26
JADA, Vol. 123, September 1992
DATABASE APPROACH FOR DENIAL PRACTICE
JO S E P H
C H A S T E E N , D .D .S .
he practice of dentistry is on the brink of m assive change. In the past, change has been stim ulated by such factors as im provem ents in dental m aterials, restorative techniques and equipm ent design. Change has also been stim ulated by state and federal law, third-party paym ent for services and changing disease p a tte rn s in society. Now change is being stim ulated by an electronic force—the computer. The early generations of computing in dentistry offered significant advantages for th e financial adm inistration of a dental practice. The latest generation offers the practitioner m uch more. Com puterized dental devices have proliferated dram atically during the p ast five years. These devices m ake possible such functions as digital radiography, voice recognition com puter charting, video im aging, CAD/CAM fabrication of dental restorations and electronic periodontal probing, to m ention a few. This technology offers the promise of exciting tools for dentistry to significantly expand the quality, quan tity and spectrum of services to the public. H istory tends to repeat itself, and the pathw ay of developm ent of this new computer technology is no exception. Each com puterized device has been developed and improved as a stand-alone product. In the past, dental equipm ent like oral evacuators, ultrasonic scalers, fiberoptic and electrosurgery u n its were introduced into the m arket individually before being integrated into the m odern dental unit. Com puter product m anufacturers initially atte m p t to capture th eir own niche in the dental m arketplace while, in the reality of a contem porary dental practice, individual products m u st ultim ately be integrated into a unified system . A unified system provides for integration of clinical d ata generated from electronic devices w ith practice m anagem ent inform ation to create a com puter-based p a tie n t record. Not every dentist would use all of the com puterized devices and software products on the m arket. Products should be available as functional modules th a t can be connected, or interfaced, w ith a database core for the individual practice. Such an interface would present advantages for the d entist while a t the sam e tim e expanding the m arket for m anufacturers. JADA, Vol. 123, September 1992
27
IM P R O V E D C O M P U T E R TECHNOLOGY
D ram atic advances in both hardw are and software technology have created the opportunity for dentistry to move from paper and pencil p atien t and office inform ation m anagem ent to the computerbased p a tie n t record w ithout its operator having to be a com puter expert. Such advances include flexible operating system s, powerful relational database software, graphical user interfaces, netw ork system s, electronic data transm ission and more powerful com puter h ardw are a t less cost th a n ever before. For the dental practitioner, a flexible operating system will offer an open program m ing architecture th a t allows d ata from various sources to be received from different types of com puters and computerized devices. The d a ta can then be stored using sophisticated database software. D ata can be entered and retrieved rapidly using these advanced database software products. Graphic user interfaces are software products th a t free the user from learning a m yriad of keyboard comm ands to operate th e computer. Instead, the user simply points to a specific spot on the com puter screen to activate a function. This converts an otherw ise complex system into a user-friendly one. N etw orks allow several com puters to be connected together in the office to facilitate several staff m em bers using the system a t the same tim e. Electronic transm ission technology also perm its infor m ation to be sent over tele phone lines from an external com puter to th e dental office. As 28
JADA, Vol. 123, September 1992
a result, a dentist can access the office com puter system from home, subscribe to an electronic bulletin board to exchange inform ation w ith other dentists, order dental supplies electroni cally and electronically tra n s m it insurance claims to thirdparty payers. Backup system s are also available which provide for con tinued operation in the event of a system failure. R edundant storage disks th a t record a copy
potpourri of electronic boxes and unsightly cables. D ental tre a tm e n t rooms are lim ited in size and m ust be designed w ith ergonomic and infection control issues in mind. Product integration would allow the developm ent of a computerbased clinical w orkstation th a t would allow the dentist to sim ply tu rn on a chairside com puter and select the function to be performed by activating graphic symbols on the com puter screen. Described here are ju st a sam pling of com puter products currently available and designed for th e dental practice. M anufacturers are continually introducing new products and software program s to this growing m arket, and products th a t do not m eet the needs of practitioners are dropping out. M ention of specific product nam es or m anufacturers in this article are included to help dentists begin a search for com puter equipm ent and software th a t will m eet their needs; it is not intended to be an endorsem ent by th e author or by JADA. U S E S FOR T H E BASE
of data instantaneously provide a m argin of security in addition to more traditional backup tape methods. T H E C L IN IC A L CO M PUTER W O R K S T A T IO N
Im agine the advantage of a tru ly integrated com puter system to which a practitioner can attach various functional modules appropriate for the individual practice w ithout congesting the office and the tre a tm e n t rooms with a
DATA
■“ T h e C om p u ter-b ased P a tie n t R ecord W hen a function generates p atien t data, the inform ation is electronically placed, or saved, in the p atien t’s database and becomes an electronic patient record. Such a system would provide an extensive database of inform ation for each patient th a t could be accessed by the entire office staff using a netw ork of com puters in the office. The dentist can access the
