by Ekram Khan
It amazes me that all of the computer-based technology available to dentists actually works. The interplay between hardware, operating system, and office software is so riddled with potential points of failure that it seems, at times, your odds at a Vegas slot machine are better than the odds of your information systems running smoothly. With practices "going digital" in greater numbers, entrusting a practice's records to a digital system appears to be a risky proposition with no quantifiable return on investment. However, the picture isn't as bleak as it may appear. When embarking on a project to implement office automation technology, paying careful attention to the details in the planning stages will yield a digital infrastructure (your hardware and operating-system software) that will serve as a solid foundation upon which you can build an integrated system that will perform consistently.
The hardware
Most of the unexplained errors, software freezes, and system crashes have their origin in poorly configured hardware. The vast majority of dentists use the Windows operating system computers. Regardless of what Microsoft publishes as the minimum hardware requirements for its software, I advise my clients to select the fastest processor — at least 256MB of RAM — and a good video card with at least 32MB of RAM. Most of my clients use Windows 2000 as their operating system. Those who still use Windows 98 will be upgrading to Windows 2000 soon. I have not migrated my clients to Windows XP yet, because not all dental-software vendors and device manufacturers have certified their software and drivers to be Windows XP-compatible. If you attempt to run your dental software on Windows XP and experience problems, the software vendor will not offer technical support. However, I know of a few pioneering souls who decided to take their chances and upgrade to Windows XP with some success. If you use just a practice-management software application that is not integrated with a plethora of additional imaging and digital X-ray products, test the waters with an upgrade from Windows 2000 to XP on one workstation. If the upgrade works with your software, then go ahead with a full deployment of XP on your network. Any operating-system upgrade will present you with a few problems, but the jump from Windows 98 to either Windows 2000 or XP is a dramatic one with significant compatibility implications. Windows XP, like Windows 2000, runs on the Windows NT kernel and is a true 32-bit operating system. Older versions — including Windows 95, 98, and Millennium — relied on DOS, so you can expect many compatibility problems with your older software applications. Fear not; there are things you can do to ease the pain.
If you have not yet upgraded to XP but are contemplating it, start with Microsoft's Upgrade Centers. There are two, one for XP Home and the other for XP Professional. There you will have access to the Microsoft Catalog, a listing of some XP-compatible hardware and software, as well as a link to the Upgrade Advisor, an application that examines your PC and flags any potential hardware or software conflicts. You can download the Advisor from the Internet, but it's not practical to do so if you have a dial-up connection, as it's a 50MB download. You may also obtain a free Update Advisor CD from a computer reseller.
If you have already installed XP, then you need a new approach. Start with Windows Update, the Microsoft service that examines your PC for any out-of-date components and then recommends OS updates and patches. Several updates or patches may be recommended, but each has brief descriptions of what it will do and how to remove it if it causes compatibility or start-up problems. Make a note of the uninstall instructions; you may need them!
Although Windows Update may suggest driver updates for your hardware, be cautious about accepting these recommendations. I have seen Windows recommend old drivers, and, worse, unnecessary changes to drivers that worked just fine. Instead of downloading driver updates randomly, ask your technology consultant or systems integrator to visit the Web sites of the manufacturers of your PC and its internal components (particularly the video card) to see if any XP updates are available. Do the same for external hardware, such as printers, scanners, digital X-ray sensors/cameras, mice, and the like. Some hardware may never work properly under XP. I have heard stories from several colleagues who had to give up their old printers and scanners.
If you have the itch to use XP and are determined to install it, try to use the Windows 2000 drivers for any hardware that is incompatible with XP. Windows 2000 is a close cousin to XP, so a 2000 driver may do the trick. I believe that the current crop of leading dental software and imaging products will be certified for Windows XP within the next year; it is inevitable. Until then, stick with the battle-proven Windows 2000 operating system.
The software
Incompatible software presents an even bigger problem. Unlike an incompatible piece of hardware that can be easily replaced, software incompatibilities are more difficult to diagnose and resolve. Some applications — particularly antivirus and system-maintenance suites made for earlier Windows editions, such as Norton SystemWorks — simply won't work with XP. You must upgrade. Naturally, you'll want to check with the software manufacturer for updates to make that old application hum in XP. But if you can't find an update and must use the old application, try the following tricks.
If you're having trouble with a specific application, the Windows XP Program Compatibility Wizard, which is part of XP's Help and Support Center, can help. After the wizard scans your system, select the problematic program from the list, then choose an OS compatibility mode, a setting that emulates a prior version of Windows. If you don't know which version of Windows the software requires, try Windows 98/Me first. If that doesn't solve the problem, try the Windows 95 mode. To skip the wizard for a particular piece of incompatible software, right-click on the program's executable file from Windows Explorer, then choose Properties. Click the Compatibility tab, check the "Run this program in compatibility mode for:" box, and choose the OS from the drop-down menu. You also can adjust the Display Settings options, because some old programs want to work in the 256-color mode. To finish, click OK.
Keeping things simple is best. The digital infrastructure for your office should be for hard-core business use, rather than as an extension of a home computer. I have seen offices that have every type of screen saver ever produced running on their systems. Screen savers were necessary in the old days of CRT monitors prone to image burn-in, but they are entirely unnecessary with modern display systems. I recently received a call from a client who was suddenly getting data-access errors within his practice-management program. He reported that when it did run, it was extremely slow. After a little investigation, I found that one of his staff had installed a "cool" new animated, 3D screen saver on the server. This screen saver was using most of the processor and memory resources on the server, slowing down the speed with which it could process data queries. To avoid compatibility problems, your office network should be devoid of games, screen savers, and all software that is not directly related to running your practice. This may mean that activities like instant-messaging your AOL buddies or watching the latest Britney Spears video may have to be relegated to the home network environment — a small price to pay for having an efficient office network.
