TECHNOLOGYTOWN: Servers, Software and Networks, Oh my! By: Thomas Giacobbi, DDS, FAGD
Editorial Director, Dentaltown Magazine

The current generation of retiring dentists started their careers without a computer in the office; today, a new dental office has a computer in every room. Computerization has spread from the front office to the back office. Beyond computerized scheduling and billing are charting, imaging, insurance claims, digital radiographs and patient education. The paperless office is the mantra of the 21st century dental practice; the common goal is to transform paper-based tasks to a digital format.

Many dentists have discovered the transition into the digital world can be quite challenging. There are literally dozens of different software and hardware manufacturers that produce systems of limited compatibility. The challenges can be especially daunting for a dentist who is either building a new practice or doing a complete overhaul of their existing technology systems.

To better understand the hurdles dentists face, I posed some questions to Dr. Lorne Lavine, one of Dentaltown’s resident technology experts. Dr. Lavine founded Dental Technology Consultants (www.thedigitaldentist.com), which assists dentists on all phases of technology integration. He also serves as a Moderator in the Computer and Technology forums on Dentaltown.com, and he has worked with close to 300 Townies who have made improvements to their office systems.

New Dental Office
DT: If a dentist is building a new office and wants to be sure it is ‘computer friendly’, what is the first step?

Dr. Lavine: As with any important decision, we recommend careful planning go into this decision, as it’s far easier to lay the infrastructure before the floor and walls are poured rather than after the fact. There are a number of decisions that need to be made. The most important is the layout of the operatory. The largest items that are placed in the operatory are the computer and the monitor. For the computer, if the office will have a cabinet at the 12 o’clock position, you need to be sure there is adequate space for the computers. Most of the major vendors, such as Dell, post the dimensions of their computer cases on their Web site. The next decision is monitor placement. The dentist will need to decide whether s/he will have one monitor in the operatory or two, and where those monitors will be placed. Common locations are in the rear cabinet, the wall, ceiling, or a light pole. Once the computer and monitor placement is chosen, the final piece is to run the cables, including network, video and audio.

To be truly “computer friendly”, the office needs to lay the infrastructure for any and all future needs. It makes sense to have the installers run network cables (called a “drop”) to any location where you feel a computer may be needed. Also, and this is especially true for offices being built on a slab concrete floor, conduits should be placed to allow for all cables to be hidden as they run from the monitors to the computers.

DT: What are the three most commonly overlooked items during the design phase of a new office?

Dr. Lavine: There are a number of common items that are often overlooked. First, offices tend to ignore the needs for proper ventilation for their computers. Many cabinets are not vented well and a closed cabinet becomes very hot. Heat is the number one enemy of computers, and this potentially damaging issue is usually not given enough attention. Secondly, offices tend to ignore long-term needs. For example, all digital pan/ceph machines and all phosphor-plate systems require a direct connection to a computer. So, it makes sense to run network cables to all locations. Finally, since many dentists are unaware of the mounting options available, they fail to realize the ergonomic factors that should go into that decision. A monitor mounted on a ceiling or sitting on a counter behind the dentist’s back will cause neck and back problems if this is the only monitor the dentist uses.

DT: Is there a rule of thumb for budgeting computer equipment in a new office?

Dr. Lavine: There’s no rule of thumb as each office has different needs. If an office wants to go “paperless” or chartless from the start, this requires a significantly higher investment as they will require not only high-end software, but will need digital x-rays, intraoral cameras, digital cameras, scanners, etc. The initial cost will be determined by the number of operatories being outfitted and the digital systems the practice is using. We’ve done some new offices for as little as $15,000 and others as high as $120,000 just for the technology systems, so there can be a wide range. The average new office we install is spending somewhere between $30,000 and $60,000.

