by Ekram Khan
Operatory computing includes two basic functions: clinical charting and imaging. Both functions are enabled by a mix of hardware and software that can be integrated into a seamless system for data acquisition and dissemination. The core of this integrated system is the clinical module of most practice-management software systems. The clinical-charting software allows you to create the foundation of the electronic patient record. It is composed of hard and soft tissue charting, as well as visual treatment planning.
You can extend this foundation by adding digital-imaging devices and software. Typically, intraoral cameras and digital X-ray systems are mated to imaging software. This imaging software is then "bridged" to the clinical module of the practice-management software to achieve functional integration. As you can see, this daunting process introduces several pieces of hardware and software into an already crowded operatory. Therefore, the "big picture" question is: "How do I introduce operatory computing into my practice without disrupting my clinical workflow and sacrificing valuable operatory work space?" The answer is to choose efficiently designed hardware deployed in an ergonomic installation.
Let's begin by examining digital devices for the operatory. The most common imaging device in the operatory that can be directly integrated with a computer is the intraoral camera. With respect to integration, this is the easiest device to work with. Almost all intraoral cameras have an S-video output. Wiring the operatory with S-video cabling within the walls is relatively easy. A computer with a video-capture card can then capture images into charting or imaging software.One consideration should not be overlooked. With the introduction of the Windows 2000 operating system, some video-capture cards have drivers that are not compatible with video-capture functions in certain practice-management software. Consult your software vendor for specifications regarding video capture within Windows 2000 operating systems. If you use Windows 98 on your operatory computers, this driver incompatibility issue will not affect you.
Digital still cameras are equally simple to integrate with imaging software, but the physical interface with computer hardware is indirect and often involves several steps to transfer the images from the camera memory to the computer. You should consider purchasing readers for the memory chips in digital still cameras that have USB (Universal Serial Bus) interfaces. These readers are the easiest to use and are commonly available at local computer stores.
While color imaging is achieved using intraoral cameras and digital still cameras, digital X-ray systems are growing in popularity. Integration of digital X-ray systems is not as simple as the integration of cameras. Digital X-ray systems don't have a common physical interface to computer hardware, making its integration more complex. Recently, some of the major manufacturers began providing sensors with USB connections to computers. So far, Schick, and Trophy have sensors with USB interfaces. Dexis provides a sensor with a PC Card (PCMCIA) interface which can be integrated using available PC Card readers. An interesting option is the Denoptix system from Gendex. The system uses phosphor plates instead of film. After exposure, a specialized scanner reads the plates. The scanner interfaces directly to a computer via a standard internal SCSI card. The computer is then connected to the computer network, which makes all of the images available to all of the workstations. This system does not provide the benefits of instantaneous availability of X-ray images that hard sensors provide, but it does provide a viable option when speed is not a concern.
Look for interoperability
When considering a digital X-ray system, I encourage you to avoid systems with proprietary interface cards and software that can't be bridged easily to your practice-management software. I often have wondered why digital X-ray systems have consistently appeared on every major market survey as the number-one digital technology product being considered for purchase, and yet, after all of these years, they only have a small market penetration. I finally discovered the answer. The major manufacturers all had proprietary systems that did not adhere to concepts of interoperability and open-architecture computing. They were all guilty of manufacturing systems that were meant to be stand-alone products until others paved the way for some level of interoperability. In the meantime, their products weren't able to achieve integration with other products for digital dentistry. Although there is much yet to be done towards full interoperability, the major manufacturers — Schick, Trophy, Dexis, and Gendex — have done a good job of providing products with the ability to work with a wide range of other digital devices and software.
Despite this developing trend towards interoperability and the ADA's Standards Committee for Dental Informatics, new products continue to be introduced by manufacturers that are proprietary in nature and designed to be stand-alone devices. I was amazed by a recent new-product announcement by a startup digital X-ray system vendor. It described a sensor attached to a tablet-style computer that the dentist carries from room to room, thereby eliminating the need for an "expensive" computer network. It is obvious that this vendor thinks that the only reason a dentist would install a computer network in the office would be for a digital X-ray system. I would encourage this vendor not to be ignorant of the fact that a well-integrated computer network will be the foundation upon which the dentist can implement an array of products and software that enable digital dentistry.
