Practice Implications. Practitioners should develop a comprehensive plan for implementing or updating the IT infrastructure in their offices. Issues to be considered in technology purchasing decisions include usability, integration, work flow support, cost-benefit analysis and compliance with standards.

Evaluating, adopting, implementing, troubleshooting and maintaining information technology, or IT, in a dental practice certainly has contributed to the level of stress. Not only is IT a relatively new and rapidly changing part of dentistry, it also is an area about which practitioners may know little. Most practitioners received no formal instruction in computing in dental school. Consequently, they are forced to make decisions about technology based on potentially biased and incomplete information from salespeople, articles touting technology, and presentations and continuing education courses of varying quality. Once a technology has been installed in the office, its benefits and drawbacks become immediately clear through daily use. As a consequence, new acquisitions that fail to live up to their expected benefits quickly lose their luster and cause dissatisfaction among their users.

Yet, technology also can provide a solution to many of the routine hassles in dental practice. Well-integrated systems, designed around the work flow of the dental team, can allow care providers to concentrate on what they do best: delivering patient care. Such systems provide information when and where it is needed, minimize indirect and duplicative data entry, capture information at the source and are easy to use. While optimal systems are far from fully realized, technology undeniably has made some progress. In 1976, only 1 percent of dentists used computers in their offices and less than 25 percent used external commercial computing services.⁴ In 1986, approximately one-fourth of all respondents in a two-state survey indicated that they did not ever expect to use a computer for accounting; while one-third each said the same for administrative, clinical and educational uses.⁵ By 2000, in a marked turnaround, 85.1 percent of all dentists in the United States used a computer in the office, and 48.3 percent of these computers were connected to the Internet.⁶ Today, in-office computers with Internet access have joined the handpiece as two essential instruments for dental practice.

Figure 1 illustrates the trends for computer ownership in dental practice, selected administrative and clinical computer uses, and Internet connectivity in the United States for the period from 1984 to 2000.^6–10 While administrative applications (such as patient registration and accounting) always have been the primary uses for computers in dental practice, clinical uses are increasing. In addition, the dental profession has been adopting use of the Internet relatively rapidly.

View larger version (49K): [in this window] [in a new window]   Figure 1. Computer ownership, Internet connectivity and selected computer uses in dental practice in the United States (1984–2000). Source: American Dental Association Survey Center.6–10

Note that the well-equipped dental office described in this article is fictitious, but that many of the illustrated products and technologies exist. At this time, they cannot be integrated into the dental office as seamlessly as we have described in this article. However, we hope that our vision will impel companies to improve the design and level of integration of their products, and will help practitioners gain a clearer understanding of what to look for when shopping for new dental technologies.

	TECHNOLOGY’S FUNCTIONS IN THE DENTAL OFFICE

TOP ABSTRACT TECHNOLOGY’S FUNCTIONS IN... THE STATE-OF-THE-ART DENTAL... GUIDING PRINCIPLES FOR... CONCLUSION REFERENCES

 
Computing applications for dental practice generally are separated into administrative and clinical categories. While most systems historically have focused on administrative functions, clinical applications are gaining importance. The Internet has opened up possibilities for functions that were unthinkable even a few years ago. For example, two-way communications between the dental office and patients, colleagues and suppliers are taking form as e-mailed appointments, case consultation and ordering.¹¹ While we describe Internet applications separately from administrative and clinical applications in this article, the Internet will become simply another communication medium in the service of either administration or clinical practice in the future.

Tables 1 and 2 list common administrative and clinical technologies, respectively, and group them into "must-have," "nice-to-have" and "optional" categories. "Must-have" applications are essential to the functioning of a dental practice (such as patient registration, practice reporting and electronic claims submission, which has become more standardized as a result of the the Health Insurance Portability and Accountability Act of 1996¹²). Applications that can add significant value, but are not required, are labeled as "nice-to-have" for reasons such as, for instance, professional development.¹³ "Optional" functions, for the most part, are either technologically immature or of interest to only a limited number of practices^14–19; some may not have been formally evaluated (decision support applications, for example²⁰), and thus their value for clinical practice may not have been established. Our goal in classifying applications as "must-have," "nice-to-have" and "optional" was not to develop a rigid prescription for every dental practice. Rather, the recommendations should be viewed as a general guideline to be adapted individually.