patien t database inform ation from anyw here in the office netw ork of com puters, or even from a home computer, via a telephone line w hen m anaging emergencies or planning treatm ent. ■" D o cto r-P a tien t C om m u n ication Once the dentist creates electronic tre a tm e n t plans, a variety of advantages arise for the practitioner. Program s such as Im ageScan (Im aging M anag ing System s) can generate detailed w ritten explanations customized for each patient, based on the n a tu re of the problems to be treated and the plan of care. These program s require very little effort on the p art of the d entist and office staff. The internal m arketing and risk m anagem ent advantages of such a program are obvious. ™ In su ra n ce C laim s P r o c essin g T reatm ent plan data can be integrated w ith existing dental insurance databases to display the coverage available to the p atien t for the planned services. Electronic preauthorizations and claims processing are also em erging advantages to the practitioner. As transm ission technology improves, digital radiographs could be sent along w ith a request for preauthori Dr. Chasteen is associate dean, zation. The Clinical Affairs and American Operations, University of Dental Washington School Association of Dentistry, Seattle, offers to 98195-9950. Address reprint interested requests and parties a questions to Dr. Chasteen. publication
w
1
entitled, “A D entist’s Guide to Electronic Claims Processing, Vendor Services and Vendor Selection.” D ata A n alysis A p atien t database provides the dentist w ith the opportunity to analyze practice trends with regard to types of patients served, diseases and conditions treated, m ethods of treatm ent, success rates and the demand for services. In addition, dentists can incorporate quality assurance m echanism s into daily operations more easily th an in the past. The database also provides a basis for m arketing strategies and offers a new layer of security as a p art of overall risk m anagem ent. ™ R eg io n a l an d N ation al R esearch This database approach could provide the dental profession the opportunity to conduct research w ithin each dental practice and to share data on a local, state, regional and national basis. The implications for epidemiologic and clinical studies using a vast data resource are significant. D E C IS IO N S U P P O R T DATABASES
In addition to p atien t data, a contem porary com puter system allows the private practitioner to access internal and external inform ation databases to assist w ith decision-making from the workstation. For example, a pharmacology software product such as the Autom ated Drug Inform ation System by SRC Systems, a condensed pharm acopeia in electronic form th a t can be added to an office system, offers the dentist im m ediate descriptions of m edications, prescribing inform ation and side effects. A
dentist can quickly obtain this drug inform ation a t chairside in far less tim e th a n looking in a reference book. The Trojan System software is a dental insurance database th a t lists third-party carriers and the benefits of each group plan. The d a ta are updated through a subscription service and assist both the dentist and the p atien t w ith financial planning when insurance coverage is available. A variety of software products designed to provide inform ation such as th a t required by OSHA are available and can be integrated in an office system , including OSHA Lookup and OSHA Plan W riter. A new approach to inventory control is m ade available by the Paterson D ental Company with its computerized Remote O rder E ntry System. D ental office personnel can order supplies and service 24 hours a day via computer modem. The office computer accesses the supply firm’s database in Minneapolis. Rush orders and service requests are routed back to the local supply house for an im m ediate response. O rder tracking can also be done through the REMO system. A growing num ber of medical and dental abstracts are available to the dentist anywhere in the office network through subscription services like Medline and Grateful Med. Access to subscription services is m ade via a telephone modem. In the next few years, em erg ing “expert system s” are likely to be commercially available to the practitioner. Such system s assist health care providers with decision m aking. Diagnos tic inform ation is provided as the dentist responds to a series JADA, Vol. 123, September 1992
29
of inquiries in a decision tree form at. D epending on the responses, such a system leads the d entist through a logical decision-m aking process. These program s are tak in g advantage of CD-ROM technology. Com pact disks, fam iliar to audio philes, perm it th e storage and rapid retrieval of large am ounts of inform ation including photo graphic and radiographic images on compact disks. DENTAL. C O M P U T E R PRODUCTS
■■ C h a rtin g M ech an ism s One m ajor obstacle to m axi m izing com puter use in clinical dentistry has been the cumbersome and timeconsum ing ta s k of inputting d a ta required for each patient. This problem is being solved through the use of such input m echanism s as voice recog! nition, touch screen charting 30
JADA, Vol. 123, September 1992
and electronic periodontal probes. C u rren t system s, such as the Zanny System, a Swedish product, or the Victor System (Pro-Dentac), developed in the U nited States, offer a voice recognition m echanism in which the d entist or dental auxiliary w ears a small headset and dictates clinical exam ina tion findings into a microphone. The com puter verifies the inform ation by repeating the in p u t through th e earpiece in the headset, avoiding entry of erroneous data into the system. This m echanism is hands-free and ergonomically sound. Voice recognition is very strong in periodontal charting, but is currently being enhanced in the areas of restorative charting and rem ovable prosthodontics. As voice recognition technology improves, these system s are likely to improve as well. A package such as A utochart
