Learning From Experience With Digital Imaging

An Interview with Dr. Claudio Levato.

You have been an early adopter of technology for a long time. Can you outline your general philosophy on why it’s important—clinically and from a business standpoint-- to incorporate the latest technologies into the dental practice?

From a business standpoint, I can’t say that my methods of investing in technology have always been wise. Many early adopters do not thoroughly investigate all the costs for adapting a new technology or application. We have to realize that the check we write for a piece of equipment is only the tip of the expense iceberg. We also have to factor in the costs associated with:

• Training ourselves and our staff
• Decreased productivity during the learning curve
• Educating our patients on the benefits to them for this new application
• Support for hardware and software
• Disposables
• Maintenence
• Ultimate replacement (all technology has a shelf life)
• Opportunity costs for not incorporating this new technology or application

So honestly, I admit that my decisions were primarily driven by my personal passion for pushing the technology envelope, and not necessarily based on proven business and clinical principles. In many cases, early adopters are the ones who establish the protocols and find the way to make a return on their investment. In my position as a technology editor and "expert", I have always challenged dentists to do their homework and always wear both hats (CEO and clinician) before making the final decision.

When I first began lecturing on technology (almost 20 years ago), I classified all technology into two basic categories for purchasing decisions. You have "DENTAL INSTRUMENTS" or "DENTAL TOYS" and yes, they can be the same object for different dentists. The only difference? "DENTAL INSTRUMENTS" have been thoroughly researched and have been shown to provide a tangible benefit to increase productivity or patient outcome, and will within a short period of time provide a positive return on your invested capital. A "DENTAL TOY" is something you simply must have because it has stirred something inside of you, and that you will not feel complete until you have. The benefit to anyone else is immaterial and there is no required return on investment because it needs only to satisfy a craving.

Describe your investigative process when deciding to purchase a new technology?

I still practice full-time, and when I come across an article or advertisement about something that may help me increase productivity or facilitate my process for delivering dental care, I go on the Internet and gather more information from multiple sources. Only once I satisfy myself that the item may have some value do I contact the company for a demonstration or visit them at a regional meeting.

I then seek another dentist who already uses the technology and get his or her perspective on it. I have found that most of my colleagues are extremely forthright with feedback , are very willing to accommodate questions, and are happy to have you visit their office to check it out yourself. The next step for me is to actually test-drive the technology, so I am very clear about my understanding of what I am buying and how the vendor will support it. If it does not meet the expectations they sold me, I would return it. Most companies are in business to provide tangible benefits and want you to be completely satisfied with their product or service, so if a company does not appear to be committed to support its product, I simply walk away.

I also consult for a number of companies, where I am asked to evaluate products before their introduction, so it is not often that I have to seek out new applications.

Specifically, what have been the top three benefits to your practice of using digital radiography?

I have been using digital radiography since 1992 and have been chartless since 1999. I could not have built a digital patient record without the digital imaging applications. The benefits of digital radiology are completely ingrained in every aspect of our practice and it is a defining cornerstone of our delivery of dental services. To answer this question I will break it up into three broad categories.

• Diagnostic benefits
• Patient benefits
• Business benefits

From a diagnostic perspective, simply having an image appear immediately on a 19-inch monitor compared to an inch-by-inch-and-a-half film that requires a light box to view is a phenomenal paradigm shift. Without any diagnostic tools, the increase in size and clarity alone allow me to quickly make a diagnosis and simultaneously educate the patient on my findings. In cases where the pathology is not so obvious, there is a myriad of tools that will allow me to extract objective data that I can use to fine tune my differential diagnosis.

The benefits for patients are equally bountiful. They can more easily view the image and the dentist can make annotations on the image to clarify findings and help patients understand their condition and options. The significant reduction in radiation exposure is also a benefit, especially since the standard of care requires we follow the ALARA principle.

The business benefits are very obvious-- the cost of the digital radiology system will pay for itself by replacing your current costs in film and processing chemicals alone. You merely have to look at what you have expensed annually on film, chemicals, mounts and processor repairs and divide that number into the cost of the system of your choice. This will give you the number of years it would take for you to break even. This is not taking into account the time savings in taking, mounting, filing, and duplicating x-ray films that are part of daily dental office life. There are a number of ROI formulas that the vendors and practice management consultants have made available, and I find it hard to fathom why we still have a minority of dentists using it.