Because many of the Internet-based services depend on network effects, their utility will remain limited until the Internet is used as commonly as the telephone.

We consider none of the Internet applications (Table 3) as "must-have," because their usefulness tends to be limited by three factors. First, large segments of the profession and the population do not (yet) use the Internet. Because many of the Internet-based services depend on network effects,²² their utility will remain limited until the Internet is used as commonly as the telephone. Second, some of the Internet applications are not fully developed. For instance, joint patient care by several colleagues (such as physicians, dentists and dental specialists) is a highly complex and interactive activity for which appropriate tools do not yet exist. Even dentists who consult with individual colleagues through the Internet are painfully aware of the effort required in organizing and sending even a limited subset of a patient’s information electronically. Third, many people believe that data that have been sent or are accessible by the Internet are inherently insecure.²³ Computer systems protected with state-of-the-art security measures have a very low probability of being compromised.^24,25 Despite the developmental status of Internet applications, they probably have the most potential to significantly change dentistry in the coming years.

	THE STATE-OF-THE-ART DENTAL OFFICE

TOP ABSTRACT TECHNOLOGY’S FUNCTIONS IN... THE STATE-OF-THE-ART DENTAL... GUIDING PRINCIPLES FOR... CONCLUSION REFERENCES

 
Ideally, the well-equipped dental office is designed with IT as a part of the infrastructure, rather than added on as an afterthought. Figure 2 (pages 36 and 37) reflects this philosophy, showing an office built around an IT design. In Figure 2, many IT devices and applications are integrated with existing technology. For example, the foot control for the hand-pieces doubles as a capture pedal for the intraoral camera. Computer hardware is small (for example, a flat screen instead of a cathode ray–tube monitor), and computing devices that do not need to be directly accessible are hidden (for example, central processing units, or CPUs, are located in cabinets).

Figure 2 takes some artistic liberties with the configuration and layout of a standard dental office. We refrained from depicting many standard office components—such as cabinets, work surfaces and sinks—to be able to focus on technology in the scene. Also, the office is laid out to show the technologies we discuss optimally, not to set an example of good patient flow and work flow design.

The centerpiece of the well-equipped dental office shown in Figure 2 is the operatory with a variety of computing devices. A monitor for patient viewing is directly integrated into the chair, rather than mounted on the wall or ceiling, as is often the case. Located at an average reading distance from the patient, the monitor provides a much better visual experience for both patient and dentist and does not require a separate pointing device. The monitor can be used to show the patient intraoral images of his or her mouth for diagnosis and treatment purposes; to present before and after images, such as in cosmetic care; and to provide computer-based patient education in topics such as oral hygiene.

The software application that drives the patient monitor is optimized for data entry and navigation without a keyboard. The dentist and the assistant simply use a specialized mouse or trackball, or their voices, to interact with the computer. The CPU for the chair computer is integrated into the base of the dental chair. A second computer—primarily for use by the dentist, hygienist and dental assistant—is installed on a cabinet behind the chair, approximately in the 12 o’clock position. This computer has a keyboard and is used for a variety of data entry and retrieval purposes, such as treatment planning, scheduling, charting and accessing Internet resources.

An intraoral camera is one of the instruments in the delivery system, rather than a separately connected device. As soon as the dentist takes the intraoral camera from the delivery system, the patient monitor switches to a view of the captured image and activates the foot control to freeze or release the image. (Of course, these functions can be configured differently based on user preferences.)

In addition to the intraoral camera, two other types of digital imaging devices are available at chairside. Direct digital radiology sensors²⁶ in different sizes are held by mountings on the chair base. Alternatively, dentists can use storage phosphor plates²⁷ that resemble traditional film. However, those plates must be scanned separately to acquire the images with the computer. A digital camera is available for extraoral photographs.²⁸ Images are transferred to the computer either through a charger base wired to a computer or through the camera’s infrared communications port. In a separate room, a digital panoramic radiographic unit is connected to the practice management system through another computer workstation.

