Practice Management Applications
By Dr. Barry Freydberg
Practice management computer software has been the primary dental application of computers and is rapidly becoming an essential component of the modern dental practice. The use of the computer to assist in recordskeeping and accounting procedures was a natural extension of general business software. Many dental practice management programs are on the market, and it is often difficult to discern differences between them. Practitioners should first have a clear vision of the tasks they want a system to perform before they can select one that is most appropriate for their needs.
Dental management software may be divided into three levels based on complexity and features. These are not necessarily clear-cut categories, since the speed of technological advancement is continually blurring the distinctions between levels, making it difficult to classify systems definitively.
Not so long ago, only the most sophisticated dental software programs were capable of filing insurance claims electronically. Today, this feature is expected of even the most basic systems. First introduced in dentistry in 1991, electronic filing has become an indispensable tool, speeding all facets of processing and paying claims. At the end of a patient visit, a member of the dental staff simply enters the procedures completed and current charges in the computer. The computer then "fills out" the electronic equivalent of the insurer's claim form and files the claim by calling another computer at the insurance company or a clearinghouse. There are no paper forms to complete, mail or misplace. In addition, there is a trend away from requirements for supporting documentation, such as x-rays. The insurance company computer sends back an acknowledgment and statement of benefits. The claim may be paid in a matter of days.
Like electronic claim filing, "multitasking" and "multi-user" capabilities are now standard in virtually all computer systems designed for dentistry. The terms mean simply that individual terminals on the system can perform a variety of tasks and that the system can support the simultaneous use of multiple terminals. These are essential capabilities that improve efficiency by ensuring that staffers do not have to wait their turn or go to a different terminal to perform work.
The above examples illustrate why it is important to understand the full range of tools available before deciding which computer system to buy. With this knowledge, dental professionals can more easily make informed buying decisions and recognize key trends in the technology.
LEVEL l SYSTEMS-THE BASICS
To be useful in today's dental practice, a basic dental management system must meet certain minimum requirements. On-screen patient information should include name, address, and phone number. The system also should accept a notation of how the patient prefers to be addressed: John Smith may want to be called "John", "Mr. Smith", or even "Jack." Other patient information should include names of family members (even if last names or addresses are different), insurance particulars, employer, social security number, and last visit and recall dates. The program must also store information on the patient's critical health problems and call attention to medical alerts, both on screen and on appropriate printed forms.
A basic system should generate treatment plans, patient statements, recall notices, and routing forms ("buck slips"). In addition, it should be able to estimate insurance benefits, produce predeterminations and claim forms and file claims electronically. The modem* required for such data communication provides a link not only to insurance companies, but also to services such as on-line vendor support, databases and bulletin boards. The program should support these applications as well.
As a rule, the content and format of management reports created by basic systems cannot be customized by the user. The information provided should be carefully scrutinized to make sure it is complete, thus eliminating the need to refer to additional documents, such as patient records or other reports.
MODEM
An acronym for modulator/demodulator; a peripheral device that translates the computer's digital signals into analog signals for telephone transmission and reverses the process for reception of telephone signals.
These are essential reports that a Level I system should be able to generate:
- gross practice production
- gross practice revenue and collection
- past due patient and insurance accounts
- outstanding insurance claims
- overdue recalls (continuing care)
- overdue predeterminations
- unbilled insurance procedures (treatment completed, but not yet billed to the insurance company)
- incomplete dentistry (treatment plans presented, but not yet completed)
- new patients
- "lost" patients (not seen by the practice within a given period)
- referral sources
Another requirement of a system at this level is basic word processing to enable users to create form letters and personalize them automatically by merging appropriate information from patient data files.
Audit trails and security features should be included. The system should track accountability by recording who did each task and when. It should also have provisions to prevent unauthorized users from accessing or altering information.
LEVEL II SYSTEMS-INTERMEDIATE
Building on the capabilities of the basic system, an intermediate system provides greater flexibility and sophistication. Interoffice communication via electronic mail is standard at this level. With it, office personnel can keep each other informed discreetly of patient arrivals, delays in the schedule and other information essential to the smooth running of the practice.
In addition, at the intermediate level, users have more ability to customize the information format. Routing forms can be created with desired information: for example, the names, ages, and dates of last visit of the patient and other family members. Treatment plans can be presented showing different options and the applicable insurance coverage, or treatment can be shown in phases. A variety of design options may be available for patient statements, and the user can specify different styles for different patients. Insurance benefit estimates become more accurate as intermediate systems "learn" insurance company fee schedules. At this level, systems can also generate instant or batched insurance forms, predeterminations and correspondence. The ability to keep records of correspondence is typical.
