Links for "Why Paperless Dentistry?  Why Now?"

(Dental Economics, August 2007)

By Linda Piccinini, RDA,  and Bruce A. Stephenson, DDS, FAGD

The concept of “paperless dentistry” is often misunderstood. And while most dental practices are now “computerized,” many practices don’t use the key features that make paperless dentistry easier and more profitable. The purpose of this article is to define paperless dentistry, to illustrate some of its advantages over paper-based systems, and then discuss why it is now so easy and inexpensive to start benefiting from its rewards.

“Paperless Dentistry” is defined as the practical use of computers as “force multipliers” or “electronic levers” so we can provide more and better patient care in shorter time with less effort¹. Paperless dentistry makes working in a dental practice easier and more profitable. Paperless dentistry does not mean the elimination of all paper! Paper is still good for many things. It makes a great “display device;” a portable, light-weight medium we can give to patients to take home showing how great they will look with porcelain veneers or to remind them of their post operative care. It does not make sense to eliminate paper where it still provides a valuable service. But paper should no longer be used for storage, searching or sorting. These tasks are much better done by computer. A common misconception is that paperless dentistry means putting all your patient records in a computer. This is actually better called “chartless²” and may not meet our objectives of providing more and better patient care in shorter time with less effort. For example, simply scanning all your patient records into computerized form could make you “chartless” without providing the key advantages of computers: storage, searching and sorting. Let’s look at each of these tasks and see how much better they are handled by computers.

Paper storage took up a lot of room and cost a fair amount of money. Paper records were often close to illegible because they involved so many hastily hand-written notes. It was not uncommon for a mature practice to have boxes and boxes of inactive charts stored in a garage or basement. But computer storage is essentially infinite and free. One-hundred years of patient records can be stored in a device about the size of a cell phone, costing less than $200. Paper records were very susceptible to fire and flood damage. But in a well-computerized office all records are duplicated and easily retrievable from both on-site and off-site backups. Even in the unlikely event of a “server crash,” these backups allow a quick restoration of all patient, x-ray, accounting, and personal records. Not a single patient record is ever lost.

Searching for paper-based records was time consuming because it was so dependant upon the accurate filing of the record by the last user. Often this last user seems to have suffered an attack of dyslexia or used the Martian alphabet! Searching for paper charts wasted time. Computers instantly retrieve any chart for any patient, then always re-filing it again correctly. And the same patient’s chart can be viewed on several computers simultaneously. One person can bill insurance while another makes an appointment and a third person completes the progress notes. The doctor can access paperless charts from home … or from any other computer in the world … using a secure, encrypted Internet connection³. You enter information only one time but can be used simultaneously everywhere in the system. You enter the patient’s birthday a single time and it is copied to the medical history, calculates the patient’s age to display in the chart, and is placed correctly on every insurance submission. The single entry is also used to track birthday card lists, is printed or emailed for referrals to other doctors, is printed on prescription forms and used to ensure that “child prophies” are not posted for adults. This “force multiplier” requires less time and labor and reduces errors. These paperless tasks are simply impossible with paper-based systems.

Information sorting delivers the greatest benefits of paperless dentistry⁴. Think about a paper ledger tray filled with patient balances. The only way to sort the paper ledgers was by alphabet. It was tedious, time-consuming, inefficient and inaccurate. A paperless practice can instantly sort patient accounts by many criteria other than the alphabet. For example, a sort of the oldest balance first or the largest balance first is much more useful than an alphabetic sort. Or a sort of the oldest outstanding insurance claims with a sub-sort by individual carrier makes calling on these outstanding claims quicker. Sorting unscheduled treatment plans by treatment plan date, or largest treatment plan first, or by specific procedures such as “pontic” or “veneer” provides a more productive way to fill a schedule. Sorting patients by overdue recall date ensures that patients get the preventive care they need and keeps the hygienist busy. Where do your new patients come from? Sorting by referral source gives you invaluable practice management information and reminds you whom you need to thank for all those referrals. The American Heart Association has just released new guidelines⁵ for antibiotic pre-medication and at least one malpractice carrier⁶ has recommended that we send a letter to all patients we previously pre-medicated. This would require days of searching with paper-based charts but can now be done in seconds with a paperless system. These are just a few examples of how a paperless practice can better patient care, in shorter time with less effort.

Most dental offices no longer use a paper appointment book but are not truly “paperless” because they fail to use the searching and sorting capabilities of a good scheduler. Management consultants now recommend the use of daily production goals. When the treatment (entered only one time when it is diagnosed) is tied to appointment, a computer scheduler will automatically display the booked production for the day. The computer does the work and it requires no effort for staff. Filling of open appointment time productively is easier because your paperless records allow an instant “chart audit” for unscheduled treatment plans. The computer automatically stores broken appointments and counts missed appointments for each patient, each provider, each day and each month. The list of broken appointments is quickly sorted to send letters, emails, or make phone calls to ensure patients are not overlooked. The antiquated axiom that only one person in the office should make all appointments has proven false.  Paperless scheduling is multi-user and decentralized. Appointments should be made in all areas of the office, especially in the operatory. The doctor, patient and chairside assistant can collaborate on when, how long, and what treatment will be done next. This eliminates confusion and errors. Patients appreciate not wasting time waiting in a line at the front desk. Patients also appreciate the legibility and accuracy of a computer-printed (on paper!) appointment card and the up-to-date thoroughness of an automatic email reminder.

