What a paperless practice really looks like

February 14, 2018

No one ever said that going paperless is easy (or cheap), but those who have done it say it's worth the price.

Being paperless is all about eliminating the scraps of paper, handwritten notes, physical patient files and the systems they are stored in, and gathering all of your information in one place. It’s about consolidating information, streamlining practices and accessing data from anywhere. As one doctor put it, it’s about pushing a button and “having your numbers,” making a noticeable difference in efficiency and enjoyment in the practice.

But what exactly does it mean to be paperless, and how can a regular practice, making its way through red tape, insurance and questions of ROI, get there?

We interviewed several dentists in an effort to outline the workflow of the paperless practice, share thoughts on operatory design and the digital technologies within it, and discuss how their practices acquire, store and secure patient data. They illuminate the benefits - as well as the drawbacks - and share guidance on how to get rid of paper in the dental practice once and for all.

The paperless workflow

For Jason Watts, DMD, being paperless means running a fully digital office. That’s apparent before the patient even steps in the door.

“I have a portal where I can upload documents that patients can access from any device,” he says. “All of the documents they fill out are digital and they instantly upload into their software. When they come into my office, they already have their records fully loaded. If not, I hand them an iPad and they fill out their documents there.”

In a paperless practice, no longer are patients sitting down with a clipboard in the waiting room before their appointment.

Their personal information precedes them so that they can instead walk into the practice and relax before the appointment, or be led directly to the operatory.

In practices where patient information isn’t gathered beforehand, patients can fill out their information on iPads or computers.

In many offices, patient information is still gathered in the waiting room just before the appointment, although in a paperless practice, it’s done on a tablet or computer.

“There are two computers in the check-in area of our reception room,” says John Flucke, DDS, technology editor for Dental Products Report. “The front desk hits a button in Eaglesoft, their practice management software, that signals the computer to display a personal welcome message to that patient. “They’ll press a button to continue, and they put all of their information in electronically. The screens are touch screen, so they can tap through all of the information. At the end, they sign on the screen, and when they click ‘done,’ the system takes that information and puts it into the standard health history and patient demographic areas.”

Dr. Flucke says it’s much easier this way because the moment the patient is finished filling something out, he or she can go to the operatory.

Mark E. Hyman, DDS, who practices in Greensboro, North Carolina, says he does it in three ways: in advance, in the reception area on a tablet or on paper. “For some patients who aren’t comfortable with it, we’ll go old school - though I’d rather not,” he says. The paper form is then scanned and imported into their software.

Going paperless means that all charting, imaging and impressioning is done digitally.

“Our radiology is all digital,” Dr. Hyman says. “We can take a panorex and a full series on the patient. We also have a CBCT, which we will take when that’s appropriate. When we do the charting on the patient, we’ll have our hygienist do the full-mouth periodontal probing. And we do a tour of the full mouth with our intraoral camera. It’s a neat way to engage the patient in their own learning.”

Incorporating digital technologies at the front desk and in the operatories makes multitasking much easier. Marty Jablow, DMD, a self-named dental technology coach, has computers at the front desk and in the operatories.

While the front desk uses one monitor for work and one just to display the schedule, multiple monitors in the operatory means that the dentist can display radiographs on one and charting on the other.

“It minimizes the amount of time that you have to look away or bring up an image to view it,” he says. “All of the images are available all the time.”

“Digital images are taken with a variety of different products,” Dr. Jablow continues. “We use both sensors and phosphor plate systems because we don’t believe that one size fits all. It’s also good for the redundancy. In case something breaks down, we’re never at a loss for taking radiographs. Having both gives us that flexibility.”

Digitizing the process from start to finish can make things smoother for both dentist and patient.

“Digital X-rays are all done digitally, from digital pan to sensor-based bitewings and PAs,” Dr. Flucke says. “We also take photos of the patients. From a restorative standpoint, it’s kind of similar. We have them update their health history every six months because things change. We take images with a combination. We have a couple of nice, digital SLR cameras, so we can take really good high-end photos outside the mouth. Not only can you take pictures of profiles in addition to teeth, but we can also switch out lenses and get really enlarged photos of different clinical situations that we’re dealing with. That all becomes part of the record, and we can send that on to the lab. We do digital impressions with the iTero. They get sent to the lab and if we have a question, we can call the lab pretty much in real time so they can see what we’re doing and offer any advice.”

