Economies of Scale: Expanding Beyond Your First Dental Practice Location

Technology–especially the computer–pervades every aspect of modern life, and that is very apparent at the dental office. While cutting-edge technology is used most conspicuously in the clinical areas, like any business, computers are critical in an administrative capacity. For doctors looking to expand their practices from a single location to a multi-site enterprise, those computers ease growing pains.

“Maybe the most important piece for a growing dental organization is your practice management software,” Anthony Fruehauf, Regional President for the Southeastern U.S., Patterson Dental, says. “As you expand, the ability to be able to take a snapshot of your practices and be able to see the data you need to see in the schedule across several locations is important.”

Infrastructure

More recent members of the dental team may not be familiar with the shrill, warbling tone of a computer modem dialing-in to a computer network. But for team members of a certain age, that sound can be all too familiar.

Older computer networks didn’t have the bandwidth (the speed and capacity) to send much more than text documents. Now, networks must be able to move multiple image files, and they’re expected to be moved fast. While a dial-up computer modem is a thing of the past, practices must still ensure that they have sufficient infrastructure to communicate the practice’s data needs.

“The absolute first thing that they need to ensure is that they have adequate bandwidth, enough internet speed at all locations,” Lorne Lavine, DMD, founder and president of The Digital Dentist says. “It’s one of those scenarios where the chain is only as strong as the weakest link. It’s the same here. If the main office has got a bad internet connection, it doesn’t make a difference. If the satellite locations or the additional ones that they purchase are fast, it’s only going to be as quick as whatever the slowest is. A number of years ago, the FCC basically said that broadband is considered 25 megabits per second or greater. We normally would suggest significantly higher than that – anywhere from 100 to 500 would be better for most offices.”

Once the network capacity is in place, practices must decide what kind of software architecture and they are going to use it – client-server or cloud.

“The next most critical decision is what are they going to do for their practice management software?” Dr Lavine continues. “And they have 2 choices: They can do a traditional client-server setup. Basically, the main office would be considered the main database and all the additional locations would log in to that database from remote locations. You can do remote access, which is not the most secure way of doing it, but you can do, what’s called a virtual private network (VPN), which certainly would be significantly more secure. The problem with a VPN is that usually about 35% to 40% of the bandwidth, the speed, is removed just by the fact that it has to be encrypted.”

The Cloud

Perhaps the best way to access the practice’s data is via The Cloud. It is a term that pervades American culture but is so prevalent for good reasons.

“The second option versus doing it that way, which has become significantly more popular over the last few years for multi-location practices, is cloud-based,” Dr. Lavine says. “Because with cloud-based, you’re not worried about connecting to other offices. You don’t have to set up special routers. You don’t need to do virtual private networks, remote access, none of that stuff. All of it is on the cloud.”

“Prior to the cloud, the dentist would have to dial into a server in a certain location and pull up that location to be able to check the schedule,” Fruehauf says. “With the advent of cloud, and for us it is our Fuse product, it really gives the practitioner the ability to look at that data in real time, 24/7, either down to the practice level or across the enterprise to really be able to run their business. They started with 1 office, and they used to be able to see everything they wanted to see from that server. As they get to the second and third offices, they want that ability, but they don’t want to have to dial into this server and pull that up.”

Dr Lavine warns not to get too mystified by the term “The Cloud.”

“It’s just a server that isn’t at your office and it’s somewhere else,” Dr Lavine explains. “Someone else is holding the data for you with The Cloud. You still want to have decent bandwidth, but there’s no configuration. Basically, everything runs through a web browser. It is much easier to do something like that, versus client-server. Where it sometimes can get a little bit tricky is when we’re talking about image management: image files, cone beam, digital x-rays, intraoral camera. They are quite a bit larger than what you would have in the practice management data, which is just basically text data. So, you need a lot more storage space, you need more bandwidth for something like that.”

Data Practices

Paper-based recordkeeping used to be the only way in which dental practices kept track of patient data. Now, however, dental practice management software is the norm, and utilizing that software can help practices expand.

“Patients are busier than ever, and there is a general demand for convenient services from consumers,” Mike Baird, CEO of Henry Schein One says. “As a result, dental practice providers and staff are more focused on offering a one-stop-shop experience. Software solutions offered through Henry Schein One help dental teams simplify practice management and improve each step of the patient journey. We help them measure their practice performance, which is essential for practice expansion. With cloud-based software solutions like Dentrix Ascend, dental analytics platforms like Jarvis Analytics, and patient communication systems like Lighthouse 360, our team can help you find the right solutions for each stage of practice growth.”

The benefit of practice management software is, of course, streamlining and efficiency. They also allow practices to study their data, track trends, and understand where they are making money.

“As consolidation accelerates within the dental industry, our cloud-based dental software solutions enable growing dental practices to streamline practice workflows, making day-to-day tasks easier for dental staff,” Eric Giesecke, Planet DDS CEO says. “They also provide access to analytics that are critical to long-term growth and profitability accessible within a single platform. With Planet DDS, growing dental practices can easily view financial performance by individual location, organization or region and make informed decisions to improve practice.”