With digital dentistry becoming a reality, it would be irresponsible to suggest that this vendor's tablet-based digital X-ray system is the end-all solution for operatory computing. It is this type of mindset that has, in the past, created problems for the end user when attempting to integrate products from several different manufacturers. The solution to the operatory computing dilemma is to manufacture products that can integrate with other third-party products. The ADA Standards Committee on Dental Informatics is working to ensure that the days of marketing proprietary devices will soon be over.
Software = device functionality
A discussion about devices for digital dentistry is incomplete without a discussion about the software that gives functional life to these devices. Many of the digital cameras and X-ray sensors come packaged with software that allows you to create and append to electronic patient records. These software programs often are linked to your practice-management software by a technique called "one-way bridging." This means that while you are in a particular patient's record in your charting software, you can start the third-party imaging software directly from within your charting software and automatically view that patient's clinical images without having to search for them again. Therefore, the charting module of your practice-management software serves as the integration conduit between the business aspect and the clinical aspect of your information system.
The practice-management systems that have comprehensive clinical-integration capabilities are: PracticeWorks, Dentrix, Softdent, and Discus Dental Software. The trends supporting the growth of cosmetic dentistry have influenced the cosmetic-imaging software packages to diversify and include device drivers for popular digital X-ray sensors and image-acquisition devices. As the industry moves towards higher levels of interoperability, we will begin to see the walls that separate different software packages disappear. Electronic communications standards such as DICOM and legislation like HIPPA (Health Insurance Portability and Privacy Act) will further advance the implementation of open standards in device and software development.
Hardware: the human interface
Now that we have briefly explored the general concepts involved with devices and software pertaining to operatory computing, you might be wondering how all of this can be introduced successfully into your operatories. The obvious first step is to computerize your operatories. On the surface, this seems easy enough to do: Buy a computer and a monitor at the local computer store, install all of your software and devices, connect to the network, and you are off and running! Life should be that simple! On the contrary, as opposed to administrative computing, clinical computing presents several environment-specific challenges that need to be addressed. The following problems are most common when considering operatory computers:
- Space constraints
- Ergonomic placement of displays, keyboards, and mice
- Infection-control precautions for devices placed within the point-of-care environment
- Functional compatibility of computer hardware with dental-specific digital devices
- Computers that are "hardened" for the harsh environment of the operatories
These issues typically have hindered the implementation of operatory computers, and, in turn, all of the devices and software designed for clinical computing. All of these issues can be addressed by combining a functionally relevant operatory layout and the new computing technologies available.
I have worked with several offices during their renovations and have been amazed at how meticulously the doctors evaluated the delivery units, chairs, cabinetry, and handpieces for ergonomic integrity. One of my clients told me that he pays particular attention to the design of products that can reduce the number of movements necessary to complete a particular task. Over the course of a long career, thousands of unnecessary movements can add up to repetitive stress injuries. The same level of scrutiny that goes into selecting your operatory equipment should go into selecting the computer hardware that will co-exist with it. The size, type, and placement of the computer's display is critical, because the nature of the tools for digital dentistry emphasize visual presentation of clinical images.
There is a growing trend to place flat-panel displays in the operatories. It is definitely a step in the right direction. Flat panels are smaller and lighter than standard CRT displays and can be placed more easily within comfortable viewing angles. Although flat panels solve certain ergonomic issues, some drawbacks do exist with consumer-grade flat panels. Look for the following features in a flat-panel display:
- 24-bit color depth (true color or 16.7 million colors)
- 160-degree horizontal and vertical viewing angles
- Dot pitch equal to or less than 0.27 mm (indicates that the pixels are closer together)
- Touchscreen (the ultimate in ergonomic efficiency)
- Complete sealing for surface disinfection
Most consumer-grade flat panels don't have these specifications. Instead, consider medical-grade touchscreen displays that are sealed to address infection-control issues for chair-mounting or near chairside placement. You can use a variety of commonly available mounting arms that enhance the utility of flat panels by allowing movement in multiple axes to achieve the ideal viewing angle for the intended viewer. Thus, when the staff is viewing confidential information while charting, the patient can't view the screen. When doing case presentations or showing patient-education content, however, the display can be easily moved into the patient's line of sight. Flat panels solve many of the problems associated with operatory computing, but they are not the complete solution. The process of selecting the actual computer to be placed into the operatory is riddled with pitfalls.
