JADA Continuing Education
Integrated office technology
How technology can help improve office efficiency
L. HURSTON ANDERSON, Ph.D.
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ABSTRACT
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Background. While innovation in the technology industry has produced ever more advanced equipment specifically for dentistry, it is important to understand how these advances actually improve internal operations in a dental practice.
Overview. The overall trend in general industry in the United States is to use technology as an instrument in enhancing productivity, and dentistry is no exception. This increased use of technology does not necessarily threaten the dentist/patient relationship. While the benefits of technology in dentistry are real, costs are not limited to just the price of the equipment itself. Each technology purchase should be evaluated on the basis of a thorough cost-benefit analysis.
Conclusions and Practice Implications. Though dentistry is essentially a personal service, selective use of technology can benefit patient care as well as contain costs. Dentists should consider technology as a partner in their practices.
Today, Americans enjoy the highest per capita productivity rate ever recorded.1,2 This has provided some positive side effects for today’s individual Americans, who also enjoy one of the world’s highest standards of living and greatest purchasing power parities.
Many factors contribute to this phenomenon, but one major factor is the effective use of technology by industry, professionals and public organizations.3 Even before the days of Whitney’s cotton gin and McCormick’s reaper, and now with the promise of nanotechnology,4 Americans have been enamored with the promise and the reality of technology’s contributions to society and to their individual lives.
Selective use of technology can benefit patient care as well as contain costs.
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IS THIS ROBODENTISTRY?
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The debate regarding how much technology is too much continues at differing levels, but no one seriously argues against technology any more, even in the dental office. However, the discussion in dentistry is different from that in general industry. While society, in general, is becoming increasingly accustomed to direct or indirect contact with automation, dentists must be careful not to allow technology to interfere with the relationship between patient and doctor or patient and staff. The public may have embraced automated teller machines and self-scanning grocery checkout counters, but no one wants to be treated by a "robodentist." When dental staff members see technology as an excuse to reduce their time with patients, they misapply that technology, and the practice inevitably will suffer. The purpose of a dental practice is to treat patients, and the purpose of every person and every device in the practice must be to enhance and improve that treatment.
This is described well by Dr. Michael Robichaux, a general dentist from Slidell, La., whose practice focus is restorative and cosmetic procedures and who is an active lecturer on the topic of improving the quality of treatment and service through better patient-doctor understanding. He once was reluctant to introduce technology into the treatment room. But in a conversation we had in March, Dr. Robichaux said he now believes that developments in digital radiography, digital imaging, digital diagnostic devices, intraoral cameras and voice-activated record keeping actually "give the patient more control than ever before. The patient can now be shown rather than told. Treatment acceptance as an issue has virtually disappeared." When patients better understand their dental needs and consequently agree to be treated optimally, their overall health improves significantly.
Does the day of the robodentist lie ahead? Perhaps. But if so, it will require a different kind of patient than we have today. Today, a patient expects to be treated by caring human beings, and technology should be used to provide more of that personal attention, not to replace it.
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SELECTING TECHNOLOGY FOR A DENTAL OFFICE
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The question is no longer whether dentists should reject or accept technology in their practices. A great deal of existing and emerging technology can help dentists to improve the treatment and service they provide for their patients significantly. To ignore or reject the use of tools that can improve treatment is to do a disservice to the patient. The dilemma is ascertaining what technology has real value and benefit, and how much real value or benefit it actually has.5
Dentists will find many legitimate reasons to make investments in technology for a dental office. Sometimes, however, the only source of information for making a decision is the sales material from the vendors themselves. No matter how sincere and honest these vendors may be, they must sell their products to succeed, and their vision can be understandably myopic, focusing on their particular products. Without this concentration, of course, none of the exciting new products we see at large dental conferences would exist. But I believe that too many things are sold with the rationale that "just one extra crown a month pays for this." Every investment in any business—including a dental practice—must follow a thorough, thoughtful and honest analysis of cost and benefit.
Some dentists’ investments in technology succeed wildly, some yield a moderate practice improvement and others result in only an unfortunate increase in the practice’s overhead. When the technology acquired shows no appreciable advantage for the patient and the practice, it must be considered a mere toy and allocated to the doctor’s personal entertainment budget. That is not to say that there never is legitimate justification for making investments in technology that do not provide a readily identifiable return on investment. Intangibles such as reduction of stress, job satisfaction, pride in the office, improved public image, and the simple easing of daily boredom can be very valid justifications for making certain investments in technology. The difficulty lies in attaching a value to these things adequately enough to know when the purchasing decision is justified.
