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Selecting Office Management Computer Equipment

by Barry Freydberg, D.D.S., F.A.G.D., F.I.C.D.

Whether or not to computerize is a question many dentists are asking today but it should not be. Like it or not, high-tech dentistry is here to stay. Too many dentists get caught in a technophobic web, hoping that the technological leaps of today will be branded experimental trends in the dental history books of tomorrow. Technology is not fleeting, but those who resist it may well be. The real questions for dental practitioners in the 90s are how to computerize and to what degree.

Where Automation Helps

Although the specific reasons for computerization vary from practice to practice, the motivating factors can be lumped under a single umbrella: common sense. Computers unleash the potential for streamlining the diagnostics, delivery, and management of dentistry in an unmatched, unprecedented and often revolutionary fashion. Generally speaking, a computer can greatly aid your practice in the following areas:

• High volume transactions: The process of adding new charts, maintaining and updating present charts, and tracking recalls and treatment procedures can be greatly enhanced by a computer system. 
• Repetitive transactions: The computer can automatically perform repetitive tasks such as posting patient charges and cash receipts, or processing insurance claim forms. 
• Templated documents: Especially in word processing, templates allow generic letters to be created and then combined with patient information in the computer. A single keystroke can generate a personalized letter to any patient. 
• Mathematical transactions: Calculating insurance charges, patient charges, accounts receivable, and lab charges can be very complex and prone to human error. A computer is both faster and more accurate. 
• Monitoring the practice: A computer can extract, synthesize, and summarize data about a practice that can be used to spot trends and plan for new approaches in management. A manual practice must be extremely organized to even approximate the effectiveness of a computer in this area. 
• Decentralization: In non-computerized offices, almost all transactions (such as billing,appointments, cancellations, and record keeping) are done at the front desk. Computerization allows the workload to be redistributed properly throughout the office. 

Of course, there are many other advantages to an automated practice. For example, by assuming most of the paperwork chores, the computer frees up time for staff to attend to other goals such as improved patient communications, marketing strategies, and other management initiatives.

Consider the Negatives

Although there are certain drawbacks to computerizing an office, many of the criticisms of technology already have been overcome, or will be shortly. Here are some of the traditional objections to automation, and why they have no grounds:

• The costs are too great: It is true that the costs of automating can be impressive once everything is accounted. And it is true that computers will not immediately generate a return on investment. However, the majority of your savings will be in time, the importance of which is easy to overlook. More available time means that patients will receive better service. Not only will this increase productivity over time, but the costs to achieve it will be proportionately less than the costs of current methods to increase productivity. 
• Technology changes too fast: The pace of technology is frantic. It is estimated that a computer purchased today will be obsolete in 18 months. Many people use this excuse to procrastinate, hoping that the pace of change will slow down. However, when you consider that your needs do not change as fast as technology does, items purchased today will serve much longer than 18 months. Also, many computers are designed to be upgraded in the future as new technology is released. Simply remove old components and plug in new ones to give your system enhanced capabilities. 
• Productivity is fine already: This may be true, but it doesn't mean it can't be better. If productivity can increase without an increase in management overhead (or possibly even with a decrease), then why not pursue it? A good computer system will allow substantial gains in productivity, especially in the areas of scheduling, recalls, and billing. 
• The staff is computer illiterate: This was a good argument a few years ago when learning a computer system almost required a university degree in computer programming. Systems today, however, have improved greatly, becoming much more "user friendly". This does not mean that staff will not require training, it means that almost everyone will be able to grasp the concepts and use the system effectively within a few months. 
• Computers will make the practice impersonal: Many fear that computerization will make the "personal" touch disappear. In most cases, the exact opposite is true. For example, patients who call about an account will not have to wait while the receptionist pulls the ledger card. In a few quick keystrokes, all information can be displayed allowing "instant" communication. Also, the computer frees up administration so that more time can be spent providing patients with the personal touch, and less time on paperwork. 
• Patients are uncomfortable with computers: Consider automated teller machines: in 1980, a survey revealed that 79 percent of people would rather use a human teller. In 1992, a similar study showed that 76 percent preferred to use an ATM because it was quicker and more accurate. Computerization benefits patients, and they know it. They may already be asking you when (not if) you are going to computerize. 