How it's done
You probably have one of these questions:
- How do I choose compatible items from all of the dental software and devices available today?
- Will I ever get a return on my investment?
In answer to the first question, I strongly believe that "the proof is in the pudding." There is no substitute for experience. We at Cieos have been in the dental-technology-integration trenches for several years and have settled on a select group of products with which we prefer to work. My client base consists of practices that have the following technology profile:
- Practice-management software — PracticeWorks, Dentrix, Dentrix Enterprise (DXOne), Softdent, DentalVision, EndoVision, PerioVision, Computer Age Dentist, or MOGO
- Digital X-ray system — Schick, Trophy, DEXIS, Denoptix, or ScanX (Air Techniques)
- Digital-imaging system — ImageFX, DICOM, or Vipersoft
- Patient-education system — CAESY DVD or CAESY Enterprise (On The Edge Server)
You can feel confident that choosing a product from this list will be a safe bet from the integration perspective. They all use a technology called "bridging" that makes it possible for each product to work with the others. There are two types of software bridges: one-way and two-way.
A one-way bridge allows you to open digital X-ray software from within your practice-management software's charting component, take an X-ray, and then look up those X-rays using the patient ID number assigned by your practice-management software. In this scenario, the X-ray images will remain in the digital X-ray software database, but those images can be referenced from within your charting software and viewed in your digital X-ray system's native software.
A two-way bridge takes this one step further by making those images appear in your charting software, rather than viewing them in the native digital X-ray software.
To illustrate, I recently had the privilege of working with Dr. Mark Sweeney at the Austin Dental Spa of Austin, Texas. His practice has been computerized since Day One. He was one of the first dentists in Texas to install the Schick digital X-ray system. His dilemma was that he had two networks running in the office — a UNIX network running his practice-management software and a Windows network running Schick, CAESY (DVD), and intraoral cameras. He wanted to consolidate into one network and convert from a UNIX practice-management software to PracticeWorks.
We installed a high-capacity, fault-tolerant server running Windows 2000; slim-profile, flat-panel, touchscreen computers in every operatory; new administrative workstations; and CAESY Enterprise (On The Edge Server). Dr. Sweeney uses PracticeWorks for management, Schick for digital X-rays, DICOM for cosmetic imaging, and a networked version of CAESY for patient education. All of this was standardized on the Windows 2000 operating system. Dr. Sweeney wanted the ability to have a patient's record open in PracticeWorks charting, take an X-ray series with his Schick system, and then see those images as thumbnails in PracticeWorks charting. Fortunately, Schick and PracticeWorks have a two-way bridge. Dr. Sweeney can spend less time using his digital dental tools and more time communicating with his patients. Because the operatory computers have a dual-display system, he can work with all of his software on the touchscreen flat panel mounted in the six o'clock position, while the patient views educational video clips from CAESY on the flat-panel display mounted at the 12 o'clock position. His objective was not only to introduce new technologies into the practice, but also to implement them without impeding his workflow. Dr. Sweeney was successful because he carefully selected from what was available and mated those digital tools to his workflow.
To prevent software-compatibility issues from degrading the performance of his computer network, Dr. Sweeney maintains a strict policy forbidding the installation of any software that is not relevant to running the practice. A tightly integrated computer network can provide greater workflow efficiency, better patient communication and case presentations, increased productivity, and a less-stressful work environment.
That brings us to the second question about return on investment. If your office becomes more efficient, more successful at presenting cosmetic cases, and more productive with fewer staff through the use of technology, you should realize a return on investment (ROI) in a fairly short period of time.
I recently had a conversation with David Taylor of Schick Technologies and asked him about returns from an investment in Schick products. He mentioned several ways that a return on investment can be easily quantified:
•Efficiency — Labor is the single largest line item in a practice. It takes approximately 45 minutes to complete a full-mouth series, including prep, exposure, and processing/mounting. If you use a direct digital system, the same job takes about 15 minutes. The 30 minutes saved by the assistant at an hourly rate of $20 translates into $10 of additional profit on each FMX.
•Practice marketing — The reduction in radiation exposure is an extremely marketable benefit that will attract new patients.
•Case acceptance — Communicating clinical information to patients is better done visually. Anyone who has ever used an intraoral camera will appreciate how involved patients become when they can see and understand their dental-related problems. Digital radiographs display 15 inches across with contrast and detail enhancements. Digital radiography is a great tool for building case acceptance with your patients. Even if you don't like to "sell" your proposed treatment, you will enjoy the reactions you get when patients see the same problems you see and ask, "What is that?" and "How soon can I get it fixed?"
I thank David Taylor for contributing the ROI information for digital X-rays. It should be noted that while EagleSoft is not in the list of practice-management software that I have used, it has a very tight integration with the Schick sensors. With EagleSoft as your practice-management software, you won't need to install the Schick software because the device drivers for the Schick sensors are native in EagleSoft. This is a significant factor to consider if you are planning to implement digital X-ray technology and currently have EagleSoft as your practice-management system.
Considering that a digital X-ray system is just one component in a completely digital practice, it seems that an overall return on investment is a sure thing. But the only way to realize a respectable ROI is to deploy a carefully implemented system using components that can be integrated. Otherwise, you will question your decision about investing in technology every time you have to reboot your system in the middle of a patient exam.
Choose a technology consultant or systems integrator with experience in dental technologies to guide you through the maze of products and plan your information-technology solution. You can then be sure your office won't be a victim of software-compatibility issues.