The all-important "box"
Operatory computers require an intense level of integration with third-party devices. I have seen compatibility issues arise from chipsets on a particular motherboard that were not compatible with some digital X-ray sensors. In that situation, an otherwise perfectly functioning computer would crash when attempting to capture images from the sensor.
Another client purchased Dell computers that had onboard video cards for each operatory. The onboard video cards would not allow installation of ATI video capture cards. We couldn't even disable the onboard card in favor of the video capture card. The doctor had to donate his new Dell computers to eager family members and purchase new operatory computers.
To avoid such compatibility issues and address the space constraints in the operatories, we provide clients with small-footprint computers that have been tested and found to be compatible with all of the major software and digital X-ray system vendors. For example, these units can be mounted on the wall or your cabinetry, and mated to sealed touchscreens, providing the ideal mix of simplified interfacing, ergonomic integrity, and broad-spectrum integration with products designed for digital dentistry.
Putting it all together
Seamless integration is the key to a successful introduction of computing technology into the operatories. Installing a flat-panel display on the chair pole without considering what will actually be driving the functionality of that display will almost guarantee problems. Integrating technologies into the operatories isn't as easy as mounting a flat-panel display and buying a computer. It takes careful planning and attention to detail.
I have walked the show floor at every major dental meeting and observed, to my dismay, several equipment and chair manufacturers bolting a flat-panel display to a chair and claiming to have solved the operatory computing dilemma. Upon closer inspection, it became apparent that some of them had the audacity to place a laptop or tower computer at the foot of the chair to drive content to the display. When asked about integration of cameras and digital X-ray systems into their sleek-looking "operatory of the future" setup, their typical answer is that the integration of devices is the responsibility of the respective product vendors. This obviously misguided attempt at crafting the "operatory of the future" perpetuates the frequent finger-pointing that occurs when components don't integrate as promised when the sale is made.
Integration is so crucial to operatory computing that a perfectly working product can be mistaken as faulty. To illustrate this example, a dentist in Montreal purchased a DEXIS system that was installed on a laptop. The system was not properly configured to work with his computer network. He had to constantly transfer images from the laptop to his server. The time it took to transfer the images (when he was successful in doing so) was so great that it negated the efficiency benefits of the system. He was so dissatisfied that he eventually returned the system. (To read the full story, go to: www.endoexperience.com/news3.htm.) The root cause of this doctor's negative experience was not the DEXIS system — it was the improper integration of the system into the network.
Dr. Anthony Vocaturo of Bayonne, N.J., was using a DEXIS system on a laptop until we successfully migrated him to operatory computers with touchscreens in every operatory. They integrated with the DEXIS sensor, intraoral cameras, dual displays, and cosmetic-imaging software. His DEXIS images are automatically saved to the server as he takes them. He has discovered the joys of seamless device integration. You can, too.
Editor's note: Look for Ekram Khan in future issues of Dental Economics, beginning with "Image Acquisitions" in January 2002 and "Clinical Health Records" in March 2002.
Computers in the operatory can accomplish the following tasks:
- Run clinical-charting software
- Run cosmetic-imaging software
- Capture images from cameras
- Provide patient education multimedia content
- Integrate data acquisition devices such as periodontal probes, etc.
The key points to remember when computerizing your operatories are:
Integration — Have the sales representatives of any digital device or software provide demo copies that you can have your chosen systems integrator set up for an in-office trial. It is the only way to verify claims made during the sales pitch. Or, chose an independent systems integrator who will vouch for the product and provide post-installation support.
Ergonomics — Careful consideration of viewing angles, reach height and distance, mounting heights, and display placement all significantly contribute to long-term satisfaction and reduced total cost of ownership for your technology investment.
Support — You need to be confident that when something malfunctions, there won't be any finger-pointing. Therefore, choose your integrators carefully.