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ESTABLISHING BUDGETARY ALLOCATIONS
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My primary business for the past 15 years has been dental practice management consulting. During that time, my colleagues and I have worked with hundreds of dental offices nationwide. My firm helps clients allocate a percentage of income toward investment in technology during their annual budgeting process.6 The percentage varies slightly for different types of practices and under different circumstances. If a dentist is considering purchasing technology the cost of which would exceed the allocated amount, he or she agrees to keep it only if there is an easily ascertainable financial gain within a few months. For instance, a practice that allocates 6 percent of its budget for equipment purchases and exceeds that allocation by $500 per month must increase income by at least $8,333 per month, or the overhead will be unbalanced. Of course, it is feasible that expenses could be reduced by a corresponding $500, but where would that be—in staff compensation? I have never seen that happen. Conversely, just as a practice should not exceed its technology budget allocation, neither should it underinvest for its future. Technology investment is a delicate balancing act that requires studied decision making.
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INVESTING FULLY, NOT ONLY MONETARILY
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This discussion focuses on the advantages to be gained from technology, but let me be clear: there is no technology available today, nor will such new technology ever exist, that will eliminate inefficiency, compensate for poor leadership, inspire the lackadaisical, improve bad attitudes or train the uninterested. In fact, a practice with faulty, inefficient internal procedures and protocols will be able only to do things the same way more quickly. Appropriately applied technology is a tool to help a good dental practice become a great dental practice, but for some it can just be another hole into which to pour cash, if their operational house is not in order.
One of the most effective users of technology I have seen is a dentist in one of the most impoverished counties in the mid-South, and his practice does not treat patients receiving Medicaid or Medicare. He has 10 treatment rooms outfitted with monitors for access to the management software, digital radiographic equipment, digital imaging equipment, digital diagnostic devices, intraoral cameras, voice-recognition charting and even digital periodontal probes. He conducts his staff meetings and daily huddles with the aid of an overhead projection device connected to his practice management software to review the schedules and to research the answers to questions that might arise. He and his staff keep two computer-aided design/computer-aided manufacturing, or CAD-CAM, chairside restorative systems busy continually for 36 hours per week. This one-dentist/two-hygienist practice produces and collects $1,000 per hour while delivering quality dentistry in a warm, caring environment.
How is this possible, especially in an area with a low per-capita income? The answer: this dentist and his entire staff embrace technology completely. They spend hours learning to use everything they have to its maximal capabilities. This dentist speaks and thinks the language of digital technology as well as does a computer engineer, and he invests many hours per week in studying, repairing, practicing on and training himself and his staff to use the technology. This is a practice that maximizes its technology investments.
No dentist could duplicate this success simply by purchasing the same technology. It takes the right dentist with the right staff to produce these results. This dentist is a technological pioneer willing to blaze new trails for eventual benefits, even if it means investing hours and hours in reading manuals, testing, training, talking to vendors and experimenting. Most dentists and dental staff members would not or could not make a similar investment. Most dentists fall between this alpha-level user of technology and the omega-level user, one who still is not sure about calculators and push-button telephones. What bridges the vast chasm between the alpha and omega users is integration.
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CREATING SYNERGY
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Integration equals synergy, the magic in which the total is greater than the sum of the parts. Synergy delivers that quantum leap in productivity that could never be realized from individual devices operating independently. When technology establishes itself in a particular industry, it begins with the most likely targets first, the places in which the greatest advantage can be felt. Then a new target is found, and then another, and so forth. Each area of automation can be assessed for its overall value to the practice, and purchasing decisions can be made on the basis of that specific application’s value. Typically, different companies deliver different solutions, and there is little or no communication among the devices. (Dr. Titus Schleyer’s7 introductory article to this supplement on page 4S discusses this issue quite cogently.) Later, the value—even the necessity—of communication among solutions spawns the creation of digital bridges, or translators from one digital language to another. While these bridges allow us to connect disparate technologies, the communication is indirect, and inevitably speed and accuracy are sacrificed.
When devices can speak directly and seamlessly with each other without the need for a third-party translator, they become more powerful and much easier to use.8 That is when the cautious "non-techie" user can begin to enjoy more benefits. We are at this point in dentistry; some enormous leaps in technology are taking place.
