The Paperless Dental Office

March 1, 2004
Going from paper record keeping to digital data management is like going from riding horses to driving automobiles. Driving requires learning new skills, greater initial investments, and scheduled maintenance expenses, but it also makes riding horses sound ridiculous.

by Parsa T. Zadeh, DDS

Going from paper record keeping to digital data management is like going from riding horses to driving automobiles. Driving requires learning new skills, greater initial investments, and scheduled maintenance expenses, but it also makes riding horses sound ridiculous. Imagine the power and advantages the first automobile owners had over the horse- and carriage-riding crowd. Using computers to keep records gives us those same advantages in speed, accuracy, and efficiency.

Computers have become an integral part of day-to-day business, setting new standards for speed and productivity. Now, many tasks may be performed at the speed of electricity. Paper has been identified as the "bottle neck" and "weak link" of business-flow systems. The sooner you make the transition, the earlier you'll enjoy a faster, safer, and more accurate business system.

Ten years ago I made an assertion that any business that operated a "PC" would be on a network of computers in seven years. Now I venture to say that any business operating a network will be paperless in less than seven years. In my practice, we had our first PC in 1988 and our network in 1993. We've been operating totally paperless since 1997 — except in the boys' and girls' rooms. We don't have file cabinets, and no part of patient records is stored on paper charts.

Minimum cost

For most modern dental offices that have computer networks with workstations in each work area, going paperless means learning to use what already is there, rather than purchasing new gadgets. Depending on when you acquired your hardware, you may need to update so hardware can handle the imaging tasks of dentistry.

The only additional expenses are for scanners and making permanent back-ups, available for less than •1,000 at Office Depot and similar stores.

Security benefits

Perhaps the most invaluable benefit of electronic data storage is its ease of replication and transport-ability.

Dental offices are vulnerable to theft, fire, vandalism, and natural disasters such as floods and earthquakes. Diligent dentists carry appropriate insurance against these losses. Buildings, furniture, and equipment can be replaced — but not patient records.

I copy all my data onto a removable drive carried in my briefcase. This way, an up-to-date replication of my patient records is always with me. The only irreplaceable component of my practice is the safest.

Economic benefits

• Labor cost savings — "Pulling and filing" patient charts takes as much as 25 percent of administrative time. Electronic storage and retrieval reduces dental office overhead more than anything else. In addition, patients will appreciate and praise your efficiency as your staff retrieves treatment histories at the click of a button.
• No "missing" chart — Frequent "misfiling," "misplacing," or "losing" charts wastes time and delays services. In extreme cases, it may result in legal challenges. Unlike paper, which may be in only one place at a time, electronic data may be accessed simultaneously from all stations.
• Space cost savings — Dental authorities recommend saving patient records indefinitely. On average, every 1,000 charts consume 24 square feet. Paying rent or a mortgage to store 20 years of records is incentive enough never to begin keeping records on paper.
• Savings on supplies, furniture, and stationery — Paper is a natural resource subject to limitations. Recently, the cost has increased many times the rate of inflation. Savings on supplies may seem small compared to savings in labor and space costs, but they can add up to hundreds of dollars a year.
• Savings on insurance premiums — If you know you won't go out of business if your office were destroyed, you may modify your insurance coverage. Don't pay for needlesss riders and coverage.

Professional benefits

• Legible and complete records — Have you been frustrated by an illegible entry in the chart? With typewritten notes, illegibility doesn't exist. We've created Macros. Typing three letters brings up a paragraph of text pertaining to procedures. Before saving it, we modify and customize the entry according to treatment specifics. For example, typing "RAC" (Red Anesthetic Corpule) will turn out "1.8 milliliters of 2 percent lidocaine hydrochloride with 1:100,000 epinephrine." We're experimenting with speech recognition software that types dictated notes directly into the record.
• Clean records — I remember when I interviewed front office candidates. One applicant was highly stressed and had quit her job because the doctor wore bloodstained gloves when handing her paper records. She said, "He wore gloves, but handed the dirty charts to my bare hands. That made me nervous." A more common scenario is when a team member with a cold passes germs to others through contact with items such as X-rays and charts. In a paperless office, team members communicate through personal keyboards and mouses. They can't infect one another with contagious diseases or get blood or coffee stains on electronic files.
• Automatic name, date, and time stamp — Customarily, we sign and date our chart notes. The time in hours and minutes adds validity to notes and helps clarify many misunderstandings.
• Accessible anywhere, inside and outside the office — How many times has one team member needed a chart while another was using it? Electronic records may be accessed simultaneously. A few months ago on a Sunday afternoon, I got a page from a woman with a common name. She insisted she was my patient from a few years back. She asked me to call in pain medications to a pharmacy. It took me a few keyboard strokes on my home computer to ascertain she was never seen by me, and when she realized I had access to my database, she hung up!
• Easy and inexpensive to reproduce — Duplicating records including X-rays and photographs is easier than ever. It takes a few seconds to print an X-ray for insurance or a patient's new dentist.
• Improved customer service — Patients' questions may be handled quickly without taking time for pulling charts.