For Dr. Watts, scanning has become a huge part of his practice.

“I have a scanner, so I digitally scan about 90 percent of my work,” he says. “The only thing I don’t scan yet is dentures or anything that’s heavily involved with blood or liquid. Other than that, I scan all partials, crowns, inlays and onlays.”

Those scans upload directly to Dr. Watts’ lab. Being able to see the file the lab gets helps make sure there are no issues with the scans. But when there are, it’s easy for the two sides to communicate. “It’s much more seamless of a transition,” he says.

Dr. Jablow feels similarly about his scanner.

“For digital impressions, I use the Carestream CS 3500 with their software, which makes taking impressions easier and more accurate,” Dr. Jablow says. “And we get quicker turnaround times because we are not losing the transportation time from the office to the lab since it’s going digitally. It’s being touched less than it would be in a conventional impression. We have a more efficient process now. Our biggest problem is that we can’t get the patients in fast enough once we get the lab work back.”

Another major advantage of going digital is the security it offers.

“We use Curve for the software, and that’s all backed up in the cloud,” Dr. Hyman explains. “We also have a redundant server, so we have on-sight storage plus a cloud backup.”

Dr. Watts also sees value in a cloud-based system. He says it is beneficial because he can work from home and access his encrypted files there, if needed.

“From the IT standpoint,it’s less complex, so it’s more cost effective,” he says. “My electronic costs are only a third of what a normal office would be with an IT storage room, where everything is hard downloaded. A lot of offices might only have one or two backup servers, so if something happens, all your files are lost and you’re starting from scratch. It’s nice to know that all your stuff is backed up.”

Increased efficiency

The benefits of a paperless practice are numerous. It increases the practice’s efficiency and profitability and reduces the opportunities for errors to arise. And, Dr. Hyman says, it’s more fun.

“It’s a joy to have your information digital,” he says. “Having your digital radiographs up in front of you in a nanosecond - instead of going through a processor - and having your intraoral camera photos right in front of you so that the patient can see it on a big monitor in front of them is a joy. You can do treatment planning through your software, so the patient can see their fees and the number of visits that you’re estimating.”

Digital tools improve the ability for the doctor to communicate with their patients and their lab as well as for teammates to communicate with the doctor.

“When we do our morning huddle, everyone is looking at our day to identify roadblocks to us being maximally efficient and effective,” Dr. Hyman says.

Another benefit of being digital is that there are multiple ways in which the team can access information.

“We don’t even have computers in our operatories,” Dr. Watts says. “Everyone on our dental team has their own personal tablet that they walk around with, which is super cost effective comparatively. I have fewer computers, no paperwork, and I’m not worried about printing and buying ink cartridges.”

It also saves time for the doctor and the patient because the data is mobile.

“I don’t have to be in the hygiene operatory with the hygienist to review anything,” Dr. Flucke says. “I can check a patient’s health history from my desk or any computer in the office. I can look at bitewings on any computer in the office. Being able to do those little things makes everything flow better.”

Dr. Jablow agrees. What impacts him the most in the operatory is having all of the information at his fingertips for any patient, including old and new images.

“The general workflow allows us to be continually updated with what’s happening in the schedule and respond to it,” he says. “We can see our appointment book in real time, so if there are changes being made, nobody is running from the front of the office to the back. It’s just updated on the screen.”

For instance, if he has a patient in the operatory and sees, from chairside, that his next patient has cancelled, he can then continue to do more treatment on his current patient if necessary.

“If I didn’t know that, I’d tell the patient we’re done for the day and bring them to the front desk, and we would have lost that opportunity,” he says.

Patient benefits

A paperless system allows for easier and more flexible scheduling.

