Dr. Larry Emmott

	The primary benefit of using digital images is that they are–wait for it–digital! It seems obvious and yet it is often overlooked. So, what makes digital images so special?

	At the basic level you need to realize the terms “paperless” and “digital” are interchangeable. A paperless chart is a digital chart and a digital radiograph is a paperless radiograph. It is not possible to have paperless records unless you have paperless diagnostics such as 

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	In the most literal sense, to digitize something means to turn it into digits or numbers. In a more practical sense, it means turning something into the electronic language a computer can understand. Digital data-everything from words and numbers to pictures, radiographs, sound and video-can be stored, transmitted and enhanced electronically with a computer and a computer network. The concept is simple but the impact is enormous.

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	The most obvious benefit of digital images is the speed of acquisition. You can view a digital photo or a digital radiograph seconds after exposure. Compare that to waiting five to 10 minutes for a film radiograph to be processed or several days for a film photo to be sent off,  processed, printed and returned.

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	If you take a radiograph that is clinically unacceptable-you missed the apex or overlapped the interproximal-with film you won’t know for minutes. Once discovered, you’ll need to start from the beginning with film placement and cone position and hope you get it right the second time. With a digital image, you can see results in seconds, and the 

 and cone will still be in place. If you missed the shot with , you can immediately re-position for a perfect image in seconds.

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	Enhancement means we can apply software tools to improve diagnostic efficiency. The most basic tool is “zoom”-blow up the image to see details more clearly. This helps the dentist diagnose and allows dentists to show patients key areas for education and treatment presentations.

	More advanced tools allow us to change contrast brightness and other features of the image to enhance diagnosis in ways that are simply not possible with film. For example, as dentists we use radiographs to diagnose several different disease types, caries, bone loss and periapical lesions.

	We are looking at several different tissues-bone, pulp and tooth among others. There is an optimized way to image each tissue and to enhance the detection of each disease type. With film we have one (rather tiny) static image we need to interpret for all these things. With digital we have an image that can be enlarged and enhanced in different ways to give us optimized views for each tissue and each disease.

	One of the most common mistakes dentists make with digital radiographs is to compare a simple raw digital image with film and decide whether digital looks like film. We are still in the middle of a difficult shift in diagnostic practices and much of what we do with a digital image is tied to what we used to do with film.

	The fact is, the digital image contains a lot of data we simply cannot see unless we use 

 tools to enhance diagnosis. Then, we can see things that would never be apparent on film.

	This is an area that still needs a lot of research and development. That is, what does the data on a digital radiograph tell me? What is the optimal image setting to detect caries or bone loss? Which tools are diagnostic and why? And what features did we look for in film, which are simply no longer important with enhanced digital images?

	Storage just means a digital radiograph can be stored on a computer hard drive with no paper folders. A more advanced feature of storage is to store the radiograph away from your office in the cloud. Cloud storage gives you greater security and easier transmission.

	Transmission means the digital data, the “stuff,” can be sent anywhere in the world using a computer network. That includes your office network, which means we can view a radiograph at various places in the office-anywhere there is a computer. You also can connect to the biggest network of all, the Internet.

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	We can send the image to an insurer for payment, a surgeon for referred treatment or to a radiographic specialist for diagnosis. When we send a radiograph to a third party we still have the original and the copy is every bit as good as the original. With film we either lose the original or send a copy that is always significantly less diagnostic than the original.

	We have seen the future and the future is digital. The future is coming and it will be amazing!

Articles

The primary benefit of using digital images is that they are–wait for it–digital! It seems obvious and yet it is often overlooked. So, what makes digital images so special?

How to integrate dental digital imaging with your paperless workflow

It is 1962 and Dr. Jones has an air compressor installed with air lines to all the treatment rooms running to units with highspeed air turbine handpieces, yet he continues to use the old belt driven dental drill because he just doesn’t trust the new system. That seems silly today, but it is the same situation many dentists find themselves in 50 years later with regards to paperless dental records.

Time and again offices have everything in place to go 

, but they still make paper because that’s the way they’ve always done it. They just don’t trust the new system. Sometimes it is the old, “can’t see the forest for the trees” issue. In this case, the trees are the individual processes that can be used to create digital information. The forest is the paperless record. The tendency is to concentrate on individual processes or technologies without integrating the process into the whole. As a result, one of the common mistakes dentists make with electronic charting is they only go part of the way.