Legal issues

Perhaps the biggest obstacle in abandoning paper records is uncertainty about relying on electronic records during legal proceedings.

Because of vast use of technology by the public, the U.S. Supreme Court has ruled electronic signatures valid on legal documents. In fact, the Los Angeles County Recorder's Office started storing records digitally in January 1999. These are the most secure documents we can retrieve indefinitely.

In addition, Congress has issued detailed guidelines for electronic commerce, eliminating questions of validity concerning digital and electronic legal documents. Altering paper documents with correction products as well as writing in pencil place document validity into question. When we keep electronic records, we have to practice that same diligence for records to remain valid. I adapted a two-stage protection plan against possible record alterations. The first stage is through the software. It doesn't allow editing of data after daily closeouts. The second stage involves a permanent copy of up-to-date data that can be referred to later.

Paperless patient management

Once this basic infrastructure is in place, you may start using your computer more. Following are some possibilities.

• Accounts receivable — The first thing you should transform into digital format is patient accounts. If you already use computers, most likely patient accounts already exist in this format.
• Appointments — Next is electronic scheduling. Appointments will be accessible to all team members from anywhere in the office. During down time, clinical assistants may visit patients chair side to schedule next appointments. During after-hour emergencies, schedulers may be accessed from home computers.
• Radiographs — The next stage is to buy a digital X-ray to make images appear directly on computer monitors as they're taken. Advantages include clarity of X-ray images and the ability to enlarge images as large as monitors. Once X-rays are exposed electronically, they are stored in the computer to be viewed by patients, discussed with other dentists, or sent to other dentists. There will be no mishandling of film in the darkroom.
• Progress notes — The most difficult transformation is converting patient records to electronic form. Initially, it could be a great obstacle, but eventually it'll be the most valuable and easiest part of going paperless. If you need to reproduce these records, they'll be legible and complete. They'll be signature stamped by whomever has entered the records, dates, and times of entries.

Another advantage is the ability to reevaluate data and make corrections if necessary. Any corrections must be made the same day, before the system closes. After the closeout, it's like ink on paper. If changes need to be made, they must be in the form of additions to the records — not deletions.

• Images — All images we create are stored in digital format by imaging software that is bridged to patient-management software. We scan letters, photos, and materials we receive on paper and film into the electronic file cabinet.

Paperless administration

Another aspect of the paperless office is administration. The following areas may be managed electronically by programs not made specifically for dentists. They cost a fraction of "dental software," and are practically flawless.

• Accounts payable — I use QuickBooks software by Intuit for accounts payable tracking, check writing, and profit-and-loss statements.
• Electronic file cabinet — We have no paper file cabinets whatsoever. Documents are stored on the server and may be accessed through our intranet or the Internet. We control each employee's access level to documents. Some files, such as payroll, are accessible only to me. Other files, such as postoperative instructions and the office and OSHA manuals, are accessible to all employees.
• Internal communication

Non-verbal light and buzzer — We use a hard-wired system to call one another and to alert the back office to patient arrivals. My experience with the wireless version of the non-verbal communicator was my most frustrating exercise with technology.
Pop-up instant-messaging system — This is a great, discrete tool for fast communication between back and front offices.
Email — Messages are saved on our server and may be accessed from any computer on our network or with access to the Internet.
External communications — There are three portals of communication from the outside world.
Physical paper is delivered by the U.S. Postal Service, Federal Express, and others.
Faxes are received and sent through RelayFax and never are printed. They are deleted, re-routed to the appropriate person, or filed in their original electronic formats. We send faxes from our office fax line, anywhere on our intranet, and the Internet.
Internet mail is not used for appointments. We inform patients that we don't process email requests for making or changing appointments. Appointments are sacred in our office. We don't make one unless we have a deposit, and we won't change one unless we have at least 48-hours notice.

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