One important factor to consider is nothing lasts forever…and that includes computer equipment. With the advances in technology, we are telling clients to expect about a three-year life expectancy for their computers. Sure, many computers will last longer, but at three years, the higher requirements of new software will likely cause the computers to slow down. A new office needs to be aware of these recurring expenses and should budget accordingly. Many offices will institute a yearly replacement of a portion of their systems so they can stagger the upgrades and not have to be faced with a major expense at one time.

DT: What is the best use of technology you have seen in a new office?

Dr. Lavine: We’ve been very impressed with the offices that have truly started a chartless practice. I’m not a huge fan of the term “paperless”, as there will always be a need for paper, whether it’s walkout statements, reminders, insurance forms, etc. However, the technology now exists for any office to completely eliminate their paper records and move to a digital format. As I mentioned earlier, it does require a higher initial outlay. Any money you save by not using cabinets for your charts is easily surpassed by purchasing high-end software capable of recording clinical notes, and all the hardware necessary to have a digital office. I’m impressed with dentists who understand the value of this technology in the big scheme of things and are willing to take the plunge. However, I also realize that until the costs of the technology come down, this type of practice is not practical for the majority of new dental offices.

Existing Dental Office
DT: What is the biggest challenge to networking an existing dental office? How do you solve that problem?

Dr. Lavine: Existing offices are always faced with more challenges as the technology has to adapt to the infrastructure, not the other way around. The biggest challenge is the running of the cables and cords. Many offices, for example, want to mount the monitor to a light pole, which is an excellent option. However, if the floor is concrete, there is no esthetic way to run the video and audio cables from the monitor to the computer, which is typically on another side of the room or in a cabinet. The monitor also needs power and many existing practices do not have adequate power outlets at the ideal locations.

The way we’ve typically solved these problems is to figure out which is more important to the dentist, function or esthetics. Since there are so many options for monitor mounting, we find that the majority of offices are happy to find a compromise that gives them both an esthetic and a functional result.

DT: Are Tablet PCs an option? What problems do you see with a wireless network?

Dr. Lavine: Tablet PCs are certainly an option, although not normally my first choice. There are a number of reasons why Tablets are not ideal. First, the screen size and resolution are usually far below what you can find with desktop systems. Most Tablets still only have a 10.5” or 12” screen, and a few are now 14”, but when compared to modern 17” and 19” monitors, they are tiny. Digital x-rays require screens with a high contrast ratio, something that Tablets don’t provide. Tablet PCs are not inexpensive; a top-end model will cost around $1,000 more than a good PC and monitor. Finally, as you alluded to, they all use a wireless connection. While wireless is not a bad option, it has certain disadvantages. It requires additional hardware. Most wireless networks needs to be configured by a network expert as there are significant security concerns with wireless. Also, the speed of wireless, especially when working with images, can seem slow. While the top speed of a wired network can approach 1000 MB/s, wireless has a theoretical maximum of 54 MB/s, and it’s closer to 25 MB/s in practice. A new standard, 802.11n, will approach 100 MB/s in practical use, but that standard is probably 12-18 months away.

Digital Radiography
DT: Many offices are adding digital radiography to their existing systems. Will this require server and memory upgrades?

Dr. Lavine: Absolutely. Many offices fail to realize what a quantum jump occurs when they go from practice management data (primarily text data) to images. While an office can have decades of practice data fit onto a single CD, that same CD, in a busy office, may only hold 2-3 weeks of images. So, when an office makes the jump to digital radiography, it almost always requires either a major overhaul of their current server or a brand new server. The servers we currently recommend have a minimum of 250 GB of storage for the hard drives and at least 1 GB of memory (RAM).

DT: How often do you run into conflicts between different technologies (i.e.: digital x-rays not playing nice with practice management software, etc.)? If the technologies are supposed to be compatible, is the problem with the network set up, the computer OS, or something else?