Along with the types of reports available in a good basic system, intermediate systems offer comprehensive financial reports. Users can insert text such as notations, and create custom reports. In addition, systems at this level enable a practice to build more thorough patient profiles—likes, dislikes, motivators and so on. The enhanced capability to collect and retrieve data greatly increases the usefulness of the stored information.
For example, the computer can identify all patients with incomplete treatment, an upcoming insurance renewal date and a given level of remaining benefits. Using that list and its word processing capabilities, the system can personalize a letter to each of these patients urging them to call soon for an appointment. Follow-up reports can quantify the response rate and the dollar value of the mailing.
Electronic progress notes can be easily accessed, are legible and cannot be changed. Additionally, input can be made quickly and is easily stored. (Courtesy of DENTECH)
Intermediate level systems offer more sophisticated referral tracking. Incoming referrals can be tracked by number and dollar amount; outgoing referrals to specialists also can be monitored.
Another feature typical of intermediate systems is the ability to provide automatic reminders of recurring tasks, such as equipment maintenance or periodic reports. Some tasks can be done without staff intervention. After a visit by a new patient, for example, the computer can follow up automatically with one letter of welcome to the patient and a second letter to the patient's doctor requesting medical information.
More powerful automated appointment scheduling is standard in intermediate systems, some of which even factor in the time it takes for different doctors and assistants to do various procedures. Invaluable support for group practices is available at this level, including revenue distribution and individual productivity.
LEVEL III-ADVANCED SYSTEMS
Advanced systems provide all the capabilities found at Level II and add a new dimension by decentralizing the practice management—that is, reorganizing the practice by redistributing the workload. While decentralization may or may not be implemented in conjunction with less sophisticated computer systems, it is the surest way to take full advantage of the powerful capabilities of Level III systems.
State-of-the-art computer systems share certain characteristics:
- Computer terminals are placed in the operatory
- All scheduling is computerized
- Responsibilities such as answering telephones and assisting patients are divided and assigned to different staff members
- The practice becomes virtually "paperless"; progress notes, medical history and most chart entries are made directly to the computer
- Most management end marketing reports are never printed; the system provides on-screen prompts to direct staff telemarketing.
Without leaving the treatment room, users of advanced systems perform scheduling and enter data such as charges and treatment plans, medical history updates, address changes, and specialized notations. Before dismissing the patient, the staffer can schedule the next visit and send the patient off with insurance papers, walk-out statement and appointment reminder card, as well as postoperative instructions and prescriptions.
Today's practice management software enables practitioners to view patient images and administrative data on screen at the same time. (Top: Courtesy of MOGO, Inc. Bottom: Courtesy of VirtualChart , a product of DecisionBase, Inc.)
Reassignment of administrative office tasks tends to reduce stress and increase efficiency. Level III computer systems speed patient checkout, eliminate duplicate data entry by both chairside and front-desk personnel and help prevent bottlenecks in the reception area. Because the appointment schedule and patient records are accessible from any terminal on the system, telephones can be answered in a quiet area separate from the reception desk—even off premises. This one change can have a positive effect on patient relations. Under the old system, front-desk staffers juggled phone calls and took messages while trying to schedule, confirm or cancel appointments, collect payments, explain insurance benefits, and pull and file records. Now reception personnel are free to greet and dismiss patients properly. Likewise, the staff members handling the telephone can give callers their undivided attention.
Because the system can be directed to generate many letters, reports, and insurance forms automatically, without staff intervention, Level III systems significantly reduce staff and doctor responsibility for managing routine tasks. Eliminating many of the printed reports required by less sophisticated systems, these programs provide on-screen directions of the next action to take: "This is the next recall contact to make"; "This is the next collection call"; "This is the next patient with incomplete treatment who is not in the appointment book"; "This is the next patient who promised to pay today, but did not."
FUTURE OUTLOOK
In the past, practice management software has been the centerpiece of dental computing. As more dentists accept the computer as a basic clinical necessity, the patient record will be the center of focus, and practice management software will be completely integrated with the record. Many procedures that are now office tasks will be automated or initiated in the treatment room.
One key issue is not quite resolved at the time of this writing: full integration of practice management and clinical applications software. "Integration" is widely promised in the marketing of today's systems, but in many cases, the promise has not yet been fully realized.