captures clinical d ata by ch art ing inform ation on schematic diagram s on the computer screen. Through the use of eith er a stan d ard computer mouse or by touching appro priate areas on the diagram s the d a ta is entered. From an ergonomic standpoint, this input m echanism is less desirable th an voice recog nition, b u t it is very accurate and provides for reliable charting all aspects of dental data. A touch-screen approach can be used w ith infection control b arriers such as rubber gloves and household plastic food w rap around the computer m onitor. U sing the mouse would be more practical from an infection control standpoint if a dental a ssista n t not in contact w ith th e p atien t or instrum entation entered the d ata as the d entist dictated the findings. This system also offers an optional h ealth history program which the patient can respond to directly on the com puter to en ter health data. B ar code technology is also being used to chart clinical data and to docum ent services rendered. B ar codes which rep resen t various oral structures, conditions and restorations are scanned by a chairside a ssista n t to input data. Such a package is offered by Palm Tree Systems. ■■ E le c tr o n ic P erio d o n ta l P ro b in g An electronic periodontal probe, such as the Interprobe (Bausch & Lomb) is an electronic device th a t provides a periodontal charting m echanism th a t directly tra n sm its pocket depth to the com puter w ithout any interp retatio n by the operator. The system can provide a printout of the findings.
*■» O ptical S c a n n in g A new dental application of the tim e-honored concept of optically scanning special data sheets is providing another m ethod of efficient input of inform ation in th e computer. U sing a system such as Im ageScan, clinical findings, health histories and patient satisfaction surveys can all be m arked on custom -designed scanning sheets and fed through an optical scanner to input the data into the computer. U sing stan d ard word processing software, the com puter can generate printed blocks of custom ized text— plans of care, medical histories and consultation reports— which can be edited for the individual patient. This infor m ation can also be saved in the com puter database and attached to the com puter-based record of individual patients. ■■ P a tie n t R ecord T rack in g In large group practices, m ili tary dental clinics and in stitu tional settings, th e dilem m a of dental record m anagem ent arises because several people m ay need to gain access to p a tie n ts’ dental records. One record tracking system, developed by Pinpoint Systems, Inc., m aintains a database th a t routs p atien t records. A pocketsized b ar code reader is used to record a tra n sfe r of a patient record from one person to another. Then the data in the reader are tran sferred to the com puter via a tran sfer device to update the database. A p atien t record can be located from the inform ation in the database w ithout routing the dental record through a central ch art room every tim e the dental record changes hands. The system can also be modified
to track in stru m en t setups, dental equipm ent and laboratory cases. ™ V id eo Im agin g A technology used in the cosmetic industry has been adapted for dentistry. System s such as D ental View (New Image Industries) use an extraoral video cam era and com puter system to record full face and close-up pictures of the p atien t’s anterior teeth. These system s capture a fram e of video and create a com puter file which can be retrieved for future reference and m anipu lation. In addition to providing “before” and “after” video images, these system s offer an im pressive communication m echanism for both the dentist and th e patient. P atients with an in te rest in improving their appearance can actually participate in an electronic “m ake over” on the computer. The possibility of a m is understanding betw een the dentist and the p atien t regarding outcome expectations is m inim ized using this electronic approach. The esthetic changes m ay involve dental and non-dental changes. For example, the general dentist m ay electronically alter the anterior teeth to demon s tra te w hat can be achieved w ith esthetic restorations, selective grinding, m inor orthodontics or a combination of treatm en ts. T reatm ent team s of restorative dentists, prostho dontists, maxillofacial surgeons and orthodontists can easily plan complex interdisciplinary plans of care. Some system s also provide a color printer which produces a printed photograph in a m a tte r of a few m inutes. In trao ral video cam eras and
com puter system s such as the D enta-Cam (Fuji Optical Systems) are used to capture images of the dental arches, individual tee th and mucosal conditions. These images, like other clinical d ata, could be included in a com puter-based patient record. ■* D ig ita l R a d iograp h y The era of using only radiographic film to record radiographic images m ay be near an end. New techniques such as Radio VisioGraphy 3200 by Trophy USA, Inc., are providing digitalized intraoral radiographic im ages th a t can be stored, retrieved and m anipu lated. This technology allows the d entist to minimize p atients’ exposure to radiation and to m anipulate the images in the com puter using a variety of available tools such as image enlargem ent, comparison of images over tim e and contrast alteration. Since these radiographic images are stored as com puter files they can be printed using a special p rin te r designed for th a t purpose. These electronic images can be tran sferred to another d entist or to a thirdparty carrier w ithout loss of image quality associated w ith film duplication or concern about the re tu rn of original films for medicolegal reasons. The im ages could also be viewed from any com puter w ithin the office com puter network. ■■ CAD/CAM F a b r ic a tio n o f P r o sth e se s C om puter-assisted design and com puter-assisted m anufacturing techniques are being used to fabricate fixed prosthetic devices. The Cerec System by Siemens Com pany is JADA, Vol. 123, September 1992