Dr. Lavine: Actually, many problems are created by the large practice management companies themselves. It’s important to understand the history of imaging software to realize how the market has become very segmented. Initially, practice management software only handled management data. As imaging started to become a reality with the introduction of intraoral cameras in the late ‘80s and then digital radiography in the mid-‘90s, there was a need to store and manipulate these images, so many companies produced image management software. The practice management companies, realizing that imaging was rapidly becoming an integral part of the modern practice, then chose to adapt existing image programs to become part of their software suite. Since many of these software companies are owned by dental supply companies, it makes sense for them to encourage their customers to purchase digital systems they sell, rather than those of other companies.

So, at this time, you really have two different market segments. You have the practice management companies that have imaging components, and you have third-party image programs that bridge to the practice management software. To complicate matters, many of the digital systems are only available from a single vendor and only work with a single software program.

We suggest that offices should decide on their image software first. Once they decide on whether to use the imaging modules of their current software or another software program, then they can choose their digital systems based on which ones are compatible with their software. While many dentists choose their systems based on the hardware specifications, I feel this is a mistake. The software is the more important decision and will dictate which systems work together and which do not.

Internet
DT: How do your clients use the Internet in their practices?

Dr. Lavine: Well, obviously, the main use is to log on to Dentaltown.com throughout the day. Seriously though, we do find that the exchange of information is a huge asset for any practice. Dentists are able to communicate with their colleagues to get answers about new products, procedures, and practice management. There are a few services that allow for online collaboration. In other words, a general dentist can upload patient images to a specialist on a secure Web site, and then the specialist can comment and make annotations before sending the information back. In this way, an ongoing online “conference” can exist between multiple providers without the delays of the mail system.

Many practices order all their supplies online and many communicate with their labs online. With online access, e-claims are quick and easy. There are many functions of software that require online access, such as sending patients reminder e-mails for upcoming appointments.

It is important to stress that with Internet access, there are a series of steps that must be taken to protect the practice’s data. Every office should, at the minimum, have anti-virus protection, anti-spyware programs, and a firewall.

DT: What is the future of office networking? Smaller computers, wireless, etc.?

Dr. Lavine: While it would be nice to see a system of computers connected wirelessly together, all speaking the same language (such as we now see with cell phones), this is not something I foresee in the next 5-10 years. There are too many competing standards to any type of market consolidation. One standard that may eventually take off is called Home Plug, which utilizes the power lines to transmit network traffic. The premise is that while network cables can be a challenge to run, all computers need power, so power lines are a nice option. At the present time, the speed is too slow to be practical for most dental practices. The size of the computers has continued to shrink over the past few years. As the price of monitors drops, though, the size of the monitors we’ll see in the ops will actually increase. The standard 15” monitor from just a few years ago is now 17” and we are currently seeing more and more offices opting for 19” monitors. While many companies are working on hybrid portable devices that can be a jack-of-all-trades, the PC will continue to be dominant for many, many years.

DT: There is a tremendous opportunity to improve office efficiency via computerization of current analog operations. However, the transition requires accurate information and a well trained staff. Regardless of where you are in the process, you will have questions, and you will find answers on Dentaltown.com! Visit the electronic version of Dentaltown Magazine on the Web and you can post follow-up questions to this article. The conversation will continue.

Lorne Lavine, DMD, is the founder and president of Dental Technology Consultants. Dr. Lavine is an A+ Certified Technician and a Network+ Certified Professional, illustrating his expertise in network design, installation, and troubleshooting. Dr. Lavine previously practiced periodontics and implant dentistry in Vermont, and recently established a Dental Technology Consultants office in Sherman Oaks, CA. His career is enhanced by his commitment to continuing education, his academic awards and appointments, and his involvement in local and national dental organizations. Dr Lavine can be contacted on the Dentaltown.com message boards or via e-mail at drlavine@thedigitaldentist.com

Thomas J. Giacobbi, DDS, FAGD is a general dentist in Chandler, AZ who owns a private practice with his wife, Grace Giacobbi, DDS. Originally from upstate New York, Drs. Giacobbi are 1995 graduates of SUNY at Buffalo School of Dental Medicine. Please send comments or questions to tom@farranmedia.com