Digital imaging - maybe!

June 1, 2000
The dental practices that have the most trouble transitioning to digital imaging are those that do not first examine their work-flow patterns.

Digital imaging - maybe!

The dental practices that have the most trouble transitioning to digital imaging are those that do not first examine their work-flow patterns.

Bruce A. Stephenson, DDS, FAGD

In many ways, I am similar to Dr. Mike Maroon. Like him, I now use direct digital radiography in my practice. However, I also have experience with another often-overlooked aspect of converting to direct digital imaging: the overall impact of transitioning a practice to digital technology. This is more than an imaging decision. In fact, treating the "film or direct digital" question as an imaging choice alone can be a mistake. After all, as Drs. Thomas Schiff and Jack Hadley pointed out earlier in this series of articles, film remains a mainstay technology from an imaging standpoint. So, if imaging is all that you are considering, no compelling reason exists to replace your conventional X-ray systems with digital imaging.

That said, converting to direct digital radiography might make sense in some practices if it is done correctly. Take a look at the big picture - and the big picture is uncharted territory for many dentists. The digital world is a very different place than the hard-copy office familiar to so many of us. So, it is no surprise to me that in going high-tech, so many dental offices end up looking like the Winchester Mystery House: overly complicated, full of illogical dead ends, and a little bit spooky!

What is the answer? Simply this: before you leap, consider your needs, resources, and readiness. Make sure that direct digital really is the right choice for you. After all, this is a business decision. The flashiest technology available will do you no good if you lose money on it - or find it so unwieldy that it ends up gathering dust in a corner of your office!

Your practice`s imaging needs

First, make sure the technology is a fit for your practice.

For example, how important are children to your business? Consider a point already raised in this series: that the sensors used by direct-digital systems are bulkier than film. In some cases, these sensors are connected to the system by a wire. This can create more problems for "gaggers" and children.

In my practice, about half of my patients are over 65. So for me, this is not a big issue. But some dentists might find sensor discomfort more important. If this is you, you may want to stick with film.

You also should consider how you will handle panoramic images. Some digital-capture systems do not support panoramic images. Others require you to purchase additional equipment to capture them. This could add 50-75 percent to your capitalization costs.

On the other hand, if your practice is entirely endodontics or implants, direct digital offers the advantage of immediate, real-time feedback. This is a timesaver that could translate into faster payback on your investment.


Dr. Maroon states that direct digital-imaging equipment is less expensive to own and use than a film-based system. In my experience, this is not necessarily true. Instead, my advice is exactly the opposite: Don`t buy direct digital-imaging equipment just because you think that replacing film with digital images will save you money. There are ways to maximize the payback on direct-digital equipment, but as a straight one-for-one substitute, direct digital is not a cheaper technology.

First, there is the cost of the equipment itself. A direct digital-imaging system will start at $7,000 to $9,000 for your first operatory and go up from there. Factors that influence system costs include the type of system and the brand. In some cases, you can retrofit your existing equipment. For a wireless digital system using a phosphor-type sensor, a retrofit will cost $13,000-$20,000. A new digital panoramic machine will cost $40,000-$50,000. And, of course, you may need to equip additional operatories.

You also need computers for viewing, manipulating, and storing your digital images. In my practice, I have a Linux network. I have Windows 98 computers in each of my five operatories, plus one at the front desk, another in a work area adjacent to the front desk, and one that we use for insurance-claims processing.

I use these computers for more than digital imaging. So, for me, they make financial sense. However, many dental practices will find that they need additional computer workstations to take full advantage of digital imaging. If that description fits you, you need to factor this into your conversion costs. In addition, don`t forget to consider the cost of periodic upgrades. Historically, computers need to be replaced every 18-24 months. At perhaps $1,500 apiece, this is a significant cost for any dental practice.

One direct-digital vendor suggests using a notebook computer that you carry from operatory to operatory. I`ve tried this, and it didn`t work for me. Notebook computers are relatively expensive. They aren`t expandable - for example, you can`t add image-capture cards to them. In my experience, despite their portability, they just don`t get moved from room to room.

You also have to consider the software and support costs of digital-imaging equipment itself. All direct-digital-equipment companies are going to charge you for software. You also will have to contract for ongoing technical support for your system.