31
one such system . Preoperative in trao ral m easurem ents of the operative field and the opposing teeth are tak e n and stored in com puter files using an in tra oral optical scanning device. This replaces th e need for bite registration and opposing study models. Tooth preparation is perform ed as usual and the shape of th e prepared tooth and its relationship to adjacent tooth surfaces is recorded using the scanner. This function replaces im pression m aking. U sing in trao ral m easurem ents, the d entist can electronically design the restoration on the com puter im age of the prepared tooth using CAD software. This is the electronic equivalent of waxing the crown. Once the design is complete, the inform ation is linked to CAM software which operates a com puter-driven micromilling m achine. Stock restorative m aterial is loaded into the milling m achine and the finished restoration is fabricated in about 30 m inutes, replacing th e casting and finishing process. Minor adjustm ents are m ade to the m illed restoration as a p art of the final fitting process and the restoration is cem ented in the traditional m anner. The d a ta accum ulated for the fabrication of th e restoration can be stored in th e computer 32
JADA, Vol. 123, September 1992
for use if the restoration has to be rem ade. A DATABASE USE S C E N A R IO
If the devices available today were tru ly integrated with a database core, the following scenario could become the description of a typical handling of patien t inform ation in the near future: A m em ber of the office staff enters a p a tie n t’s demographic inform ation a t registration to establish th e basic patient database to which clinical inform ation will be added as the p atien t progresses through the diagnosis, care planning and tre a tm e n t phases. U sing optically scanned question naires, or a p a tie n t’s direct responses to screen displays of a b attery of health questions through touch-screen tech nology, the basic h ealth history can be recorded. The dentist or staff can en ter the clinical exam ination findings using either touch-screen in p u t or voice recognition technology. These findings are stored in the com puter and become a p a rt of the p atien t’s database. If desired, the d entist could directly enter periodontal probing data using an electronic probe, elim inating the need for interpretation and secondary input by either th e dentist or the assistant.
The dentist can tak e video photographs to record existing conditions and to identify the p atien t using video imaging equipm ent. Likewise, he or she can tak e radiographs using digital techniques ra th e r th an traditional film m ethods, and the inform ation can be added to the p atien t’s database. W hen indicated, electronic occlusal analysis and m yography can be used to record occlusal relationships, m andibular m ovem ent p atterns, and muscle activity. As care planning progresses, the dentist can expand video im aging to develop a proposed plan for the im provem ent of the p atien t’s esthetic appearance through orthodontic therapy, orthognathic surgery or esthetic restoration of teeth th a t m eets the expectation of the patient. T reatm ent plans and tre a tm e n t are recorded in the computer, which can generate paper copy upon demand. THE
NEAR FUTURE
The issue of integrating individual products ultim ately comes down to an agreem ent in standards and operating systems. This will likely occur in response to a dem and created by dental practitioners. Once a database system is employed, it is likely th a t common use of a computerbased patient record will follow.
Some legal issues need to be addressed, but the demand for this change is on the rise. A pioneer in electronic chart ing technology, Dr. Richard Suddick, professor of dentistry at the University of Texas Health Sciences Center at San Antonio, views the potential for a completely “paperless” dental office in the following manner. “The concept of ‘paperless’ should be defined in the context of the clinical work station. First it is highly improbable that there will ever be a completely paperless practice. The concept simply means that all relevant clinical and accounting information in the office is acquired by a computerbased data input system and resides in permanent memory in a well-organized database. This means that relevant reports can be summoned easily for any combination of data elements by the practitioner, or researcher. The preparation of statements, letter, case presen tation and so on will continue to require paper for the fore seeable future. Similarly, reports which require concen trated study, presentation or distribution could be summoned whenever appropriate.” Now that this technology is at the doorstep of the dental profession, it is essential that educational opportunities are made available for dentists, dental students, and dental auxiliaries to learn to operate
an integrated system as it becomes available. Like the gadgets which emerged in the past, some will fall to the wayside and others will become an integral part of contemporary practice. As surely as the vulcanized denture gave way to acrylic and the cable driven handpiece yielded to the air driven handpiece, human judgment will be made easier through the resources available to the private practitioner in the computer system in the office of the 1990s and beyond the year 2000 .
E d itor’s note: The products named in this article are cited purely as examples of product types or categories. Their mention should not be construed as an endorsement by the author, The Journal of the American Dental Association or the ADA. That other products within a category are not named does not signify that these products are any less acceptable.