A computer is available in the waiting area so that patients can enter their personal registration data and their complete health and dental histories.

An optional item in the clinical area is a personal digital assistant, or PDA. This device can be used to download selected information from the practice management system and serve as a pocket-sized reference resource on drugs and other clinical topics.^29,30

The front desk, as well as the back office (not shown), also are equipped with computer workstations. A device that combines the functions of a laser printer, fax machine, scanner and copier is a space-saving and economical way to provide several disparate functions. The telephone is connected to the computer, so that phone numbers do not have to be dialed manually. The user simply highlights the phone number on the computer and lifts the handset, and the number is automatically dialed. A computer is available in the waiting area so that patients can enter their personal registration data and their complete health and dental histories, as well as review dental health information relevant to them.

The nerve center of the practice is the server room. This locked, climate-controlled and secure room contains the server, which all workstations in the practice use to store and retrieve data. Thus, current data are accessible in real time on all workstations. The server is a computer built for performance, reliability and stability. It should have one or more fast CPUs to perform user tasks without delay. Its disk storage should be a redundant array of inexpensive disks, or RAID. A RAID minimizes the probability of a debilitating disk crash. A built-in tape backup device is used nightly to back up practice data. Backup tapes are stored either in a fireproof safe or off site. Note that a keyboard and monitor are not required in the server room. The server can be administered remotely from a workstation in the back office (or any other workstation in the office, should the user choose to allow this possibility).

A digital subscriber line or cable modem provides a high-speed connection to the Internet.⁷ A router, connected to the modem, serves two functions. First, it is the hub for all network connections in the office. All computers in the office are wired with standard Ethernet cables and communicate through this hub. Second, it functions as a hardware firewall that protects the equipment and data traffic against attacks by Internet hackers. The server also is connected to a separate dial-up modem that is used for software maintenance and as a backup connection to the Internet in case the primary connection fails.

Another option for networking computers in the office is a wireless network. Encrypted wireless fidelity, or WiFi,^31,32 a new wireless networking standard, provides secure connections with a bandwidth of approximately 11 megabits per second (actual throughput depends on the quality of the radio connection). Wireless networks afford much greater flexibility in the placement and number of computer workstations. In addition, they open up possibilities for integrating wireless digital cameras, printers, PDAs and similar devices. However, they have historically had a lower bandwidth than have hard-wired connections.

The falling prices and high performance of today’s computers have made the cost of workstations a secondary consideration. In addition, the incremental price of a license for a multiuser practice management system tends to be much lower than it was even a few years ago. Therefore, dentists should consider where and when information is needed as the primary factor for how many workstations to buy and where to place them. Many times, productivity and efficiency gains exceed the purchase price of an additional workstation by several magnitudes.

Our vision of the well-equipped dental office is not a prescription that can be directly implemented "as is." The decisions on which technologies to purchase, and how to combine them, should be guided by a few general principles.

	GUIDING PRINCIPLES FOR TECHNOLOGY ACQUISITION

TOP ABSTRACT TECHNOLOGY’S FUNCTIONS IN... THE STATE-OF-THE-ART DENTAL... GUIDING PRINCIPLES FOR... CONCLUSION REFERENCES

 
Implementing the technologically well-equipped dental office is no small challenge. Rapidly evolving technology, a plethora of different products, the dearth of objective information and evaluations, and limited background knowledge about IT make this a difficult endeavor for many dentists. Focusing on a few guiding principles, however, will increase the likelihood of a successful implementation.

Many times, productivity and efficiency gains exceed the purchase price of an additional workstation by several magnitudes.