A Word of Caution

Some dentists, faced with climbing overheads and diminishing take-home pay, turn to technology as a romantic "miracle solution" to improving their homework and end up buying the wrong system. As a result, instead of being a savior, the new technology contributes to the problem of the practice.

There are some things that a computerized system will not do. For example, a computer can help track and age your accounts receivable, but it cannot make collection calls for you. If collection procedures are weak, any gains made by computerization will easily be offset by a lack of administrative ability. A computer will not make up for staffing problems, undefined job descriptions, ineffective office policies, or inadequately trained personnel. A computer will not boost morale. And a computer will not force the office to get organized. Certainly it may help, but it is common to find practices with dental software full of wonderful, but unused, organizational tools. A practice with management problems may find those problems magnified by a computer. Dentistry is being inundated with new technologies, including voice recognition charting, computed radiography, periodontal devices, intraoral cameras, optical character readers, CAD/CAM, lasers, and electronic data interchange. But is all this technology justified? Certainly each has its own merits, but if you were to purchase everything in the marketplace, your costs could exceed $100,000. Obviously, the key to technology is choosing applications that best serve individual needs and provide the best price/performance ratio. For some dentist, the benefits may be highest in voice recognition charting. For others, an intraoral camera may be the most beneficial. Whatever is best for a given office, the fact is that technology is no longer an option: it is an essential component of our way of life.

Practice Management Systems

Unlike some specialized technologies, such as CAD/CAM or computed radiography, a dental practice management systems provides a significant, reliable benefit to almost every dentist. In the vast majority of cases, the benefits of installing a system easily justify the costs. However, this does not mean that the costs are insignificant or the selection process easy; they aren't. A poorly selected system can cost a practice many times its purchase price without providing any improvement. Selecting a system carefully is critical for long-term success with technology.

Choosing a Platform

As the name implies, platform refers to the base of the entire computer system. It determines the corner of the vast computing world in which your system belongs. There are two basic aspects to the platform:

• Computer hardware: includes all the mechanical and electronic devices that are used to compute, store data, input, and output information. 
• Operating environment: the basic program that controls the hardware. It allows other programs (such as a dental practice management system) to save files onto the disks, print reports or display information. More than anything else, the combination of the above platform factors determines the "compatibility and "upgradability" of your system. For example, Macintosh and IBM computers are generally incompatible because they typically use different hardware standards (Apple vs. IBM) and different operating systems (Macintosh System vs. Microsoft DOS). You also can have incompatible systems that use the same hardware, such as an IBM machine using the Unix operating system versus an identical machine running the Microsoft DOS operating system.

Perhaps the most discussed platform these days is Microsoft Windows. Windows has become incredibly popular in recent years. It contains important features that allow different software programs to share information in compatible way. This environment is particularly suited to handling more than one program (for example, computed radiography combined with the dental practice management system). So, if your current of future needs involve two or more different technologies, it is likely that Windows will be a strong contender as the platform of choice.

Compatibility is important because once a platform is chosen, it is difficult and often expensive to switch platforms. So, IBM compatible hardware is selected, all future equipment purchases will have to be IBM compatible. You couldn't, for example, run out and buy a hard disk drive designed for a Macintosh. Similarly, if you choose Windows as the operating environment, all the programs you buy (including your dental practice management system) should be compatible with Windows; you wouldn't be able to use a Macintosh or Unix program.

This sounds fairly straightforward, but it can get confusing when the nuances of all options being investigated are considered. For example, the Unix operating system, unlike MS-DOS or the Macintosh System, can use different kinds of hardware: you can have Apple hardware running Unix, or IBM-compatible hardware running Unix.

