The Paperless Office

Practicing dentists keep reading and hearing about the “paperless office” or the “totally digital office. Are software and technology vendors pushing this in order to increase their bottom line, or is there really something to it? Is it the future of dentistry or just hype? Why would you ever want to make this transition? What does this look like and how does it work? Would digital charts require more or less staff and doctor time than traditional paper charts? This article takes a look at what the paperless office is, how it works, its potential benefits, and its pitfalls.

THE FRONT DESK AND HYGIENE DEPARTMENT

Have you ever wasted valuable time by searching for a patient chart? How often have you looked in a patient's chart to find an x-ray, and it was no longer there? Maybe it was sent to an insurance company or it had fallen out of the chart. Do patients ask questions about other family members while they are in the treatment room, requiring someone to take valuable treatment time to go to the front, pull the chart, and look up the requested information?

The most obvious place to see the advantages of going digital is at the front desk. If transactions are still posted using the archaic pegboard system, surely it is time to post charges and payments on a computer. Quicker entry and retrieval of this information are only 2 advantages. Another major advantage of computerizing the front desk area is the simplification of preparing insurance forms. After entering patient and insurance information, these forms are printed error-free with the touch of a button. This frees up time for the front desk personnel to accomplish other productive tasks.

One of the major fears in beginning a journey to a paperless office is the general fear of computers—more specifically, fearing the possibility that information may get lost. Most computers and dental software, including backup systems, are extremely user-friendly. Of course, consideration should be given to the use of a backup system, as one is essential for an office's survival.

By now the majority of dental practices have computers in place at the front desk. An added incentive is that all of the insurance forms can easily and quickly be submitted electronically using a direct dial-up modem or via the Internet. A hidden benefit often overlooked is that because of savings in time, the necessity of adding more front desk help is avoided or delayed as the practice grows. Some insurance companies are even beginning to insist that all claims be submitted electronically. Therefore, if an office is not set up to do this, it will have to pay someone else to do this for the office.

The next step to consider is adding or using electronic scheduling. This allows scheduling from any computer in the office, allowing more than one person to schedule at a time. It also eliminates fighting over the paper book to make and/or check appointments. Computers in other areas of the office, such as in the treatment rooms or sterilization area, permit all staff to make an appointment from anywhere in the office. This also frees up more front desk time. The electronic scheduling is a safer means, because unlike the traditional schedule book, it cannot be misplaced.

Using a computer in the hygiene operatory, the hygienist can reschedule from the treatment room. This allows for customized and personalized treatment because the hygienist knows if the patient is difficult or easy, and whether or not radiographs and/or fluoride treatments will be needed at the next visit. This again frees up more front desk time and delays adding more front desk hours as the practice grows.

In addition, hygienists can use a voice-activated periodontal charting program if a computer is in the treatment room. The benefits of a voice-activated charting program are numerous. Time is saved through not having to put down the probe and mirror in order to record information. The greater infection control issue is obvious. The charting is very visual, and it is easy to compare one visit with the next to see if the periodontal conditions are improving or deteriorating. The greatest benefit, however, is that patients want to know what the numbers mean. Visually, they can see their chart, with a green area for healthy and red for disease, and view their progress over visits. Hearing the computer observe, "bleeding...bleeding...bleeding..." alerts patients to take their disease process more seriously.

As the office progresses to becoming paperless, several wonderful things occur. First, there is more cross-training between the front and back positions. This leads to a better understanding of the other staff members' duties and stresses, ultimately better serving the patients. Going through the digital transformation process also identifies flaws in the presently used systems, forcing the doctor to examine his or her organization to upgrade, organize, and refine the business systems.

There is a slow transference of front desk duties to the back, which results in more time for the front desk staff to complete other tasks. This shift also requires staff to be trained in the new systems and to do more cross-training. For example, when the staff starts scheduling in the treatment room, the scheduling guidelines must be clearly defined, learned, and used by everyone in the office. The patients' perception of a technologically up-to-date office is enhanced, because they know the office keeps up with the latest changes in dentistry. It is a "wow factor" for patients, who may observe, "My former dentist never did any thing like this before. This is the most thorough examination I have ever had. It is really neat, and I appreciate it. Thanks, Doc."

DIGITAL RADIOGRAPHY

Once computers are placed in treatment rooms, there is a learning curve to use digital radiography effectively, especially in learning to place the sensors so they are comfortable for the patient. Start with the easy ones and run both systems until the staff is comfortable with the digital system. Once this is the case, shut down the darkroom. As long as the traditional paper charts are in use, it is okay to run a dual system; traditional files can still be filed.

The benefits of digital radiography are many, including providing better and safer treatment for the patient. The amount of radiation the patient receives is greatly reduced; exposure will be decreased by 5 to 10 times for the digital image. Additionally, the patient can view the image on the computer screen. When he sees an x-ray on a 17-inch computer monitor, he sees bone level, tartar, impacted teeth, and dark areas or cavities. This major step takes the mystery out of dentistry for the patient, builds trust, and ultimately boosts treatment acceptance.