For example: The office may use a paper chart in the treatment room during diagnosis to mark future treatment. Then they take the paper chart to the computer and enter everything again. They will use the computer to create an estimate, insurance forms and schedule. Then they will go back to the paper chart to enter procedure notes, back to the computer to take a payment, back to paper for a prescription, back to the computer for the next appointment, then back to paper to check the x-rays.

The office ends up with a mess. Everything is done at least twice, the paper chart is still needed, and no one is ever sure if something is on paper or in the computer. As a result, the computer chart doesn’t save time and money. It makes things worse.

Many dentists believe that to go paperless they must convert all their old records by scanning everything into a digital format. This is a huge, time consuming and expensive task with a very limited benefit. Do not try and scan in all the old records. Going paperless is a process not an event. You do not one day shred all the old records and declare the office paperless. At first you will need the paper charts on all your patients as you will be referring to the previous paper entries. As time goes on you will need to refer less and less to the old paper records. After a year all the current x-rays will be digital and all the patients recent entries and treatment plans should be digital. It is now possible to stop pulling charts. However, at first you will need to refer to the old charts fairly often for entries or x-rays more than a year old. Eventually you will rarely ever need to pull a chart.  You still don’t shred those old records-the paper charts are the archive.

Let’s be clear. Maintaining and referring to old paper records does not mean you continue to make paper entries. Once the system is in place, you simply stop making paper. Everything new is electronic; everything from the past is paper.

Dentists often see paper records as inexpensive and digital systems as costly. However, the costs to create and maintain paper charts can be significant but we often don’t see it because it is hidden in the process of doing business.

Paper charts don’t just appear in the office for free. The paper folder and all the other papers cost about $2.50 each. Other chart contents, like x-rays and photographs, can be even more costly. A set of bitewings with film, processing and mounts can be a dollar or two. It is reasonable to add at least another $3 to the cost of each chart for a total of $5.50 each. If you have 2,500 charts they cost you at least $13,750 to create and every time a new patient walks in it’s another $5.50-cha-ching!

Storing the records isn’t free either. A typical office with 2,500 charts will need three or four full size lateral files to hold them all and a file room to keep them in-let’s say $11,500 (for the files and the build out). Not to mention all the “inactive” charts stashed away somewhere else.

Common misperceptions about going paperless

	I believe I just got a glimpse of the future.

	For some time I have been speaking and writing about the far out ways we could be using digital technology in the future. Things like cloud computing, data mining, self learning virtual brains, data base marketing, artificial intelligence and fully automated e-services.

	All of these far out future ideas have been put into play with a new online service called Practice Activator from ActionRun.

	Practice Activator is an online e-service that contacts and re-activates non-responsive patients. This is not a new idea, what is new are the tools that ActionRun has developed and applied to this task.

	Early attempts to use digital technology to re-activate patients simply automated the tasks we had sought to do with paper records. That is to look up patients who have not been seen in a couple of years and then send them a notice. A slightly more sophisticated application could scan uncompleted treatment plans and send messages to those people which could even include a motivational note.

	However, a car is not merely a faster horse. To truly take advantage of the power of digital technology we can apply tools that were just not possible with paper records; tools that essentially mimic the thought processes of a human mind.

	Here is a really simple example. The computer examines records and discovers a patient who had a root canal completed on a molar but has no record of ever having a final restoration placed on that tooth. The system knows this is a potential problem; with no intervention from a human operator.  The patient is then contacted and advised to return for treatment.

	However it gets even better. The computer looks at the patient’s personal factors, such as age, sex, insurance status, motivators, medical conditions etc. and tailors the re-activation message to appeal specifically to that patient. Mass customization.

	It gets better. The computer tracks the responses and learns what works and what doesn’t and modifies its search and response tactics as a result. This is a type of artificial intelligence called a self learning system. What makes it even better and more sophisticated is that the system uses aggregated data from well over one million connections. The learning is not restricted to your office and your data but can call upon the accumulated wisdom or knowledge base of many many dentists.

	The program can be effective with very basic digital data. That is patient demographic information (age, sex, address) and a ledger (what treatment was done when). However additional data such as treatment plans, histories and diagnosis will add to the system and provide even better results. While a relatively new system, Practice Activator has already proven to be highly effective for those offices that have put it to work

	Let’s review. Data is retrieved from your dental office computer and is analyzed (mined) by a sophisticated system online (in the cloud). Based on over a million transactions a self learning system (artificial intelligence) identifies a patient needing treatment. Based on his/her need the patient is contacted (data base marketing). All your office staff needs to do is answer the phone when the patient calls to schedule (automated e-service).