“If you walk in and there’s a 10 o’clock opening in hygiene, where’s your short call list? You can have something written on a piece of paper, or you can push a button and there’s everyone that’s due for hygiene,” Dr. Hyman says. “We work very closely with Solutionreach as well, so we can zip an email first thing to 50 patients who are due for hygiene and say, first one in gets this 10 o’clock appointment today.”

Dr. Hyman says that in one six-month period of working like this, his practice experienced a $100,000 increase in appointments that had “fallen through the cracks.”

Of course, not having paperwork lying around the office means no growing piles to file or scan and no chance to lose information. Having digital prescriptions (i.e., “e-scripts”) also keeps them safe from forgery. Doctors can issue e-scripts with their software, which are instantly sent to the pharmacist. E-scripts keep patients and doctors safe from lost or altered prescriptions.

Paperless files also make patient communication easier. With patient portals, patients can access patient forms online, upload completed forms and even pay through the portal. And with mobile, digital files, doctors can help patients stay on top of their diagnoses and treatment plans - even if they aren’t currently following one.

“I have two screens in my office, so if someone comes in with four bitewings, I’ll put an enlarged bitewing on one screen and the patient’s chart on another screen and look it over,” Dr. Flucke says. “If someone has something from their last visit that they didn’t get done, I see their chart and know that I can remind them to have a situation taken care of since it’s been six months or a year since we told them about it and it’s not getting any better.”

Having imaging software in the operatory that captures and displays the images to the patients has helped to enhance patient education for Dr. Watts.

“I have the imaging software on tablets and they can instantly load into the cloud software,” he explains. “From there, I’m able to analyze and educate patients by handing them the tablet I use. We go over their X-rays together and we dictate the treatment from there.”

Beware of crashes

With a digital, paperless practice, there has to be some form of backup. A practice can choose to back up their data to a local server, or they can back it up to the cloud. There are risks to both, which is why having more than one form of backup is smart. As Dr. Flucke says, it’s good to have a “backup chain” with as many links in the chain as possible. To ensure a good backup chain, he says, practices should strongly consider having an expert set up a good backup system for the practice.

“A lot of times, dentists think that if they have a carbonite backup, they’re good,” Dr. Flucke says. “You might be. But you need to have a disaster plan in place. I’ve had my system go down three times in my career. If patients come in and don’t remember what they’re here for, it’s a nightmare.”

“If you’re backed up in the cloud and the cloud crashes, everyone’s in trouble,” Dr. Hyman adds. “That’s why I think you should have a redundant backup.” He utilizes both an on-site and cloud backup.

Because of the risk of a crash, some practices still rely on paper. While having digital files makes things run more efficiently, the risk of losing that data keeps many from fully committing. Those are the practices that keep paper files - just in case.

“I don’t consider a backup a solution, I consider it a minimal effort because it’s about office continuity,” Dr. Jablow says. “In my office, we use DDS Rescue, a redundant server that takes a snapshot of the entire server - not just my data - 30 times a day. In effect, I’m not just backing up my patient data, I’m backing up the entire server. At the end of the day, that information is transferred online to multiple service centers to protect it. In the event that the server fails, the in-office redundant server can be switched over in about 10 minutes. In the event that the office is totally compromised in terms of fire or theft, the entire server can be virtualized online.”

Dr. Jablow’s practice made it through Hurricane Sandy. Because his office was without power, he had to rely on virtual access to his data.

While dentists fear a server failure or a cloud crash, physical damage to paper files is a very real possibility, so the only semi-secure option is to have multiple backups - which is why Dr. Watt’s decision to store data on a local server, in the cloud and in paper files isn’t as over-the-top as it may sound.

“Many practices in the U.S. face a grave danger of a hurricane, tornado, flood, theft or hardware failure,” Dr. Hyman says. “You can lose your data and what a nightmare. I think it’s imperative for every practice to backup in the cloud.”

The cloud is far from risk-free, however. Aside from the fear of a crash, there is also a fear of a breach.

“We’ve got HIPAA to be concerned with, so you have to protect your data and make sure that your network is safe,” Dr. Flucke says. That’s why he suggests having an expert set it up for the practice. “I don’t do the security on my own network. No way.”