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A LOGICAL TECHNOLOGICAL PROGRESSION FOR NEW PRACTICES
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During the past few years, my practice management business has become more and more involved with new dental office start-ups—what we call "de novo" practices. We gain a couple dozen new clients each year for their first 15 months of practice. Most of these new practices are owned by recent graduates of dental school. With these dentists, we create a technology plan with phases based on easily measured plateaus of success. We deal with each dentist individually, recognizing his or her personality and interest in technology. Some are satisfied with minimal technology, and some will choose to make investments ahead of schedule, realizing that to do so may reduce their personal income. Some people like to play golf three times a week at a great club, and others prefer to read manuals and tinker with electronic devices. Neither group is right. They simply are different.
Practice management software.
First, every dental practice, including a de novo practice, must have good practice management software. Costs are quite competitive—and, frankly, are irrelevant. No office should try to operate with a manual system today. This software is like the heart and major arteries of the circulatory system, and it is impossible for a dental office to treat patients efficiently without it. Each software vendor emphasizes its products’ strengths and downplays the products’ weaknesses. Certainly, we make recommendations on the basis of our experience (for instance, Dentrix software [Dentrix Dental Systems, American Fork, Utah] produces the daily reports that allow us to make tactical decisions), but often the quality of local support is the most important deciding factor among the top three or four software packages. The one requirement is that whatever software is purchased must be capable of seamless integration with all the other technologies that the practice will be using as it grows and matures.
New practices need to be able to build a database for patients for scheduling and billing purposes. Also, tracking referrals is very important. Any growing practice must set goals and monitor progress toward achieving them. Hygiene drives any general practice; that requires a software system that allows the implementation of an effective recare protocol and of patient tracking. This does not mean that all patients will require prophylactic treatment twice a year, but the practice must have records of each patient’s preventive status at all times. Looming on our horizon are lawsuits by people who consider themselves patients but who refuse preventive procedures without acknowledging their personal responsibility.
Accounting software.
From its first day of operation, every practice needs accounting software to keep track of loans, credit card use and bank accounts, as well as to monitor overhead by categories and to control purchases. The doctor can handle this task, but a dentist’s per-hour earning potential is much higher than that of a bookkeeper. Typically, an accountant’s main objective is to organize the books in a way to facilitate the filing of taxes and to respond, if necessary, to Internal Revenue Service audits. This is not an optimal structure for managing an operating business. Tax returns are historic documents, while dentists need current status information to manage their practices properly. Generally, accountants should be used for filing taxes only, especially if there is someone else available to handle the day-to-day bookkeeping. Employees can be assigned to this task, but that has some inherent difficulties (such as undermining both the employer-employee relationship and appropriate financial checks and balances). No employee ever should be involved with payroll unless he or she is trusted and discreet enough to be designated as the office manager.
Digital radiography.
Should new practices begin with digital radiography? More than half of our clients do because they know it is inevitable, and the capabilities are improving enough in this technology that it is possible. Cost issues keep more frugal dentists from making the initial decision to invest in digital equipment, and they may decide to take advantage of the market’s good deals on used radiographic equipment instead. The initial investment in digital radiographic equipment is a good deal larger than that in conventional radiographic equipment and such equipment involves ancillary issues of associated costs—for instance, the need for more expensive and usually larger computer monitors owing to resolution requirements. Digital radiography is improving in user-friendliness, but it still is less comfortable for the technologically averse. While retraining issues can be rather significant for existing practices switching to digital radiography, staff in new practices can be trained in it from the beginning. The quick answer to whether a practice should begin using digital radiography is "Yes," but with provisos.
Diagnostic tools.
It is a good idea to invest in intraoral cameras and other diagnostic aids as quickly as economically feasible. There are many ways in which practices can attract new patients; that has never been an issue in my firm’s experience, assuming certain critical steps are taken. However, maximizing the potential of new patients is another issue. Often, patients’ acceptance of treatment is too low in dentistry today, owing to factors such as the individual dentist’s comfort level, experience and even age. The tools mentioned earlier in this article—digital radiography, digital imaging, digital diagnostic devices and intraoral cameras—are helpful to even the accomplished presenter of treatment plans who has 30 years’ experience. For the less accomplished clinician, these tools can more than double patients’ treatment acceptance. Depending upon the practice’s experience with treatment acceptance, appropriate use of these tools can increase production as much as 10 percent almost immediately.
CAD/CAM restorative systems.