The cost savings are many—first, no more film, chemicals, or film mounts to buy, store, or inventory. The biggest cost savings come from the images appearing instantaneously, saving an incredible amount of staff and doctor time. The need to retake films incorrectly placed or "eaten" by the film processor disappears. There will no longer be wasted time while the dentist waits for radiographs of different steps during an endodontic procedure or implant procedure. Ditto for time spent waiting for radiographs of the emergency patient with the pain-ful or broken tooth. The total of these wasted hours multiplied by the hourly overhead more than pays for the investment in digital equipment over the course of a year. Time is money.

Digital x-rays are legal and actually preferred in court. A backup of data, including x-rays, from each year should be stored in an external safety deposit box. Many software companies have incorporated audit trails in their programs to identify any tampering or manipulation of the digital image. As further protection, x-rays can never be lost or misplaced, and no staff time will be spent looking for misfiled x-rays. They can be easily attached to insurance forms using an electronic claim submission, which also saves the front desk time. If the digital radiography device is integrated with the office's computer software, after the image is taken it can be immediately viewed from that patient's file from anywhere in the office. A copy can be sent to a specialist along with a referral letter. Digital radiographs can be quickly sent via e-mail to colleagues anywhere in the world. Once the recipient receives it, he can view it, save it to a file, or print it on photo paper with a quality color printer.

 The diagnostic quality of the digital image is at least equal to or surpasses the best conventional film image. This is the way dental radiography is going.

Digital radiography is environmentally friendly. There are no processing chemicals, processor cleaning chemicals, or noxious fumes in the office, and no more concerns about recycling, legally disposing, or flushing chemicals down the drain.

CLINICAL CHARTING

The last step our office took toward "going paperless" was in 2002 with the implementation of the total Softdent Clinical Charting system. This is being what is known as a paperless office, although this is really a misnomer. What it really means is that we do not have a physical chart for the patients. We cannot pick it up, open it, or carry it around-or lose it. This was the step that initially seemed to take the greatest leap of faith, because everything is in the patient chart: all of your treatment records, health histories, personal comment sheets, photographs, etc. A digital system is safe, and it works.

A digital clinical chart is everything presently in a paper chart, but it is in digital format on the computer. It ties everything together in one place. All of the personal, financial, and insurance information; health and dental histories; and all clinical treatment and recommendations, treatment plans, prescriptions, correspondence from other specialists, digital photographs, digital x-rays, and imaging are in the digital record. The doctor or any staff person can access any patient record from wherever he or she is in the office. With external hard drive backups, the doctor can take home digital charts to access all of this information.

Having everything in one digital chart as opposed to the traditional paper chart has several advantages. One chart takes no physical space-no more filing shelves or cabinets. All information in a paper chart has a corresponding place in the digital chart. The digital chart cannot be displaced, lost, or destroyed; nothing in it can get lost. Digital charts are backed up daily and retained off site for further protection. If a patient asks about another family member, any staff person can easily retrieve the information on the nearest computer, which is located in every treatment room, the consultation room, and the front desk area. Anyone can answer questions about any patient without getting out of his or her seat to locate a file somewhere in the office.

Entering clinical information is a necessary part of every visit, just as in using traditional paper charts. Major benefits of updating electronically are that the record is always legible and automatically time and date stamped. Each procedure code allows for generic notes that can be used, added to, or changed. There are separate codes for each type of anesthetic used in the office. When the appointment is posted, the quantity of anesthetic used is posted, and everything else shows up automatically. Each major clinical charting program has its own version of clinical notes.

Digital intraoral cameras belong in each treatment room. If the same type is purchased throughout the office, the staff will only be required to learn to use this type. This also allows for greater consistency of the photos from one room to the next. Digital photos become a part of the digital clinical record. The patient sees what we see in his mouth, but larger than life. We can discuss treatment recommendations with patients while they view their record. If a patient postpones treatment, a new photo at the next visit can demonstrate deterioration over time-this motivates the patient to proceed with treatment.

Digital photos can be attached to electronic claims when requested by insurance companies, saving time spent writing narratives for cracked teeth, inlays, onlays, scaling and root planing, and crown lengthening procedures. When the insurance companies "lose"these or the whole claim, it is very easy to resubmit using the appropriate digital radiographs and photographs. This makes it a lot easier for the dental consultant to have enough information to approve the claim as submitted.

The ease in handling correspondence from other dentists is another consideration. Documents can be scanned into the patient's file quickly in the office. With time, more of this correspondence will be done by e-mail, which is even quicker and easier to incorporate into digital charts. Phone consultations are also entered into the patient's clinical notes on the computer while the phone call is in progress. No more forgetting to enter it in the patient file later or trying to remember and reconstruct the conversation and decisions at a later date.

Prescription writing and tracking is a valuable tool for both patient safety and legal considerations. All prescriptions are printed and given to the patient or faxed or e-mailed to the pharmacy. No more time is spent calling pharmacies to leave messages. The prescriptions are always legible, which will prevent misreading of the prescription by the pharmacist. When each prescription is printed, it is recorded in the patient chart and becomes part of the prescription history for any patient.