To understand how a truly integrated system should function, consider this example. A doctor, while examining a patient, sees that tooth number 14 requires a crown. That information, entered as a graphic notation on the patient's computer chart sets in motion a string of actions: The management software automatically sends a predetermination to the patient's insurance company, creates a treatment plan, tracks and ages the plan and, when the dental work is completed, updates the electronic chart and bills the patient and the insurance company for the procedure. True integration seamlessly links the clinical and accounting applications, eliminating duplication of tasks. A telephone number changed on the patient's chart, for example, is changed automatically in any other computer record containing that patient's phone number. All the records are kept simultaneously current, without the need to re-enter the data in different applications.
Widespread availability of true integration is only a matter of time. If technological trends continue as expected, one day it will be as easy to assemble an information management and clinical system as it is now to choose components for a home entertainment system. Dentists will be able to select various types of application software, regardless of the manufacturer, to customize a fully compatible, integrated computer system.
The clearing of another technological hurdle—voice data entry—will be an additional benefit in the dental setting. Supplanting touch-screen, mouse* or keyboard entry, voice-recognition technology will enable the dentist to dictate notes directly. The advantages are obvious: the convenience and time savings of hands-free entry, combined with improved infection control.
MOUSE
A hand-guided pointing device that lets the user draw or select commands on-screen by pressing buttons.
THE CLINICAL WORKSTATION* AND ELECTRONIC PATIENT RECORD
The clinical workstation is one of the newest examples of computer-based high technology to emerge in the dental environment. The purpose is to consolidate multiple high technology devices and software for use in the dental treatment room. Once fully adapted to clinical practice, the clinical workstation should prove to enhance the effectiveness of the dentist, hygienist, and assistant. In its most sophisticated form, this workstation will integrate clinical patient information with practice management software used by administrative staff to eliminate redundancy of data entry. Computers have made possible many new adjuncts to clinical care. These include intraoral video cameras; direct digital radiography*; devices to measure tooth mobility, intrasulcular temperature, periodontal pocket depth, and the magnitude and location of occlusal contacts; and video and CD-ROM devices for patient education. Until recently, all of these applications have been developed independently, necessitating the purchase of multiple "black boxes", monitors* and printers that take up considerable space in the treatment room. In addition, because these devices have typically not been interlinked, there has been no coordination of the data they provide.
WORKSTATION
Generally thought of as a computer interface on a network linked to a server or central computer, but may refer to a single computer for individual use.
DIGITAL RADIOGRAPHY
The production of radiographs using an electronic capture device (such as a CCD) rather than film.
Ideally, with the clinical workstation, input* mechanisms for these devices will be all connected into a single computer, monitor, and printer. The data from all of these devices will be collected, stored and presented in a coordinated manner familiar to the dentist: the patient's record (chart). The electronic patient record, an emerging concept officially known as the Computer-based Oral Health Record (COHR), will then serve as the center for integration and use of the data collected by all of these devices.
Various areas of medicine have been using computer-based patient records (pharmacy, emergency rooms, nursing, laboratories and radiology) for several years. Standards for medical patient records are still developing. Most authorities agree that computer-based records should make use of standardized glossaries of terminology, organized in an easily accessible and logical manner to facilitate documentation and to provide the best basis for patient management and assessment of diagnosis and care. The American Dental Association is currently developing such standards for the COHR.
MONITOR
A peripheral device resembling a television. Its CRTscreen displays characters and images.
INPUT, INPUT DEVICE
The entry of data into a computer and the interface that makes the process possible, such as a keyboard, a barcode reader or scanner (as contrasted with output).
One way the COHR can facilitate ease of documentation is to minimize the need for free text entry (i.e. typing) by the use of hierarchical organization of terms, similar in format to an outline. If this electronic record makes use of a graphical user interface (GUI)* such as Microsoft's Windows TM or Apple's Macintosh TM, it can incorporate both graphics and pictures with text. The ability to link images with descriptions to enhance documentation is a powerful addition to dental records, which have in the past been little more than a record of procedures performed. As dental care moves more into the area of chronic care, it will be necessary to document a patient's conditions and arrive at a diagnosis before making a treatment plan. Furthermore, chronic care such as for periodontal diseases, malocclusion and temporomandibular joint disorders requires on-going monitoring and evaluation of the patient's status, which can be performed automatically in the COHR.
As the intraoral video camera has enabled dentists to more clearly identify problems and assist in patient education, the COHR's ability to integrate images for patient education and the sharing of clinical information will be of significant value. The COHR will also allow for the transmission of intraoral images and narrative histories via modem and telephone lines to a regional or national diagnostic center or dental school department in seconds and at a lower cost than paper, envelope and a postage stamp. It is conceivable that a response could be transmitted back while the patient is still in the dentist's chair, eliminating the need for a return appointment to report the results or proceed with the next step.