As noted earlier, there are examples of tremendous success with CAD/CAM chairside restorative systems. About 18 percent of my firm’s clients are using these systems, and those who have devoted time and attention to perfecting the use of this technology are delighted with the results. They especially like the immediacy and improved service to the patient, reduced number of appointments per patient and direct cost savings.9 This form of technology has a great future in dentistry. Each new generation of CAD/CAM systems is easier to use and faster than the previous generation. However, many dentists have invested only their money in this technology, which is not a sufficient commitment to yield success. It is like buying a membership in a health club to get in physical shape and then never actually going to the club. Too many of these systems are collecting dust and increasing overhead, needlessly.
Other technologies.
Other forms of technology that have proved their worth after analysis are inventory control, voice-recognition progress charting, privacy-ensuring systems and, especially, patient educational systems. Web sites are becoming an essential marketing tool for all dental practices, and the capabilities to make and receive payments, accept appointment time requests, communicate with suppliers and laboratories online are increasing in importance.
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ESTABLISHING TECHNOLOGY PLANS FOR EXISTING PRACTICES
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Establishing a technology plan and budget for an existing practice is a little more difficult than it is for a de novo practice. First, there must be a thorough understanding of the personality and interests of the dentist. We find it essential to gauge his or her computer literacy. Then, we assess the technological investments the practice already has made and how much they are used in the practice. Our company estimates that dental practices use less than 20 percent of the capabilities they have purchased. The unfortunate situation we frequently encounter, however, is that they have reached their technology budget limit. The only solution in this case is to help the practice begin to better use what it has and to improve internal procedures, protocols, training and mind-sets enough that production can increase, thereby automatically increasing the percentage allocated for technology. In cases in which the extant technology simply is inadequate to support the required growth, there is no choice but to exceed the budgetary allocation. This comes from the dentist’s portion of the practice’s income, however, and that may require changes in long-term financing, consolidation or other financial considerations.
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HOW PRODUCTIVE IS THE PRACTICE ALREADY?
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From a business point of view, a dental office can be compared to a factory. A factory is built with full knowledge of its daily output potential based upon investments in facilities, staff and equipment. Likewise, every dental office has an optimal production potential, based on the dentist’s investments in these same areas. This potential can be measured on the basis of a few variables.10 The dentist already knows, based on his or her bank account, if he or she is producing at an abnormally low percentage of his or her potential. However, more precise measurement can be useful when considering investments in staff, facilities or technology.
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CONCLUSIONS
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Can technology help improve office efficiency? The answer is resoundingly affirmative. Can technology reduce staff costs? It is my opinion that nothing available today that retains the requisite level of patient care will reduce staff costs, but the proper application of technology can make everyone much more productive and can improve patient care. There are few instances in dental offices of excessive overhead. There are, however, numerous instances in dental offices of underproduction based on overhead costs. This is the area in which technology best benefits dentists, their staffs and their patients.
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FOOTNOTES
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Dr. Anderson is a co-owner, Professionally Managed Practices, 14805 Farnham Way, Tampa, Fla. 33624, e-mail "wisdom{at}tampabay.rr.com". Address reprint requests to Dr. Anderson.
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REFERENCES
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- Brooks D. Why the U.S. will always be rich. New York Times Magazine; June 9, 2002:88–91.
- Standard of living in the United States. Wikipedia (online encyclopedia). Available at: "en.wikipedia.org/wiki/United_States/Standard_Of_Living". Accessed July 14, 2004.
- Gorman L. Technology and productivity growth. NBER [National Bureau of Economic Research] Digest Oct. 2001. Available at: "www.nber.org/digest/oct01/w8359.html". Accessed June 28, 2004.
- Freitas RA Jr. Nanodentistry. JADA 2000;131(11):1559–65.
- Levato CM. How to profit from computers: intangible benefits of climbing new peaks. Dent Econ 1998;88(8):96–104.[Medline]
- Uglem SK, Anderson LH. The practice management cookbook. Tampa, Fla.: Professionally Managed Practices; 2004.
- Schleyer T. Why integration is key for dental office technology. JADA 2004;135(9 supplement):4S–9S.
- Denning PJ. The invisible future: The seamless integration of technology into everyday life. New York: McGraw-Hill; 2002.
- Boyd L. Dentist manufactures crowns while you wait. Asheville Citizen-Times; June 1, 2003. Available at: "cgi.citizen-times.com/cgi-bin/story/wncbusiness/35981". Accessed July 14, 2004.
- Professionally Managed Practices. Free practice production potential analysis form. Available at: "wisedentist.com/evaluationform.htm". Accessed June 10, 2004.
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ABSTRACT
IS THIS ROBODENTISTRY?