Benefits

The benefit of practice management software is ease and efficiency of administration. And the more efficient and effective administration, the stronger the practice’s expansion will be.

“As organizations grow, production becomes paramount, because costs go up,” Fruehauf observes. “If you’ve invested in technology, but it’s not properly supported and properly trained, then the patient is not getting the same experience in every location. I think that one of the things that Patterson does well is–not only do we partner with the best of the best in technology–but we take very seriously our ability to train and support that technology to ensure that the practices are performing optimally, at all times. And if not, if something happens, we react very quickly to get to them and make sure that the practice is up and running.”

“Clinical excellence is not possible without organizational excellence,” Baird says. “Expanding beyond a practice’s first location is a monumental step in terms of growth, and it’s important to ensure that there are systems in place for essential functions such as HR, credentialing, revenue cycle management, recruiting, patient marketing, and KPI measurement.”

But it isn’t just improving operational efficiency and providing analytics that practice management software provides. It takes some of the pressure off administrative staff.

“Labor shortages are one of the biggest challenges dental practices face, with 2 out of 3 dentists describing recruitment as ‘extremely challenging’–and 70% say administrative employees are among the most difficult to recruit,” Giesecke says. “Denticon Practice Management software eases the administrative demands that lead to burnout and dissatisfaction by automating patient communication and engagement. For example, Denticon takes pressure off administrative staff while reducing appointment no-shows and increasing treatment acceptance through automated appointment and payment reminders. And since payments automatically post to the practice ledger, there’s no manual entry required. The result: decreasing both operational costs and administrative burden for staff.”

On the clinical end, that software provides opportunities and efficiencies to improve patient experiences. The ability to share the practice’s files like images, provides the practice the ability to share critical information not only with other locations, but also with other professionals.

“Over time, it tracks what dentistry’s been done on the patient,” Fruehauf says. “It also stores the radiography, which is an important piece of the practice management software. What’s important today is that you have software that’s fully integrated with the digital products that you have in your office, so that you’re not running digital radiography software that is not integrated into your practice management software, because then you’re really working between two softwares. When you take that digital image, it’s directly integrated into the patient’s chart as part of the software. And then your ability to really explain the case to the patient is much improved, because now you’re looking at an x-ray on a 32-inch monitor that the patient can see, versus holding up a really small X-ray and trying to get them to understand what you’re offering.”

“Given that nearly half of American adults delayed dental care during the pandemic, patients may require more urgent treatment,” Giesecke adds. “With Apteryx Imaging, our cloud-based imaging solution, we offer anytime, anyplace access to dental images. This means patients get the advice and care they need when they need it, including in emergency scenarios or during off-hour consultations. Our cloud imaging software lets dentists easily share images with collaborating physicians with just a few clicks, and our advanced imaging enhancements allow dentists to make diagnoses with even greater accuracy. These include brightness adjustment, spot enhancement, filters, labeling and annotations, and more.”

Growth

As practices expand, cloud-based dental practice management systems make growth easier and reasonably pain-free.

“Cloud would be easier because, again, you’re just using a web browser,” Dr Lavine explains. “Assuming that the cloud company has things set up properly and they’ve got plenty of storage and bandwidth, you could have 10 computers, you could have 1000 computers, and it wouldn’t really change the user experience as long as the cloud company has the ability to host the data and to serve it out at the speeds that that are necessary. You could add more computers per location, and it really should have no effect on the practice at all, other than the bottom line, because typically most of those companies will charge fees based on either the number of locations you have or the number of computers that are accessing it.”

“It really is that easy with a cloud-based solution,” Fruehauf says. “The software is going to look the same in every location. As soon as you add a location, then it really is just flipping a light switch. In order to keep the patient experience consistent, it’s about making sure the staff is trained. One of the things that dentists find out as they add locations is the reason their first location was really successful was predominantly because of the dentist and their staff. And now you’ve got to replicate that right for the second location. Our job is to make sure that, from a functionality standpoint with the software, we make sure that they’re well trained and that the software is functioning properly, so that if people must bounce back and forth between offices, for whatever reason, that experience is the same for them. And so, it’s relatively easy, from a technology standpoint, to add that second office. The ability to have the staff fully trained and ready to go when you open that second office is really, really paramount.”

Connecting an additional practice is as easy as logging in to website.

“Once an initial location is connected to the cloud, our clients tell us that implementation and setup for additional locations that join the organization is an increasingly easier process as you scale,”Giesecke says. “Our team has helped thousands of organizations migrate to the cloud and scalability is one of the strongest benefits of adopting our cloud-based software.”

“The goal of scalability is to create a ‘rinse-and-repeat’ model where definitions and decisions only need to be defined once,” Baird says. “When you move to a cloud-based software like Dentrix Ascend, you create your foundation at set-up and simply add your locations as you grow. No need to re-design the database for every new location. Whether you are converting your practice management software or leveraging BA/BI tools, you will be creating economies of scale for your growing organization.”