JADA, Vol. 123, September 1992
DATABASE APPROACH FOR DENIAL PRACTICE
JO S E P H
C H A S T E E N , D .D .S .
he practice of dentistry is on the brink of m assive change. In the past, change has been stim ulated by such factors as im provem ents in dental m aterials, restorative techniques and equipm ent design. Change has also been stim ulated by state and federal law, third-party paym ent for services and changing disease p a tte rn s in society. Now change is being stim ulated by an electronic force—the computer. The early generations of computing in dentistry offered significant advantages for th e financial adm inistration of a dental practice. The latest generation offers the practitioner m uch more. Com puterized dental devices have proliferated dram atically during the p ast five years. These devices m ake possible such functions as digital radiography, voice recognition com puter charting, video im aging, CAD/CAM fabrication of dental restorations and electronic periodontal probing, to m ention a few. This technology offers the promise of exciting tools for dentistry to significantly expand the quality, quan tity and spectrum of services to the public. H istory tends to repeat itself, and the pathw ay of developm ent of this new computer technology is no exception. Each com puterized device has been developed and improved as a stand-alone product. In the past, dental equipm ent like oral evacuators, ultrasonic scalers, fiberoptic and electrosurgery u n its were introduced into the m arket individually before being integrated into the m odern dental unit. Com puter product m anufacturers initially atte m p t to capture th eir own niche in the dental m arketplace while, in the reality of a contem porary dental practice, individual products m u st ultim ately be integrated into a unified system . A unified system provides for integration of clinical d ata generated from electronic devices w ith practice m anagem ent inform ation to create a com puter-based p a tie n t record. Not every dentist would use all of the com puterized devices and software products on the m arket. Products should be available as functional modules th a t can be connected, or interfaced, w ith a database core for the individual practice. Such an interface would present advantages for the d entist while a t the sam e tim e expanding the m arket for m anufacturers. JADA, Vol. 123, September 1992
27
IM P R O V E D C O M P U T E R TECHNOLOGY
D ram atic advances in both hardw are and software technology have created the opportunity for dentistry to move from paper and pencil p atien t and office inform ation m anagem ent to the computerbased p a tie n t record w ithout its operator having to be a com puter expert. Such advances include flexible operating system s, powerful relational database software, graphical user interfaces, netw ork system s, electronic data transm ission and more powerful com puter h ardw are a t less cost th a n ever before. For the dental practitioner, a flexible operating system will offer an open program m ing architecture th a t allows d ata from various sources to be received from different types of com puters and computerized devices. The d a ta can then be stored using sophisticated database software. D ata can be entered and retrieved rapidly using these advanced database software products. Graphic user interfaces are software products th a t free the user from learning a m yriad of keyboard comm ands to operate th e computer. Instead, the user simply points to a specific spot on the com puter screen to activate a function. This converts an otherw ise complex system into a user-friendly one. N etw orks allow several com puters to be connected together in the office to facilitate several staff m em bers using the system a t the same tim e. Electronic transm ission technology also perm its infor m ation to be sent over tele phone lines from an external com puter to th e dental office. As 28
JADA, Vol. 123, September 1992
a result, a dentist can access the office com puter system from home, subscribe to an electronic bulletin board to exchange inform ation w ith other dentists, order dental supplies electroni cally and electronically tra n s m it insurance claims to thirdparty payers. Backup system s are also available which provide for con tinued operation in the event of a system failure. R edundant storage disks th a t record a copy
potpourri of electronic boxes and unsightly cables. D ental tre a tm e n t rooms are lim ited in size and m ust be designed w ith ergonomic and infection control issues in mind. Product integration would allow the developm ent of a computerbased clinical w orkstation th a t would allow the dentist to sim ply tu rn on a chairside com puter and select the function to be performed by activating graphic symbols on the com puter screen. Described here are ju st a sam pling of com puter products currently available and designed for th e dental practice. M anufacturers are continually introducing new products and software program s to this growing m arket, and products th a t do not m eet the needs of practitioners are dropping out. M ention of specific product nam es or m anufacturers in this article are included to help dentists begin a search for com puter equipm ent and software th a t will m eet their needs; it is not intended to be an endorsem ent by th e author or by JADA. U S E S FOR T H E BASE
of data instantaneously provide a m argin of security in addition to more traditional backup tape methods. T H E C L IN IC A L CO M PUTER W O R K S T A T IO N
Im agine the advantage of a tru ly integrated com puter system to which a practitioner can attach various functional modules appropriate for the individual practice w ithout congesting the office and the tre a tm e n t rooms with a
DATA
■“ T h e C om p u ter-b ased P a tie n t R ecord W hen a function generates p atien t data, the inform ation is electronically placed, or saved, in the p atien t’s database and becomes an electronic patient record. Such a system would provide an extensive database of inform ation for each patient th a t could be accessed by the entire office staff using a netw ork of com puters in the office. The dentist can access the