In addition, it makes sense to purchase a rider covering the replacement of your sensor, should anything happen to it. Nobody likes to admit that the wheel of a chair rode over a sensor, but it does happen! Even with normal usage, sensors are fragile and they do break. Purchasing a replacement will cost you several thousand dollars. You are better off paying a few hundred extra dollars annually to protect yourself from that expense.

Another option for transitioning to digital imaging that it is far less expensive is to use a scanner to digitize your films. You can buy an excellent scanner for around $1,000. Scanners tend to have a long, usable life. Scanners also are versatile. You can use them for everything from dental films to the 35mm snapshots of your vacation. They are excellent for cosmetic- and intraoral-image capture.

Scanners are a nice interim step, because you can quickly and inexpensively enjoy one of the biggest paybacks of digital imaging: filing insurance claims. Just digitize your panoramic films, print them on a laser printer, and mail them. If an image gets lost, you can just reprint it. (Some dentists even print their images on the back of their claim forms. That practically guarantees they won`t be lost!)

Industry and technical volatility

Industry instability is a risk we face anytime we buy a computer system or a software package. Manufact-urers merge with other companies. Sometimes they get into trouble or go out of business. The last thing you want is to spend tens of thousands of dollars on a direct-digital system and then discover a few months later that no one is around to support it.

Diagnostic digital imaging for dentistry is still a new technology. It`s not clear yet which systems have staying power or which manufacturers will be around long- term. Another source of volatility is the technology itself. Direct digital imaging for dentistry still is in its infancy. The technology is changing rapidly. Hardware and software that are "cutting edge" today will be tomorrow`s antiques.

At some point, the industry will reach equilibrium. In the meantime, take an objective look at the companies offering digital-imaging equipment. Watch for signs that vendors might be struggling, such as staff turnover or, for publicly traded companies, jittery stock prices.

Second, know your capacity for risk. If your direct-digital system is rendered obsolete in a year or two - either because advancing technology left it behind or the company was bought by a competitor - will that be acceptable? Or would the stress be more than you could tolerate, personally or financially?

Is your practice ready?

In my experience, practices that have the most trouble transitioning to digital imaging or any type of digital technology are those that invest in the technology without first examining their work-flow patterns.

Automating inefficient work flow only makes inefficiency more expensive. According to one report, the main complaint about management software is that it hasn`t allowed dental offices to reduce staff. Why is that? Because dentists install the software, then use it to perform tasks in exactly the same way that they handled these tasks before.

For example, consider scheduling. For years, "experts" have advised dentists to designate one person to handle scheduling. This made sense when we used manual scheduling books. But everything changes when you install a computerized scheduler.

Good computerized schedulers can increase office efficiency by 25 percent or more. But, to achieve this, you have to change your work-flow patterns. In my office, anybody can make or change appointments from any computer terminal. We no longer have bottlenecks at the front desk. By the time a patient leaves an operatory, his or her next appointment has been set.

I also have computerized my charts. Anytime my staff needs to check patient documents, they can do it from wherever they are sitting.

We are not a fully paperless office. As long as some correspondence and records about patients arrive on paper, we will keep hard-copy charts. But, for most transactions, we use our electronic files. As a result, I have dramatically improved productivity in my office. I have fewer staff than I did five years ago and I`m working fewer hours, but my practice`s net has increased.

What does this have to do with digital imaging? It`s a question of being ready. When I bought my first scanner, I already had my patient records in digital form. It was a simple matter to attach a file of a digitized panoramic X-ray to the patient`s digital insurance-claim form. Furthermore, the productivity gains I made by computerizing my front-desk work flow has helped finance my digital-imaging system.

I didn`t expect digital imaging to pay for itself as a stand-alone investment, but, rather, to be a part of an overall automation strategy.

If, on the other hand, your practice is not networked and you have not re-engineered and decentralized the management of patient recordkeeping, digital imaging could make your practice even more complicated instead of easier.

Under the right circumstances, digital-imaging technology can be an asset. If your practice is ready, you may even find that a direct digital radiography system is a wise choice. However, before you commit, make sure you have fully evaluated your readiness, the risks, and the costs. Doing it right is the only wise alternative to not doing it at all.

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