The author's recommendation is to compare upgradability when faced with decisions like this. Ask which platform will give you the best reliability now and expandability in the future. This is a choice that only you can make, but there are a number of related factors that must beconsidered:

• The marketplace: In 1993, nearly 80 percent of the desktop computer market was devoted to IBM or IBM-compatible computers. It stands to reason that most of the future software developments and hardware advances will occur in this market since it is likely that the greatest amount of energy in research and development is happening here. 
• Other technology: By purchasing a system wisely, it is possible to add on other technologies (such as intraoral cameras or voice recognition charting) without having to purchase another computer system. Buy a system that meets the greatest number of your present and future needs, and don't underestimate future needs. 
• Number of users: To a computer, the number of users is how many people will be working on the computer at the same time. If you have only one workstation, even if four different people use it during the day, the computer only considers them as one person. By comparison, if there are two workstations, both being used at the same time, the computer sees two users. Some operating systems and hardware environments are limited in the number of users they can accommodate. Choose a platform that can meet present and future needs. 
• Vendor support: Since it takes a lot of effort to develop a dental practice management system, most vendors select only one or two platforms on which to base their programs. Ultimately, the platform chosen must be compatible with the dental program selected, so weigh platform and vendor decisions carefully.

Choosing A Vendor

When purchasing a computer system, you must recognize a number of inescapable facts:

• There never has been, and most likely never will be, a computer system that is immune to hardware failure. Eventually, something will break down. IBM equipment is considered very reliable, yet one of IBM's biggest sales tools is the speed with which they will react when there is a hardware problem. 
• There never has been, and probably never will be, a computer program that is entirely "bug free". Software bugs are programming errors or incompatibilities in the software that can cause erratic problems or even system crashes. Because of the vast assortment of hardware available and the complex relationships that different software packages must establish with a computer system, eventually there will be a problem. 
• No matter how much you search, you will never find a software package that does absolutely everything you want both now and in the future. You need to ask yourself three important questions: "Who do I call if I have a hardware problem?" "Who do I call if I have a software problem?" "Who ensures that my dental software will continue to meet my needs in the future?" The answer to all these questions is, of course, your vendor. If the right vendor has been selected, and the package offered is appropriate for your practice, none of the above facts are limitations. In other words, a good dental package from a good vendor is a winning combination. A good dental package from an unsatisfactory vendor is guaranteed to lead to frustration and extra costs.

The right vendor will provide maintenance contracts that help overcome hardware troubles quickly. This vendor also will provide support and updates to the dental package that will fix any bugs encountered, and will remain competitive by adding features to the package over time. The most important component to successfully using technology in a dental practice is the support and ongoing commitment of a dedicated vendor.

Stability & Growth

The dental computer industry is enjoying its second decade, with several companies celebrating more than ten years in business. These businesses have survived a fairly long time (for computer companies) in a difficult market. Many companies have not made it. Some have failed and others have merged. Even now, new firms are emerging, but not at the same rate as in the mid-eighties. These young firms can be very competitive with their more established rivals. So, the age of a company alone does not provide a sufficient indication of its dynamics and ability to meet your needs. Generally, computer vendors can be classified as national, regional, or local. This factor can be an indication of how the company will interact with the purchaser in the future. A national company may have more resources to devote to research and development, so the long-term ability of the company to keep up with changes in the marketplace may be better. However, a local company may be able to respond more quickly when problems with your system are encountered, and a local company may listen more closely when you have suggestions about software improvements. Each of these factors must be balanced in choosing a vendor. To create a rough guideline as to how dynamic a vendor is, it is important to know:

• The sales method of the company. 
• The number of years it has been in business 
• The location and number of installations in the past year. 

Company A appears to have a larger installation base than Company B, a closer look reveals that Company B may be a more stable vendor. The average number of installations per year for Company A is 640/8 = 80. So, last year it installed five fewer systems than its own average. Company B, meanwhile, has an average installation rate of 275/5 = 55 per year. Last year it installed 10 more systems than its average. This may indicate that Company B is meeting the needs of the marketplace more effectively, even though it is a local company.