patien t database inform ation from anyw here in the office netw ork of com puters, or even from a home computer, via a telephone line w hen m anaging emergencies or planning treatm ent. ■" D o cto r-P a tien t C om m u n ication Once the dentist creates electronic tre a tm e n t plans, a variety of advantages arise for the practitioner. Program s such as Im ageScan (Im aging M anag ing System s) can generate detailed w ritten explanations customized for each patient, based on the n a tu re of the problems to be treated and the plan of care. These program s require very little effort on the p art of the d entist and office staff. The internal m arketing and risk m anagem ent advantages of such a program are obvious. ™ In su ra n ce C laim s P r o c essin g T reatm ent plan data can be integrated w ith existing dental insurance databases to display the coverage available to the p atien t for the planned services. Electronic preauthorizations and claims processing are also em erging advantages to the practitioner. As transm ission technology improves, digital radiographs could be sent along w ith a request for preauthori Dr. Chasteen is associate dean, zation. The Clinical Affairs and American Operations, University of Dental Washington School Association of Dentistry, Seattle, offers to 98195-9950. Address reprint interested requests and parties a questions to Dr. Chasteen. publication
w
1
entitled, “A D entist’s Guide to Electronic Claims Processing, Vendor Services and Vendor Selection.” D ata A n alysis A p atien t database provides the dentist w ith the opportunity to analyze practice trends with regard to types of patients served, diseases and conditions treated, m ethods of treatm ent, success rates and the demand for services. In addition, dentists can incorporate quality assurance m echanism s into daily operations more easily th an in the past. The database also provides a basis for m arketing strategies and offers a new layer of security as a p art of overall risk m anagem ent. ™ R eg io n a l an d N ation al R esearch This database approach could provide the dental profession the opportunity to conduct research w ithin each dental practice and to share data on a local, state, regional and national basis. The implications for epidemiologic and clinical studies using a vast data resource are significant. D E C IS IO N S U P P O R T DATABASES
In addition to p atien t data, a contem porary com puter system allows the private practitioner to access internal and external inform ation databases to assist w ith decision-making from the workstation. For example, a pharmacology software product such as the Autom ated Drug Inform ation System by SRC Systems, a condensed pharm acopeia in electronic form th a t can be added to an office system, offers the dentist im m ediate descriptions of m edications, prescribing inform ation and side effects. A
dentist can quickly obtain this drug inform ation a t chairside in far less tim e th a n looking in a reference book. The Trojan System software is a dental insurance database th a t lists third-party carriers and the benefits of each group plan. The d a ta are updated through a subscription service and assist both the dentist and the p atien t w ith financial planning when insurance coverage is available. A variety of software products designed to provide inform ation such as th a t required by OSHA are available and can be integrated in an office system , including OSHA Lookup and OSHA Plan W riter. A new approach to inventory control is m ade available by the Paterson D ental Company with its computerized Remote O rder E ntry System. D ental office personnel can order supplies and service 24 hours a day via computer modem. The office computer accesses the supply firm’s database in Minneapolis. Rush orders and service requests are routed back to the local supply house for an im m ediate response. O rder tracking can also be done through the REMO system. A growing num ber of medical and dental abstracts are available to the dentist anywhere in the office network through subscription services like Medline and Grateful Med. Access to subscription services is m ade via a telephone modem. In the next few years, em erg ing “expert system s” are likely to be commercially available to the practitioner. Such system s assist health care providers with decision m aking. Diagnos tic inform ation is provided as the dentist responds to a series JADA, Vol. 123, September 1992
29
of inquiries in a decision tree form at. D epending on the responses, such a system leads the d entist through a logical decision-m aking process. These program s are tak in g advantage of CD-ROM technology. Com pact disks, fam iliar to audio philes, perm it th e storage and rapid retrieval of large am ounts of inform ation including photo graphic and radiographic images on compact disks. DENTAL. C O M P U T E R PRODUCTS
■■ C h a rtin g M ech an ism s One m ajor obstacle to m axi m izing com puter use in clinical dentistry has been the cumbersome and timeconsum ing ta s k of inputting d a ta required for each patient. This problem is being solved through the use of such input m echanism s as voice recog! nition, touch screen charting 30
JADA, Vol. 123, September 1992
and electronic periodontal probes. C u rren t system s, such as the Zanny System, a Swedish product, or the Victor System (Pro-Dentac), developed in the U nited States, offer a voice recognition m echanism in which the d entist or dental auxiliary w ears a small headset and dictates clinical exam ina tion findings into a microphone. The com puter verifies the inform ation by repeating the in p u t through th e earpiece in the headset, avoiding entry of erroneous data into the system. This m echanism is hands-free and ergonomically sound. Voice recognition is very strong in periodontal charting, but is currently being enhanced in the areas of restorative charting and rem ovable prosthodontics. As voice recognition technology improves, these system s are likely to improve as well. A package such as A utochart
