipment. Computer hardware has approximately a 5-year life span. That is not to suggest that a system is not functional well beyond that point, but the added features and speed of new hardware is typically well worth the cost of upgrades.
Technological Advances and Computer Literacy
As computer technology advances, dentists need to be more computer literate. According to Mr. Walker, computer knowledge must be developed on two planes. He feels the dentist must learn the basic skills necessary to operate the tools. This includes basic operation of the hardware and software. More important, the dentist needs to be knowledgeable enough to evaluate the tools themselves in context with his or her own office practice needs. Otherwise, the system components can become "toys" that do not address core tasks within the office. Mr. Seltzer suggests that dentists commit at least 30 minutes a day to becoming more technologically literate and spend at least 8 days a year taking courses. Dentists should use the daily time to enhance the techniques they have learned at 1- to 3-day courses that teach specific skills. Fundamental computer courses can be found in the yellow pages under "Computer Training." Courses specific to dentistry and computers are offered by consulting firms.
Dr. Freydberg adds that in the 1960s and 1970s, systems were sold as "turnkey" products. Today, this term does not apply because the dentist really does need to be more knowledgeable about how the computer operates and what features can be added. That is not to say that all computer components will work seamlessly with all software packages. He likes to quote Paul Rhodes who says, "The dentist needs to know if he or she is buying a system that is seamlessly integrated or seemingly integrated" into the office environment.
The Internet
According to Mr. Seltzer, the Internet is becoming increasingly important to the dental profession, and every dental practice needs a web page and to have Internet access in the office (not just at home). The Internet touches nearly every aspect of practice, from ordering supplies at the lowest prices to obtaining invaluable clinical and practice management information. From a marketing and communications perspective, dentists use their own web pages to communicate with patients and market their practices. Some dentists have integrated internal and external marketing programs to bring more patients into the practice than conventional methods, such as yellow page advertising. The integrated program can use display advertising, targeted mailings, or community programs to promote the web page. Prospective patients visit the web page, where they become motivated to join the practice. Costs for a marketing program that integrates the Internet are typically 1% to 4% of gross annual production, which is often less than many dentists invest in yellow pages advertising.
Choosing the Right Equipment
One issue that becomes clear is that the vast assortment of available software and hardware has to be investigated for a dentist to buy or lease the right system. Mr. Walker believes that it comes down to ensuring that your office needs mesh with the system capabilities because not all systems have similar strengths and weaknesses. He feels a system integrator is vital to act as the glue and make sure all choices are compatible and work together. Mr. Seltzer’s experience has been that technology often fails or does not live up to a dentist’s expectations because it was a mismatch from the beginning in relation to the needs of the practice. He feels an office "self-assessment" is the first and most critical step in selecting the proper system. The office must also invest in ongoing training, however. He recommends that training should be 20% of the cost of the system for the first year and 10% thereafter, to ensure the staff is taking advantage of updates and enhancements that the software has to offer. Otherwise, the technology will not result in all the benefits anticipated.
The paradox in computers for the dental office is that there is always going to be better hardware and new software available next year. Although the dentists want to have this new technology, how do they make a decision? Mr. Seltzer suggests that dentists considering incorporating computers into their offices should poll colleagues who have computerized offices. If they can find systems in 6 similar offices that have been working well for 6 months or more, the dentists can gain some confidence that the decision they are making is a good one. Mr. Seltzer also feels that finding an established vendor will provide a sense of security and stability. He says that although the lure of new developments can be enticing, it is critical that the system be up and working in "real world" conditions before it can be considered proven and reliable over time.
According to Mr. Walker, dentists are deciding on an important "marriage" when they select a computer system and, like a real marriage, it is not something that should be done after a casual meeting at a convention booth. It should be done carefully because this is going to be the heart of the practice. Not only is the dentist getting married to a system, but he or she is investing in the vendor for the long term. The dentist needs to feel comfortable that the people factor, not just the technology, will be a relationship that he or she can live with.
Conclusion
Technology has changed many facets of the dental practice, and computers continue to play a role. According to our experts, office productivity and efficiency can be significantly improved when computer terminals are installed in treatment rooms. This makes information readily accessible to the entire dental team and reduces the bottleneck often experienced at the front desk. There is wide diversity in dental computer packages with specific strengths and weaknesses for each. Therefore, the dentist must make a careful selection to ensure that the system purchased will meet office expectations. Our experts agree that the self-assessment process is always the starting point for choosing the proper company or product. A dental consultant who can visit a practice and see how it works can provide invaluable insight into this decision.
It is also critical to include the staff in this process. Dental practices that have invested both time and money to network computer terminals into the treatment rooms report that they would never want to remove them. Although these powerful tools have the potential to benefit the practice in many ways, they cannot function without complete staff involvement. For this reason, the investment in a new system must be accompanied by proper staff training and continuing updates. The multiple benefits realized from this approach will make the dental practice highly efficient, productive, and enjoyable through the next milennium.