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A six-step plan to a paperless practice.

Most dental practices recognize technology as part of everyday life in the practice. Dentistry has undergone a paradigm shift over the past 20 years where systems that were once analog (paper, film) are now being replaced by digital counterparts. This trend is evident in practices that are trying to become completely paperless. While I don't agree that any office can be truly paperless, eliminating the need for a physical paper chart is something that any office can achieve. The goal of this article is to discuss the sequence necessary to accomplish the goal of going paperless.

The challenge for most offices is to develop the best plan to evaluate their current and future purchases to ensure that all the systems will integrate properly together. While many dentists are visually oriented and tend to focus on the criteria that they can actually see and touch, some of the most important decisions are related to more abstract standards. I have developed a six-point checklist that I feel is mandatory for any dentist who is adding new technologies to their office, and I recommend that the steps be completed in order:

1. Practice Management Software. It begins with the administrative software that is running the practice. To develop a chartless practice, this software must be capable of some very basic functions. If you want to eliminate the paper, you'll need to consider every paper component of the dental chart and try to find a digital alternative. For example, these include entering charting, treatment plans, handling insurance estimation and processing with e-claims, ongoing patient retention and recall activation, scheduling and dozens of other functions that are used on a daily basis. Many older programs do not have these features, and if your office wants to move forward, you will have to look at more modern practice software. It's important to understand that we would prefer that the practice management software programs be able to handle all of these functions; however, most fall short of this happening. Fortunately, there are a number of third-party programs that can provide functionality where the practice management programs cannot. The systems I've recommended in the past include Dentforms (www.medictalk. com) to handle patient signatures and online forms, DemandForce ( for patient confirmations and surveys, and Uappoint (www.uappoint. com) for confirmations and online scheduling.

2. Image Management Software. Whether or not to use image management software is the most challenging decision for any dental office. Most of the practice management programs offer an image management module: Eaglesoft has Advanced Imaging, Dentrix has Dexis, Kodak has Kodak Dental Imaging, and so on. These modules are tightly integrated with the practice management software and will tend to work best with digital systems sold by the company. Having an integrated image module makes it very easy to attach images to e-claims with a few mouse clicks. Note, though, that there have been many changes in ownership of these programs over the past year. Sirona purchased Schick, Kodak was acquired by Onex, Dentrix sold off their imaging to Dexis, and Lightyear went out of business. In other words, your investment in these programs may not be long-term. However, there are also many third-party image programs that will bridge very easily to the practice management software and offer more flexibility and choices with slightly less integration. There is no perfect system ... it really boils down to paying a premium for tighter integration or paying less for more flexibility. Some of the better known third-party image programs include Apteryx XRayVision, XDR and Tigerview.

3. Operatory Design. Yesterday's single intraoral camera and TV in the operatory are being replaced by more modern systems. The majority of offices are placing two monitors in each operatory: one for the patient to view images or patient education or entertainment, and one for the dentist and staff to use for charting, treatment planning and any HIPAA-sensitive information (e.g., daily schedule, other information that you would prefer that the patient not see). Windows and other software have built-in abilities to allow you to control exactly what appears on each screen. There are numerous ergonomic issues that must be addressed when placing the monitors, keyboards and mice. A keyboard that is placed in a position that requires the dentist to twist his or her back will cause problems, as will a monitor that is improperly positioned. Another important decision for the office will be whether you prefer the patient to see the monitor when they are completely reclined in the chair. If this is the case, then the options are a bit more limited for monitor placement. There are some very high-tech monitor systems that not only allow the patient to see the screen, but create a more relaxing environment for patients who are considering longer procedures. The Dental Chair Potato ( is the best example of a system that makes life easier for the dentist and staff as well as the patient.

4. Computer hardware. After the software has been chosen and the operatories designed, it's time to add the computers. Most offices will require a dedicated server in order to protect their data, as well as having the horsepower to run the network. The server is the lifeblood of any network. It is important to design a server both to be bulletproof (that is, having redundancy built-in for the rare times that a hard drive might crash) and to be easily restored. The workstations must be configured to handle the higher graphical needs of the office, especially if the office is considering digital imaging. The computers placed in the operatories are often different from the front desk computers in many ways: they'll have dual display capabilities, better video cards to handle digital imaging, smaller cases to fit inside the cabinets and wireless keyboards and mice. An often-overlooked consideration is that the smaller the computer, the more heat it can generate. Heat is the number one enemy of computers. Many dentists will place their computers inside a cabinet at the 12 o'clock position, and having proper ventilation is absolutely critical. Dell has a line of Small Form Factor computers that are ideal for dental operatories.

5. Digital systems. The choice of image software will dictate which systems are compatible. Digital radiography is the hot technology at this time because of many factors. For those who can afford them, cone beam 3D systems are in demand. The dentists who have digital radiography report more efficiency because of the ability to view take and view images more rapidly, better diagnostics, cost savings due to elimination of film and chemicals and higher case acceptance through patient co-diagnosis of their dental needs. All systems have pros and cons, and dentists will have to evaluate each system based on a set of standards that are important to the practice. For some dentists, it might be image quality. For others, it may be the cost of the systems, the warranty of the sensor, the company's reputation, or the compatibility of the sensors with their existing image management software. Keep in mind that intraoral cameras are still an excellent addition to any office since they allow patients to see the things that typically only a practitioner could see.

6. Data Protection. With a chartless practice, it is crucial to prevent data loss due to malware or user errors. Every office should be using antivirus software to protect against the multitude of known viruses and worms, as well as a firewall to protect against hackers who try to infiltrate the network. You should also have an easy-to-verify backup protocol in place so you can recover from any disaster. The different backup protocols are varied, but it is crucial that the backup is taken offsite daily and can be restored quickly. Online backup is now a reality and a very viable option for many practices that want a true set-it-and-forget-it system for their daily backup.

For offices that wish to be chartless or paperless, it's crucial to evaluate all the systems that need to be replaced with a digital counterpart and to take a systematic approach to adding these new systems to the practice. Most offices would be well advised to replace one system at a time and get comfortable with it before adding new technologies to the practice. The typical practice will take 6-18 months to transition from a paper-based office to a chartless one, but the reward at the end will be well worth the journey.

Lorne Lavine, DMD, founder and president of Dental Technology Consultants, has over 20 years invested in the dental and dental technology fields. A graduate of USC, he earned his DMD from Boston University and completed his residency at the Eastman Dental Center in Rochester, NY. He received his specialty training at the University of Washington and went into private practice in Vermont until moving to California in 2002 to establish DTC, a company that focuses on the specialized technological needs of the dental community. He has vast experience with dental technology systems including extensive hands-on experience with most practice management software, image management software, digital cameras, intraoral cameras, computers, networks, and digital radiography systems. He writes for many well-known industry publications and lectures across the country. In addition, he is a member of the Speaking and Consulting Network. He is also the former technology consultant for the Indian Health Service.
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Title Annotation:technology update
Author:Lavine, Lorne
Date:Feb 1, 2008
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