	The future is coming and it will be amazing!

 I believe I just got a glimpse of the future.  For some time I have been speaking and writing about the far out ways we could be using digital technology in the future. Things like cloud computing, data mining, self learning virtual brains, data base marketing, artificial intelligence and fully automated e-services.  All of these far out future ideas have been put into play with a new online service called Practice Activator from ActionRun.

A glimpse of the future

	Remember when e was just a letter? Well now it stands for “electronic” and anything e like e-mail or e–commerce is electronic mail or electronic commerce. But in practice it usually means a service that is not just electronic but it is online. Often as it becomes an e and goes online the “whatever” migrates from being a product to a service.

	For example let’s look at a dental product that has become an online e-service to explain the differences and advantages of going e. The product is patient education. For many years the patient education market was dominated by Caesy. Caesy dominated for many reasons not the least of which it was a very well designed product. Caesy evolved over the years from a standalone player to DVDs to a network server based system. However, in all those configurations Caesy was sold to a dentist and installed in the dental office.

	As a dentist you can purchase a full Caesy networked system with a local server for about $8,000. It is possible to get upgrades for an additional fee, but for the most part, once it is delivered and installed the dentist owns the system as is. It is the dentist’s responsibility to maintain it and make needed repairs. As the owner the dentist can, in theory, sell the system to someone else if he/she can find a willing buyer. However we all know in reality used technology has virtually no re-sale value which means the $8,000 is not really an investment but is spent money.

	Migrate the idea of a patient education product to the Internet and it becomes an e-service like 

	As a dentist you do not need to buy ToothIQ but you pay for it as a monthly service. It is software as a service (SaaS). The fee varies depending on what you get but can be as low as $39 a month. For the $8,000 purchase price of Caesy you can have 205 months of Tooth IQ. (That’s more than 17 years.)

	Let’s review; if I want to start using a professional digital patient education system in the office next week I can invest $8,000 and wait until it is delivered and installed or I can sign up online for $39 and start using it immediately.

	Low start up cost is just one of the benefits of online e-services.

	“With a Web based e-service you can access it from anywhere using any computer that has Internet access.”

	With the old installed system, upgrades are periodically sent to users (usually for an additional fee) and the user needs to install the upgrade and hope it works with his/her system. The unspoken issue, the elephant in the punch bowl, is that locally installed computers can vary to an almost infinite degree and new software upgrades may not work on the hardware in your office while the same upgrade works just fine running on the system in the office next door.

	With a Web based e-service the upgrades are added constantly. Monthly subscribers get the improvements instantly at no additional fee. The service is Web based so it does not matter how the local computers are set up, or networked, how old they are, or which OS they are using. As long as the computer has Internet access and an up-to-date Web browser with the correct plug-ins, you can use the newest latest version.

	This also protects you from one of the most frustrating aspects of modern technology; rapid, (like speed of light rapid) obsolescence. Everything high tech continues to evolve and improve at an incredible rate. That means that once you have made your $8,000 investment it will be out of date in just a few years and be selling on eBay for $1.98.

	With the old system installed in the office the only way to access or view the program is to go to the office and use a computer that is hooked up to the system. With a Web based e-service you can access it from anywhere using any computer that has Internet access.

	Another advantage of a Web based system is it is very easy to integrate aspects of the program into another online medium. For example with ToothIQ you could make the educational animations part of your Web page, add them to e-mails or make them accessible to patients using smartphones or other mobile devices.

	ToothIQ is a good example of the power of an e-service but it is just the beginning. We are seeing e-services such as 3D Diagnostix that provide online assistance with cone beam scans, e-services to analyze your practice performance such or help with blling, and even e-services that combine physical equipment in the practice with automated online tools such as Cubex which manages inventory and orders supplies to save a practice time and money. In the near future we will be using the Internet in very creative ways we have not yet even imagined.

Dr. Larry Emmott, an authority on dental technology, is a speaker, writer and consultant. To find out about his high-tech training programs, Technology Guides and other services, visit drlarryemmott.com or call 602-791-7071.

 OK, what is an e-service?  Remember when e was just a letter? Well now it stands for “electronic” and anything e like e-mail or e–commerce is electronic mail or electronic commerce. But in practice it usually means a service that is not just electronic but it is online. Often as it becomes an e and goes online the “whatever” migrates from being a product to a service.  From physical to e

Dr. Larry Emmott

Articles

How to integrate dental digital imaging with your paperless workflow

Common misperceptions about going paperless

A glimpse of the future

E-services: Get more, pay less