Computerized progress notes are the easiest and cheapest paperless task to master and instantly provide great increases in time savings and office efficiency. Yet this seems to present the biggest psychological hurtle for many dentists. Even the Federal Government wants you to be paperless⁷! It has set the goal for all medical records to be paperless by 2014. Paper charting was slow, often illegible, and required an unnecessary and non-productive amount of the doctor’s time. Paperless charting does not require typing! It uses either a few mouse clicks or taps on the screen with a stylus to provide paragraphs of accurate, legible (and correctly spelled!) and individually customized notes. Several sentences of comprehensive documentation for a procedure such as a crown are completed in less than one second in the progress notes and copied to an insurance submission without ever touching a keyboard. The use of blank templates for examinations, consents, medical histories, treatment plans and financial arrangements ensures that all relevant information is quickly recorded. An informal survey of our clients shows paperless charting saves an average of two hours of doctor time per week and is usually completed before the patient leaves the operatory. More and better patient care in shorter time with less effort!   (For more information on the specifics of free paperless progress notes, visit our website at www.PaperlessDentistry.com or "charting notes.")

Dental images (x-rays, intra-oral camera images and extra-oral digital photographs) provide another practical illustration of how a paperless dental practice uses storage, searching and sorting very profitably.  Imaging also illustrates how paperless dentistry is constantly evolving as technology changes. Fifteen years ago, dental photography required cumbersome cameras and inconvenient 35 mm film. No one disputed that it provided good documentation and great patient motivation and education.  But it was expensive and difficult. Storage took up a lot of space and sorting took up a lot of time. Computer imaging and inexpensive cameras have now eliminated all the disadvantages and made it so easy to graphically show patients their problems. Even the least expensive home “point and shot” digital camera takes wonderful “smile” photos with an image on a 19” color monitor right in front of the patient in seconds. When the patient inevitably asks, “Are those my teeth?” you no longer have to point out all the dental imperfections … just let the patient look at the monitor and they will find them all by themselves. You don’t have to “sell” dentistry, patients ask for it. Using a light, portable intra-oral camera not only enhances your own ability to see and document caries, cracks, fracture lines, and deteriorating margins but allows the patients to spot them right along with you. Digital radiography is rapidly becoming the standard by which patients judge a modern dental practice. They have heard it provides better diagnosis with less radiation and they are increasingly seeking practices that provide this improvement.

You can see the advantages but what makes this such a profitable time to add paperless dentistry to your office? One reason is because each day you wait costs you money, stress, confusion, wasted time, and all the lost opportunities for a better practice.  This is no longer “bleeding edge” technology. It is sound, practical, easy, widely used, inexpensive, cost-effective and fairly rapidly achievable.  Consider how reliable and inexpensive computers have become⁸. All computerized practices, paperless or not, need a reliable file server and a bullet-proof on-site and off-site back up system⁹. Such systems previously cost several thousand dollars. Now for an average office they are only a few hundred dollars. Even a server and backup system for a large multi-doctor practice with many operatories can be relatively inexpensive with the help of a knowledgeable consultant. Dentists have often been over-sold and misinformed on computer hardware. Keep in mind, small practice or large, you want a “sturdy truck,” not a “sports car!” While computers are now very reliable, workstations do occasionally “crash” and require “re-booting.” But your file server should run for years without crashing. If yours doesn’t, you should consider a new file server … or a new computer consultant. Rock-solid reliability and tested, redundant backups are required for all dental offices but have never been less expensive or more easily obtainable.

Spending a lot of money is no longer a prerequisite for paperless dentistry. Neither is changing your brand of dental software. Most dental software companies have already provided the basic features needed. You do not need your dental software to provide special “automatic charting” features. You only need a place in the software to store your charting. The charting itself can more easily and accurately be produced “outside” the dental software using programs such as OpenOffice⁹ (free), Microsoft Word¹⁰ (often either cheap or free), or EasyNotesPro¹¹ (inexpensive and very slick). The completed charting is then simply “pasted” into the place provided in dental software. Similarly, your imaging features need not be provided by your dental software. Software specifically for digital x-ray and imaging usually provide better features than the ones included with practice management software. Any of these separate imaging programs can now be seamlessly linked to virtually any management software.

These days, the advantages of paperless dentistry are not determined by your brand of dental software. They are determined by how well you use that software. Quality dentistry is determined by the skill of the dentist, not the brand of the handpiece! It’s the painter, not the brush! And, like skill in clinical dentistry, paperless dentistry is a journey, not a destination. It can most easily be done in increments rather than attempted all at once.  Skills increase through practice and training. Capabilities expand as the computer technology continues to increase. But there has never been an easier time to seize the advantages of paperless dentistry … providing more and better patient care in shorter time with less effort. You, your staff, and your patients deserve it!