DIGITAL PHOTOGRAPHY

Another advantage of having all of the treatment plan and clinical photographs in a digital format is that it allows several options in presenting treatment plans to the patient or following up later on uncompleted treatment. In our case, Softdent has a Powercase module that enables a dentist to import the patient's photos into a Microsoft PowerPoint template for quick, easy presentation. It is also possible to copy any of these photos and treatment plan items to a Microsoft Word document and send it to the patient either via e-mail or snail mail.

A quality extraoral digital camera is also needed in a digital office. Several good options are now available for taking professional-looking, extraoral photos. Using either a card reader or fire wire attached directly to the computer, the images can be imported directly into the patient's digital file. These digital extraoral photos, combined with the digital records, open the possibility to incorporate digital imaging into the system, which will also integrate seamlessly into the patient's digital file. Dicom Imaging is under the Practice-Works umbrella and is also owned by the Kodak Company. The staff and the patients really love this addition. At the beginning of an appointment, the hygienist or assistant assigned to that patient takes a few digital extraoral photos of the patient. While the appointment is progressing, the treatment coordinator imports the images into the patient's file. At the conclusion of the appointment, the patient can see how he would look with whiter teeth. The staff member pulls up a smile photo of the patient on the computer monitor and lightens the patient's teeth incrementally by sliding a bar with the mouse. The patient sees his image with teeth a little whiter or very much whiter. This picture is easily worth ten thousand words. If the patient has expressed an interest in additional changes in his smile, this can also be accomplished easily with this system.

THE PAPERLESS OPERATORY

What do a paperless office's operatories look like? Our operatories are a pretty standard type of design with 2 open entrances into each room and a power wall in between that holds the x-ray machine and all of the umbilical cords for the rear delivery cart. The patient faces an outside window with his head to the entrance. An 18-inch counter runs the length of the room on each side with closed cabinets below and a sink. On the corner on the left side is a 17-inch computer monitor for patient viewing. The computer box is under a counter. This monitor displays the x-rays and photographs to the patient. Behind the patient on the power wall is a second monitor for staff viewing only. This helps with the HIPPA issues, because no one else can see it. This is where we do all of the patient charting, health histories, treatment planning, and scheduling. Hygienists or assistants can use a wireless keyboard and mouse conveniently for total versatility in each room. Mounted on the wall in the right corner facing the patient is a traditional television screen to play the muted CAESY (Patterson Dental) education system in a continuous loop.

The flow of the digital system allows more treatment to be done in less time. When I enter the operatory to do operative work, the assistant has the appropriate radiograph displayed on the patient monitor directly in my line of sight over the patient's head. The treatment plan chart-visual, in red-is on the monitor behind the patient, also in my view when I sit down and greet the patient. It is very easy to see the intended treatment for the day and to double-check it with the appropriate x-ray and in the mouth. Things are visual for the staff members and the doctor, minimizing mistakes.

Hygiene checks are equally easy. The hygienist will have the appropriate x-rays on the screen where the doctor can quickly review them. Any suspicious areas or areas of concern for the patient will have intraoral photos taken for a quick review. After the patient is greeted, the hygienist tells the doctor the following 4 things: patient concerns, concerns discovered by the hygienist, recare prescription time, and any treatment previously recommended but not yet completed. These recare exams are thorough, quick, and easy.

A CAESY server can easily be added to operatories that are networked. When a patient has a question about a procedure, the staff member can quickly pull up the appropriate module and play a 2- to 3-minute, clearly presented information session for the patient. These tutorials save thousands of words a day. In the reception room, a 42-inch plasma TV plays the Smile Channel (CAESY education system) with subtitles. When the patients see what is possible, they ask a lot of questions, opening opportunities to improve their smile and their well-being.

Many dental professionals assume our patients know more about their oral health than they really do, or even worse, assume they understand the dental vernacular. One of our primary goals as professionals is to teach our patients and make them aware of their oral conditions. By having visuals for patients to see, especially when they are of conditions in their own mouths, their understanding level increases significantly. This technology is great and saves time and money; however, the real significance is the benefit to the patient. When people see, they understand. When they understand, they make better choices. When they make better choices, they have better oral health. Being high tech does not take away the necessity to be high touch. Continuously improving our listening and verbal skills must accompany this journey of going digital.



Dr. Dykstra started his solo dental practice in 1978 in Hudsonville, a small town in western Michigan. His original office was expanded 3 times, and in 1994 he built his dream office with just more than 3,800 square feet of working room. Dr. Dykstra’s practice is in the top 1% or 2% of production and collection of solo practices in the United States, and his overhead is consistently in the low to mid 50% range. He went paperless in the fall of 2002, and has successfully incorporated total electronic records with digital clinical charting, digital radiography, digital intraoral and extraoral photography, and digital imaging. He added a laser to his practice in 2003. In addition to working full time in his practice, he does limited speaking and consulting work through Anchor Dental Consulting, which he founded to help dentists successfully integrate technology into the dental office. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Dykstra conducts in-office presentations of Kodak technology and receives product benefits from that company.



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