You recently opened a second office to accommodate a new associate. Can you describe some of the challenges you’ve faced when choosing/implementing/networking technology for this satellite office? Include what you learned from the experience.

Many of my contemporaries are looking at transitioning from active practice, and after 32 years of dentistry I find myself looking for more windmills to slay. Actually, I did not go looking for this, like many things in my life it found me.

A little background information may be necessary to help explain why we took on this new challenge. My wife Sharon and I have been working together since 1979, when she took a position with me as a summer dental assistant while in hygiene school. She later worked for me as a hygienist and after we were married in 1982, she went to dental school. She has been the managing partner of our practice, putting structure in place while I kept adding more technology and applications into the mix over the decades. One of our assistants, Gilbert Abadilla, decided to go to dental school and when he graduated in 2005, he came back to us and said he wanted to join us in practice.

Our current practice is in a dental building with 20 dentists with no space for expansion. A dental broker brought us a 45-year-old practice for sale in a neighboring community about 15 miles away. This practice was the same distance from our home in the opposite direction with similar demographics. As we did our due diligence, we felt this could be a good opportunity to meet several of our long range goals. With four daughters ranging from age 15 to 23, my wife and I are looking at about 10 more years of full-time practice. With Gil looking to become part of our corporation we needed to implement a growth plan to accommodate him and probably additional dentists as we transition out of full-time practice.

The challenges we faced were that the new practice is old and technology unfriendly whereas our practice is extremely technology dependent and completely chartless. The first step was to win the trust of the staff and patients and to ultimately merge the practices into a single entity with two locations. We closed on the practice in November of 2007. The new practice had a single computer at the front desk that was used primarily as a billing tool. This was very helpful in that we did not have to manually add all the patients into the database. We converted the data to Patterson Eaglesoft Version 14.00 and immediately put in a computer network with a server and administrative and clinical workstations. We had two stand alone Eaglesoft networks that we could access remotely via the Internet using LogMeIn Pro. This was a functional decision while we researched a more definitive option. Our ultimate goal was a single practice with two locations, connected in real time with patient records completely accessible at both locations. Working with Eaglesoft, we decided to switch to Eaglesoft Insight enterprise software and run a T1 line between the two locations. We put a new larger, faster server into our main practice and this serves both locations.

The biggest challenge we faced was that both offices had to completely close for a full week so that both Eaglesoft databases could be merged into Patterson Eaglesoft and the software could be tested and verified accurate with the original back up data.

The planning and execution was critical, we had several conference calls with the Patterson Dental Supply crew and they gave us referrals for the T1 line and routers necessary for the data flow. We set the week of the 2008 Chicago MidWinter meeting as our conversion date since we normally close for most of that week anyway.

Sounds simple enough, but as with all things technological, stuff happens! Some of the issues that came up were a miscommunication with the company providing the T1 line and which routers were necessary to connect both locations and the additional costs. This was a hardware compatibility issue that we were not expecting. Another issue was duplicate information from the merged data since a couple of patients were seen in both locations prior to the merge. I was also under the assumption that a T1 line was comparable to real time computing. A T1 line has physical properties that limit the amount of data transmission per second (1.544 MB/sec) which is only a problem in accessing large files. What that means is that the second location has slower access time for images and other large files.

These are all minor issues compared to the benefits of a centralized database and the immediate access to reports and monitors for running our business, not to mention the patient benefits of dual locations with no interruption of care or patient record access.

What is your message for dentists who are still on the fence about "going digital?"

Being on the fence is not very comfortable for anyone, and it is usually a temporary condition because ultimately you will fall on one side or the other. My suggestion is to take a deep breath and jump forward before you fall back. I know it can be scary, but I have yet to meet any dentist who went forward with computerizing their offices or adding digital radiology and cameras that would go back to the way they practiced before. Change is inevitable and most often uncomfortable for all of us. If we take the time to do the research, we can minimize the pain and accelerate the benefits significantly. There are countless resources out there to help you move forward, but the first step has to be a mental affirmative decision that you want to make the change.