Dr. Jablow agrees. “Having the right IT guy is critical,” he says. “It’s like going to the dentist. You have to trust the person and hope they know what they’re doing.”

What about the cost?

Having technology means signing up for constant updates and add-ons. That’s just the way of the digital world, so it’s something dentists should be prepared for, Dr. Jablow advises.

“Everything now is an add-on,” he says. “I call it the monthly creep. Every month, I have services that cost me more and more money but are considered ‘essential,’ such as reminders, social media, backup, redundancy. All of these come with a price tag that never goes away, and they become critical parts of our office.”

These expenses, which cost Dr. Jablow’s practice thousands of dollars a month, weren’t a concern 10 years ago.

“Where does it start or stop?” he asks. “Does the price decrease, or are we just going to be looking at paying more and more for software as a service in what we’re going to be considering essential add-ons?”

For those who only have paper charts, this is not a concern. Of course, they risk losing their data completely. Pay for the insurance, or take the risk of paying dearly when your worst fears come true.

“The drawback is that you have that initial investment in your equipment, but you also have to recognize that it’s not a one-time expense,” Dr. Hyman says. “You’re going to continue to upgrade your hardware and software, because that’s the way of the world. It has to be budgeted for.”

Going digital comes with a harsh reality of risk and cost. And now, there is less of an option for practices to wait for the release of retirement, when new owners will be responsible for moving the practice into the future.

“As a Baby Boomer doctor transitioning the practice, if you bring in a young gun and you’re not fully digital, the young doctor is going to look at you as being old school and behind the times, and they’re going to know that they will have to invest in more computers and hardware and software and intraoral cameras, cone beam scanners and digital sensors,” Dr. Hyman says. “Those are the dues you pay as a Baby Boomer doctor to have your practice look cutting-edge to your patients and to your young potential associates and partners that are going to come in and buy your practice some day.”

As with everything in business, the obstacles to being paperless for many doctors are cost and the feeling that things are good enough.

“I would ask doctors to think of the big picture,” Dr. Jablow says. “Don’t think about the amount that the software costs. What’s it costing you if it’s freeing your team up and you’ve got a hold of your information to fill in holes in the schedule and you can make sure doctors and hygienists are reaching their daily goal? If you don’t have control of your information, you are just shooting in the dark, or you’re spending tens of thousands of dollars on marketing, trying to get new patients in when you already have $1 million of undone treatment sitting on your books.”

And the most important thing? “The biggest part of the digital office is increased efficiency,” Dr. Jablow says. “Time is money. That’s what it comes down to.”

Getting started

“I think the trying parts are making the decision that you need to go to the next step and getting past the fear,” Dr. Jablow says. “That’s usually the biggest problem with people in integrating technology. They’re scared of making bad decisions that will cost them money, so they just freeze and don’t do anything because what they’re doing works.”

A good place to start is to make the most out of the software that’s already in the practice, since the majority of practice management software features go unused. Then, start building slowly from there.

“Most of the paperless stuff is about reducing filing issues and figuring out how to get the paper into the digital system,” Dr. Jablow explains. “One of the first things practices need to do is purchase a paper scanner and a shredder. That will allow your front desk to at least get a little more efficient to get those documents into the computer.”

The next step is to get computers in the operatories and get comfortable with using them there.

“If you’re not the tech guy in the office, get out of the way,” Dr. Jablow says. “There is usually some tech person in the office who’s a lot more comfortable than the doctor. If that’s the case, empower them. Let them be in charge of it. Don’t do something you’re not comfortable with.”

Dr. Hyman’s final piece of advice is to not worry about scrimping and saving on those early costs.

“I hear so many doctors asking, where can I save $100 on my software?” he says. “How about getting the finest software and the finest intraoral cameras so that you’re maximally efficient and effective and you can add hundreds of thousands of dollars to your practice?

“Be a big-picture thinker,” he continues. “Have the confidence to know that the most successful dental practices in the country are highly digital, paperless and cutting-edge. And they have a budget every year for technology, knowing that they are going to have to continuously invest in the practice so that they can keep it at a superior level. It’s good business to know that this is a consistent investment - and getting better.”