Training

While accessing data is a benefit of a cloud-based practice management solution, the uniformity of the system–be it server- or cloud-based–is a benefit for employee training. And more robust Internet-based instruction makes training pain-free and effective.

“That’s not limited to cloud, to be perfectly honest,” Dr Lavine says. “With Open Dental ,which does have a cloud version now, but for decades was client-server, one of their claims to fame is that they had their entire manual basically broken down into training modules and videos on their website. Now we’re seeing that’s what a lot of companies are doing, whether it’s a cloud-based or client-server. When I started my practice, we were shut down for 3 days. It was 3 days of intense training. I know my staff, and they were a great staff, but their eyes were starting to glaze over by lunchtime on the first day. There’s only so much you can incorporate.”

And in some cases, practice management software developers have streamlined training even further.

“Some of the smarter practice management software companies out there said, ‘OK, we’re not going to do 2 days or 3 days in a row,’” Dr Lavine says. “We’re going to do a half day. Let’s get you guys up to speed. Let’s get you functional and call us with any questions, and then we’ll do another half day in 2 weeks. And, over the course of 4 to 6 weeks, you’re pretty much done at that point. You still have access to some type of online training or manual. That’s not something that’s exclusive to cloud, but one of the beauties of cloud is that you can have all that stuff online and have it easily accessible.”

Employees can be trained efficiently on the software, and that uniformity allows them to work at any location.

“This is a major benefit to any centralized management system,” Baird says. “Once you train a team member, they can rotate between all your offices. What happens when an assistant calls out sick? Now you can have an employee from another location looking for more hours to backfill the position for the day. Keep your production numbers high by empowering your team to support multiple locations.”

“Training is generally consistent across locations based on need,” Giesecke adds. “As new locations are added, our training team offers training for internal administrators by location, extensive training resources, and optional on-site support on the day the location goes live. Our team members ensure that practice staff are highly familiar with the platform and feel comfortable using it prior to launch day. Additionally, we offer a self-help portal to provide answers to frequently asked questions, detailed videos that show staff how to navigate the software screen-by-screen and ongoing troubleshooting for support across locations.”

Software

Practice management software is not a one-size-fits-all consideration. The size and complexity of the practice dictates the type of software one needs. In addition to client-server and cloud architectures, when practices grow sufficiently large, they may need their own custom solution.

“The third type would be for like a large DSO, for example,” Dr Lavine says. “It’s not that common for me to see DSOs that are using off-the-shelf software solutions. In a lot of cases, they’re using customized software or software that they develop on their own, just because their needs are so much different than a solo practice or even a small multi-location setup.

“The other thing that comes into play is financial,” he continues. “We work with a lot of offices that are single-location and are cloud-based. They just like having cloud, and it is the right solution for them.”

One issue he warns practices to be cognizant of is being overcharged for cloud-based software subscriptions.

“That’s one of my pet peeves, because it’s a monthly subscription,” he explains. “If you have a client-server setup, a Dentrix, an Eaglesoft, an Open Dental – ones like those – typical monthly fees are a $100 to $150 a month. That’s pretty standard for the base software. Many of the cloud-based solutions out there, where you’re talking $500, $600, $700 a month is normal. One of the ways that some of the sales reps will justify the higher fees is to tell an office, ‘If you go cloud-based and everything’s online, you don’t need a server, you don’t need powerful computers. So, look at all the money that you’re saving in hardware.’

“There’s 2 reasons that I have an issue with that,” he continues. “Number one, if you’re paying $500 a month more than what you would pay with a client-server set up, over the course of a year, that’s $6000. That’s a server and 2 or 3 workstations. And by the time you get to the middle of year 2, you’ve already made up that difference, and you’re paying that extra $500 a month, ad infinitum.”

While The Cloud’s security can be touted, practices aren’t giving up all of their security needs to cloud vendors. They are still responsible for other HIPAA concerns.

“It’s myopic on their part to say that because, while true, that much of your patient data resides in the practice management software, certainly not all of it resides there,” Dr Lavine says. “You have images, emails, QuickBooks, Invisalign, Word documents, spreadsheets, scan DOBs – there are just so many things that’s got a patient name, a date of birth, a chart ID, phone number. All of that is considered electronic protected health information, which falls under HIPAA, and one of the tenets of HIPAA is that you need to track who accessed that data and when did they access it? What do they do with it? That is significantly easier to do with a server and a server operating system. So, for those reasons, even for offices that we work with that are all-in on cloud, almost every one of them still has a server, because they still have other data that needs to be backed up. They have other data that needs to be encrypted. So, for those reasons, it’s my contention that cloud is always going to be more expensive. Practices should get the software that’s right for their practice. Price shouldn’t be the overriding factor, but when something’s three, four times the cost, certainly you can’t ignore it. You can’t just say, ‘Well, it’s going to cost more.’ There’s usually typically a lot of other factors. At the end of the day, if the dentist, if the staff are upset with the software, if it doesn’t meet your needs, it won’t make a difference how much you’re saving. You’re not going to be happy.”