captures clinical d ata by ch art ing inform ation on schematic diagram s on the computer screen. Through the use of eith er a stan d ard computer mouse or by touching appro priate areas on the diagram s the d a ta is entered. From an ergonomic standpoint, this input m echanism is less desirable th an voice recog nition, b u t it is very accurate and provides for reliable charting all aspects of dental data. A touch-screen approach can be used w ith infection control b arriers such as rubber gloves and household plastic food w rap around the computer m onitor. U sing the mouse would be more practical from an infection control standpoint if a dental a ssista n t not in contact w ith th e p atien t or instrum entation entered the d ata as the d entist dictated the findings. This system also offers an optional h ealth history program which the patient can respond to directly on the com puter to en ter health data. B ar code technology is also being used to chart clinical data and to docum ent services rendered. B ar codes which rep resen t various oral structures, conditions and restorations are scanned by a chairside a ssista n t to input data. Such a package is offered by Palm Tree Systems. ■■ E le c tr o n ic P erio d o n ta l P ro b in g An electronic periodontal probe, such as the Interprobe (Bausch & Lomb) is an electronic device th a t provides a periodontal charting m echanism th a t directly tra n sm its pocket depth to the com puter w ithout any interp retatio n by the operator. The system can provide a printout of the findings.
*■» O ptical S c a n n in g A new dental application of the tim e-honored concept of optically scanning special data sheets is providing another m ethod of efficient input of inform ation in th e computer. U sing a system such as Im ageScan, clinical findings, health histories and patient satisfaction surveys can all be m arked on custom -designed scanning sheets and fed through an optical scanner to input the data into the computer. U sing stan d ard word processing software, the com puter can generate printed blocks of custom ized text— plans of care, medical histories and consultation reports— which can be edited for the individual patient. This infor m ation can also be saved in the com puter database and attached to the com puter-based record of individual patients. ■■ P a tie n t R ecord T rack in g In large group practices, m ili tary dental clinics and in stitu tional settings, th e dilem m a of dental record m anagem ent arises because several people m ay need to gain access to p a tie n ts’ dental records. One record tracking system, developed by Pinpoint Systems, Inc., m aintains a database th a t routs p atien t records. A pocketsized b ar code reader is used to record a tra n sfe r of a patient record from one person to another. Then the data in the reader are tran sferred to the com puter via a tran sfer device to update the database. A p atien t record can be located from the inform ation in the database w ithout routing the dental record through a central ch art room every tim e the dental record changes hands. The system can also be modified
to track in stru m en t setups, dental equipm ent and laboratory cases. ™ V id eo Im agin g A technology used in the cosmetic industry has been adapted for dentistry. System s such as D ental View (New Image Industries) use an extraoral video cam era and com puter system to record full face and close-up pictures of the p atien t’s anterior teeth. These system s capture a fram e of video and create a com puter file which can be retrieved for future reference and m anipu lation. In addition to providing “before” and “after” video images, these system s offer an im pressive communication m echanism for both the dentist and th e patient. P atients with an in te rest in improving their appearance can actually participate in an electronic “m ake over” on the computer. The possibility of a m is understanding betw een the dentist and the p atien t regarding outcome expectations is m inim ized using this electronic approach. The esthetic changes m ay involve dental and non-dental changes. For example, the general dentist m ay electronically alter the anterior teeth to demon s tra te w hat can be achieved w ith esthetic restorations, selective grinding, m inor orthodontics or a combination of treatm en ts. T reatm ent team s of restorative dentists, prostho dontists, maxillofacial surgeons and orthodontists can easily plan complex interdisciplinary plans of care. Some system s also provide a color printer which produces a printed photograph in a m a tte r of a few m inutes. In trao ral video cam eras and
com puter system s such as the D enta-Cam (Fuji Optical Systems) are used to capture images of the dental arches, individual tee th and mucosal conditions. These images, like other clinical d ata, could be included in a com puter-based patient record. ■* D ig ita l R a d iograp h y The era of using only radiographic film to record radiographic images m ay be near an end. New techniques such as Radio VisioGraphy 3200 by Trophy USA, Inc., are providing digitalized intraoral radiographic im ages th a t can be stored, retrieved and m anipu lated. This technology allows the d entist to minimize p atients’ exposure to radiation and to m anipulate the images in the com puter using a variety of available tools such as image enlargem ent, comparison of images over tim e and contrast alteration. Since these radiographic images are stored as com puter files they can be printed using a special p rin te r designed for th a t purpose. These electronic images can be tran sferred to another d entist or to a thirdparty carrier w ithout loss of image quality associated w ith film duplication or concern about the re tu rn of original films for medicolegal reasons. The im ages could also be viewed from any com puter w ithin the office com puter network. ■■ CAD/CAM F a b r ic a tio n o f P r o sth e se s C om puter-assisted design and com puter-assisted m anufacturing techniques are being used to fabricate fixed prosthetic devices. The Cerec System by Siemens Com pany is JADA, Vol. 123, September 1992