Support & Maintenance

A recent survey of computerized dental practices showed that many felt their hardware and software support was inadequate. The same study found that most respondents felt they had failed to establish a clear agreement with the vendor concerning the maintenance and update services that would be provided. This demonstrates the importance of clearly understanding the long-term service the vendor will provide to you. In general, these services fall into three categories: Hardware support, software support, and software updates.

Hardware support refers to the services the vendor will provide if you have trouble with your computer equipment. Vendors typically charge a monthly support fee for this service. It is important to know:

• Does the vendor have an in-house hardware support department or does it contract out to a third party? 
• Does the support fee include the full cost (including labor) to repair and replace any equipment that malfunctions? 
• If the vendor is national or regional, does it have a local representative who can come to your office if the problem cannot be solved any other way? 
• Is there an 800 number for toll-free support? What are the hours (in your time zone) that support is available? 
• How is the support contract affected if you install additional equipment purchased from other vendors? 
• If you have a system failure, does the vendor provide a guaranteed response time to get you up and running? 

Software support refers to the services the vendor will provide to help with any problems with the dental software. Vendors typically charge a monthly support fee for this service. It is important to know:

• If you decide to have someone else provide hardware support, will the vendor work with that company to solve any problems? 
• If the vendor is national or regional, does it have a local representative who can come to your office if the problem cannot be solved any other way? Under what circumstances would the system have to be sent to them? 
• Is there an 800 number for toll-free support? What are the hours (in your time zone) that support is available? 
• How much training does the company advise you and your staff to receive to effectively use the program? How much training is included in the initial package price? 
• Is there a limit to the number of calls or amount of time that can be used to contact the support department? 
• If you must be called back when you report a problem, is a call-back guaranteed within a specified number of hours?  Can the vendor connect to your computer via a telephone line to diagnose and fix problems? Software updates are sometimes included in software support fees and sometimes charged separately. Software updates contain enhancements to software and correction of any software bugs that have been reported. 

Regular software updates are essential to maintaining the usefulness of a system through the years. It is important to know:

• How many updates have been released in the past two years? 
• What future enhancements are planned for the software? 
• Under what conditions are enhancements to the software not included in updates? For example, if the vendor adds an entirely new module to the program, is the upgrade automatically sent at no additional fee? 

References

Typically, vendors will provide three or four of their best references to you. Often, you will find that these references are people who have a vested interest in the software. They may have played a part in software development (as a test site) or they may be personal friends of the vendor. As a result, you may not hear an accurate evaluation of the program from these individuals. Instead, ask your vendor to provide a list of all clients, and have them indicate which ones have practices similar in size and management style to your own. Then, randomly select clients from this list to call for references.

Evaluating the Software

Match your practice needs and requirements as closely as possible with the capabilities of the systems selected. The best selection process compares individual software capabilities between vendors. Although this process will not guarantee the selection of a perfect system, it will greatly increase the odds of purchasing the best software for your practice.

Each dental software package has a flow and design philosophy that is unique to the system. This philosophy usually is based on the approach to dental management of the original system designer. Software purchased from companies that have been in the marketplace for years is the distillation of years of experience with end-users. Therefore, when looking at dental software, you actually are buying into someone else's management philosophy and expertise. Because their philosophy may differ from yours, the system may not appeal to you even if it contains all the desired features. You will need to balance the features of the system with its design philosophy to find one that meets your objectives.

System Categories

When determining your needs, it is useful to divide dental practice management systems into three fundamental types: basic, intermediate, and advanced. Basic systems contain the essential features necessary for the smooth operation of an automated practice. Systems without these crucial features can be crippling. With the choices now available, no practice should consider a system with less than basic features.

Practices (especially group practices) that need more sophisticated features may wish to consider an intermediate system. The difference between a basic and an intermediate system is the diversity and sophistication of the features. The intermediate system has fewer limitations and more options for customization. This allows practices that are more management-oriented to streamline their operations electronically. In addition to features of a basic system, an intermediate system contains the enhancements and additional features listed in table three.