A strategic plan. Having a strategic plan is a must for any technology implementation. Regardless of whether an office has already implemented some technology or starts from scratch, a plan provides a blueprint that can guide technology decisions for several years. The planning process should result in

– a statement of expectations;

– a prioritized list of needs and goals for the office;

– an overview of the available technologies that could meet those needs;

– a comparative assessment of those technologies;

– a timeline for acquisition of each technology;

– a list of necessary resources, such as money, personnel, renovations and training needed for implementation.

The plan should be reviewed and updated periodically. A good plan is so essential that practitioners may want to consider enlisting professional assistance in its development.

Usability. Suboptimal usability of technology can be a surreptitious and insidious drain on productivity. For instance, even a few extra mouse clicks required to perform a clumsily implemented task on the computer can add up to significant productivity drain and frustration in the long term. User-centered design^33–36 leads to systems in which the user, not the imaginations of engineers, is the focus of the design process.

Usability can be assessed with a very simple test. Choose a task commonly performed with the product (such as charting a mesial-occlusal-distal restoration on a tooth or taking a single-tooth image with an intraoral camera). Count the number of actions (such as mouse clicks and focus adjustments) needed to complete the task. An excessively large number of actions, especially in comparison with that required by other similar systems, can indicate usability problems.³⁷

Integration. The plethora of technology devices requires a high degree of integration. Typically, many vendors have placed the burden of integration on the user, and that is why examples of poor integration abound. For instance, many intraoral cameras turn on automatically when the handpiece is removed from its holder. Yet, all of them currently require manual activation of the capture mode on the computer, unless the software already is in that state. In a well-integrated system, the complete system should go automatically into capture mode. The consolidation of the dental technology industry offers the hope that such a level of integration indeed will occur in the future.

Work flow support. Integration correlates closely with work flow support. The separate evolution of many different technologies—such as billing and insurance processing, charting and digital imaging—has not encouraged the development of systems focused on the work flow of administration and clinical practice. One of the few systems in dentistry designed "from the ground up" around the work flow of clinical practice is the All-in-One system from Planmeca Oy (Helsinki, Finland).^38,39 Systems that optimally support a specific work flow usually are preceded by thorough studies that analyze how clinicians work.⁴⁰ Optimal systems eliminate duplicative data entry, provide information and functionality where and when it is needed, and distribute tasks effectively among team members.

Cost-benefit analysis. A rigorous cost-benefit analysis should underpin all but the most obvious technology decisions. A commonly made mistake is focusing on purchase price exclusively. For many systems, other costs (such as maintenance and opportunity costs) exceed the purchase price by several magnitudes. Dentists, therefore, should evaluate costs and benefits in detail.

Standards. Systems considered for implementation should conform to existing and evolving standards. For instance, digital imaging devices and programs should comply with the DICOM standard published by the American College of Radiology and the National Electronics Manufacturers’ Association.²¹ Dentists also should closely monitor the work of the American National Standards Institute–accredited Standards Committee on Dental Informatics⁴¹ to stay informed about current and emerging standards.

	CONCLUSION

TOP ABSTRACT TECHNOLOGY’S FUNCTIONS IN... THE STATE-OF-THE-ART DENTAL... GUIDING PRINCIPLES FOR... CONCLUSION REFERENCES

 
We hope that this vision of a technologically well-equipped dental office will accomplish several things. First, we would like it to be a concise and general guide to the use of computer technology in readers’ practices. While this article hardly scratches the surface of computing in dentistry, the references and resources described will give readers a starting point for further exploration. Second, we wanted to provide a more user-centered, integrated view to the dental technology industry. The high degree of fragmentation of the dental IT industry has not served the profession well. Many of us struggle to make basically incompatible devices work with each other. We expect the industry to focus more attention on the design and evaluation of user- and patient-centered systems.

The type of research that underlies the creation of advanced systems for dental practice, research and education is the domain of an area of study called dental informatics.⁴² Dental informatics uses research methods from cognitive science, computer science, information science and telecommunications to develop innovative solutions to problems in dental practice. Many problems in dental practice are not trivial and straightforward, and therefore require rigorous research efforts. Without well-founded methodological approaches, computer technology will fall far short of what it could do for patients and for the profession.