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one such system . Preoperative in trao ral m easurem ents of the operative field and the opposing teeth are tak e n and stored in com puter files using an in tra oral optical scanning device. This replaces th e need for bite registration and opposing study models. Tooth preparation is perform ed as usual and the shape of th e prepared tooth and its relationship to adjacent tooth surfaces is recorded using the scanner. This function replaces im pression m aking. U sing in trao ral m easurem ents, the d entist can electronically design the restoration on the com puter im age of the prepared tooth using CAD software. This is the electronic equivalent of waxing the crown. Once the design is complete, the inform ation is linked to CAM software which operates a com puter-driven micromilling m achine. Stock restorative m aterial is loaded into the milling m achine and the finished restoration is fabricated in about 30 m inutes, replacing th e casting and finishing process. Minor adjustm ents are m ade to the m illed restoration as a p art of the final fitting process and the restoration is cem ented in the traditional m anner. The d a ta accum ulated for the fabrication of th e restoration can be stored in th e computer 32
JADA, Vol. 123, September 1992
for use if the restoration has to be rem ade. A DATABASE USE S C E N A R IO
If the devices available today were tru ly integrated with a database core, the following scenario could become the description of a typical handling of patien t inform ation in the near future: A m em ber of the office staff enters a p a tie n t’s demographic inform ation a t registration to establish th e basic patient database to which clinical inform ation will be added as the p atien t progresses through the diagnosis, care planning and tre a tm e n t phases. U sing optically scanned question naires, or a p a tie n t’s direct responses to screen displays of a b attery of health questions through touch-screen tech nology, the basic h ealth history can be recorded. The dentist or staff can en ter the clinical exam ination findings using either touch-screen in p u t or voice recognition technology. These findings are stored in the com puter and become a p a rt of the p atien t’s database. If desired, the d entist could directly enter periodontal probing data using an electronic probe, elim inating the need for interpretation and secondary input by either th e dentist or the assistant.
The dentist can tak e video photographs to record existing conditions and to identify the p atien t using video imaging equipm ent. Likewise, he or she can tak e radiographs using digital techniques ra th e r th an traditional film m ethods, and the inform ation can be added to the p atien t’s database. W hen indicated, electronic occlusal analysis and m yography can be used to record occlusal relationships, m andibular m ovem ent p atterns, and muscle activity. As care planning progresses, the dentist can expand video im aging to develop a proposed plan for the im provem ent of the p atien t’s esthetic appearance through orthodontic therapy, orthognathic surgery or esthetic restoration of teeth th a t m eets the expectation of the patient. T reatm ent plans and tre a tm e n t are recorded in the computer, which can generate paper copy upon demand. THE
NEAR FUTURE
The issue of integrating individual products ultim ately comes down to an agreem ent in standards and operating systems. This will likely occur in response to a dem and created by dental practitioners. Once a database system is employed, it is likely th a t common use of a computerbased patient record will follow.
Some legal issues need to be addressed, but the demand for this change is on the rise. A pioneer in electronic chart ing technology, Dr. Richard Suddick, professor of dentistry at the University of Texas Health Sciences Center at San Antonio, views the potential for a completely “paperless” dental office in the following manner. “The concept of ‘paperless’ should be defined in the context of the clinical work station. First it is highly improbable that there will ever be a completely paperless practice. The concept simply means that all relevant clinical and accounting information in the office is acquired by a computerbased data input system and resides in permanent memory in a well-organized database. This means that relevant reports can be summoned easily for any combination of data elements by the practitioner, or researcher. The preparation of statements, letter, case presen tation and so on will continue to require paper for the fore seeable future. Similarly, reports which require concen trated study, presentation or distribution could be summoned whenever appropriate.” Now that this technology is at the doorstep of the dental profession, it is essential that educational opportunities are made available for dentists, dental students, and dental auxiliaries to learn to operate
an integrated system as it becomes available. Like the gadgets which emerged in the past, some will fall to the wayside and others will become an integral part of contemporary practice. As surely as the vulcanized denture gave way to acrylic and the cable driven handpiece yielded to the air driven handpiece, human judgment will be made easier through the resources available to the private practitioner in the computer system in the office of the 1990s and beyond the year 2000 .
E d itor’s note: The products named in this article are cited purely as examples of product types or categories. Their mention should not be construed as an endorsement by the author, The Journal of the American Dental Association or the ADA. That other products within a category are not named does not signify that these products are any less acceptable.