Practices wanting to take full advantage of electronic data and communications potential should consider an advanced system. These systems are intended to be the information center for the practice, replacing much of the paperwork. Some even provide voice communications.

The introduction of computers was accompanied by sweeping predictions of a "paperless office". While a totally paperless office is still a futuristic concept, recent advances in dental software and hardware have greatly reduced the amount of paperwork. In addition to the features of basic and intermediate systems, advanced systems contain more additions and enhancements. It is important to realize that advanced systems differ from both basic and intermediate systems in the amount of commitment they require. Basic and intermediate systems are intended to integrate into a present management philosophy, and do not require a large restructuring of the way the team works. Advanced systems are designed to become the central management and administrative tool. As a result, advanced systems often require a redefinition of the tasks and responsibilities of team members, and demand dedicated effort to implement all the features. However, the resulting new management model of the advanced system redistributes the practice workload, creating greater efficiency and reduced work duplication.

The most important factor in selecting the most appropriate dental software is your practice management philosophy. The choice has very little to do with the size of your practice. A small practice can implement an advanced system as cost effectively as a large practice. Instead, you need to decide how far you want to go to integrate technology.

Vendor Demonstrations

After you have determined which vendors supply the type of package you are looking for, demonstrations of each package are essential. For the most part, the features of any system can be categorized into the following areas:

• Patient registration 
• Patient billings 
• Treatment planning 
• Insurance processing 
• Continue care and recall management 
• Management reports 
• Appointment scheduling 
• Database management 
• Word processing 
• Marketing 
• In-Operatory features 
• Group practice functions 

Be sure to have your vendor demonstrate functions in each of these key areas. Keep notes about the features you like and dislike about each software package. While the vendor is demonstrating the software, keep in mind that they will purposely show you the best and most powerful features of their package, and will avoid areas in which it may be weak. Be sure to receive a complete demonstration of all the features you want in your system.

Do not place much emphasis on the speed at which the computer system appears to operate during demonstrations. This is primarily dependent on the amount of data in the vendor system and the kind of hardware being used. If possible, have the demonstrations performed on comparable systems. Otherwise, accept the fact that hardware alone can make one program seem faster than another when, in reality, it may not be.

References

As with choosing a vendor, do not purchase any system until you have checked with some current users about their satisfaction with the system. Talk to a variety of people to get an overall feeling about the program. Ask them for opinions about the strengths and weaknesses of the program. What areas would they change? Are there certain features that they never use? Are there important features that are missing? Would they buy the system again?

Evaluating the Hardware

Once you have selected a platform, vendor and software, it is time to choose hardware. Since a wide variety of equipment is available, it is beyond the scope of this article to describe hardware needs in detail. Your vendor should provide a detailed recommendation about the type of system your office needs. It is important to take the time to learn about the hardware you are buying. Ask for an explanation of why each piece is needed, whether it is the most current technology, what warranty comes with it, and its future upgradability. The best advice is to avoid buying second-rate, old technology since this will simply require replacement of the system sooner. A premium system will contain the latest technology available and can be upgraded easily in the future as your computing demands change.

Summary

Even though you will never find a dental management system that will do exactly what you want, there are a tremendous variety of systems out there with some incredibly powerful features. Look for a system that can handle most of the tasks you need. Keep your eye on other technologies that you may want in your practice. The system you purchase now should be able to handle whatever technologies you decide to add on in the next three to four years.

Once you have made the decision to purchase, the transition to automated management begins. It will be necessary to train you and your staff on how to use the system. Depending on the system chosen, it may be necessary to adjust your management strategies in a number of areas to take advantage of the system's features. This may cause a few adjustment problems at first, but things will work out with a little time and effort.

In the next few years, advances in technology integration will allow you to seamlessly blend practice management, voice charting, intraoral cameras, CAD\CAM, lasers, EDI, video imaging, etc., into a single potent system for complete clinical and practice management. A dental practice management system is the first step to realizing that future. Shop wisely and invest your time in learning the terminology and techniques of automated information management.

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