T. Roy Nakai, DDS, MSD
How many of you have experienced the following scenario? I recently had an appointment with my ophthalmologist, and out of curiosity and my interest in efficiency and office flow, I decided to track my time for this visit.
Visit time vs. treatment time
I wanted to see how much actual human contact I received for the total time of the appointment. I checked in at the reception desk and, after a few moments, was greeted with "hello." I then received a medical history update form to fill out, which I did in the waiting area in a minute and a half. I waited for about 17 minutes before being escorted to an exam room where I sat by myself perusing the equipment and walls for about another eight minutes. A nurse practitioner came in and asked me the reason for my visit. I told her it was a routine annual checkup. She then asked if I had any new medical, drug, or vision conditions develop since my last visit. She gave me an eye chart exam, then left the room saying the doctor would be in shortly.
Twelve minutes later, the doctor came in and cordially asked me how I was doing and how he could be of service to me. I reiterated my reason for the office visit and then proceeded through an additional eye chart exam, but this time with pupil-dilating solution placed in my eyes. After a few more queries, he related his findings to me and told me to pick up a prescription for eye drops I may need periodically for eye redness. Five minutes later, the nurse came back in and escorted me to the front desk, where I waited for my chart to be completed and brought up. That took about two minutes, and then another four minutes to wait for the prescription to come up from wherever someone had taken it. I was there at the front desk for another three minutes while they finished with the insurance forms and billing information. One hour and 20 minutes after I arrived, I walked out the door. My total time of actual human contact time was 19 minutes.
I use this scenario to illustrate an example of what is replayed in thousands of dental offices at this very moment. It is a combination of many things and not exclusive to busy practices. Where do we look to not only examine these inefficiencies and delays, but to develop solutions so we can limit or eliminate them? I have, like many of you, taken continuing-education seminars on better practice-management skills to address the issues of office efficiency and effectiveness. Spending time in hundreds of practices has allowed me to witness these inefficiencies, and I can appreciate the source of a majority of them. They evolve from "bottlenecks" in the dental practice. These bottlenecks ultimately rob us and our patients of time.
The factor of time
In my recent article in Dental Economics (March, page 68) titled, "What do Nordstrom, Wal-Mart, and Digital Dentistry have in common?" I focused on customer service and its relationship to digital dentistry. I want to continue with this train of thought because a pivotal concept is time. As we all know, time is the most precious element in a dental practice. Effective use of time is critical for efficiency and flow. This enables us to have sufficient time to spend with our patients to lend them the attention they require and deserve. The end product of this, if done properly and effectively, should be exceptional customer service and office profitability.
Dentistry is not alone when it comes to evaluating the value of time and its relevance to efficiency and proficiency. This concept is exemplified in major businesses such as Motorola, G.E., and Texas Instruments with the development and utilization of specific methodologies called Six Sigma and Continuous Flow. These companies have realized the value of advanced management skills and incorporated them into their every operation to make better use of time.
The strangling bottlenecks of dentistry
Let's return our focus to dentistry and our specific bottlenecks so we can better understand what is happening with the time and energy squandered daily in our own profession. I define a bottleneck as any system or procedure that inhibits efficient use of space and time. Most of us will agree with the existence of three bottlenecks as related by David Ahearn, president of Design Ergonomics, of Westport, Mass. Dr. Ahearn is a rabid fan of efficiency and has made it a personal crusade to not only define and delineate these bottlenecks, but also to develop clinical and operational flow procedures to eliminate them.
• The front desk
• The sterilization area
• The dental operatory
I will expand on these to include the following bottlenecks —
• Paper- and chart-driven offices
• All nondigital formats
• Compartmentalized offices
• Untrained office personnel
• Poor appointment scheduling
Instead of analyzing each one of these bottlenecks, let us concentrate on the two that focus on digital components and leave the others for another time. These two —
• paper- and chart-driven offices
• all nondigital formats
— have profound impacts on the operations of the dental practice, and are at this moment at the forefront of so-called high-tech dentistry.
Meaningful statistics — Where are you?
High technology and digital dentistry are largely becoming synonymous terms in dentistry today. Statistically speaking, 89 percent of dentists have computers in their offices according to a survey in Dental Products Report in March 2000. Of these dental computers, it is estimated that a third of these have been installed in clinical operatories. Fifty percent of dentists have an intraoral camera, but I would say that only 35 percent have it embedded into each operatory for immediate availability to the doctor, assistant, or hygienist. We have 15 percent to 17 percent of dentists who are using some form of digital radiography, and some 3 percent of dentists who are totally paperless.
So why go through this exercise in statistics? I am a great believer in two contemplative sayings. The first one is a primary tenet from the business-management programs of Six Sigma. It states, "If you don't measure it, you cannot change it or evaluate whether or not your changes have been effective." The second saying is a quote attributed to the great New York Yankees baseball manager Casey Stengel — "If you don't know where you're going, how will you know when you get there?" So, doctor or staff member reading this article, where are you and your practice along this continuum?
Let us now examine each of these statistics as they relate to dental bottlenecks and their strangling effects on office efficiency, customer care and service, and bottom-line profitability. I have always loved Joe Steven's comments from the Kisco Perspective Newsletter that patients come back to their dentists 85 percent of the time because of what happens outside of the mouth, and 15 percent of the time for what happens inside of the mouth. This tells us that our patients are perceptive people and, like my visit to the ophthalmologist, cognizant of pretty much all that goes on with them during their dental visits.
My experience has shown that although 89 percent of dentists have computers, most only use 50 percent to 65 percent of their capabilities. Every portion of your software you are not utilizing and instead persist in transcribing onto paper and placing into the patient's paper chart is a bottleneck, creating inefficiency.
Converting paper to digital format
Let us examine a couple of these common areas. What do you have within your dental charts? Yes, a plethora of valuable information is in them, but in a format that creates a bottleneck. It is difficult to easily and conveniently access it. It is not readily available to share at multiple areas in the office without being transported physically. It requires time to peruse and obtain the needed information. Computerizing this identical information makes it accessible to anyone with a computer terminal. Another important advantage of digital formats is that they allows one to standardize and legibly format the information. For example, if I create a medication prescription form from a templated digital format, I can rely that it is uniform information — not prone to human entry errors. I can print the prescription on a laser or inkjet printer, which can then be signed by the dentist. This enables me to reproduce, track, and store this information. In contrast, with a manual format, one has prescription pads lying around the office and in treatment rooms. The doctor fills them out and then files the small paper slips into patients' paper charts for historical storage.
The same is true for any clinical notes that consume large chunks of time during the course of a treatment day. Whether the dentist, hygienist, or dental assistant writes the entries, that precious commodity — time — must be used. With manual input onto paper clinical charts, we again are faced with exactly the same potential for entry errors and inconsistencies that our paper prescription forms created. By using computer-driven, digital formats, we are able to circumvent these problems as well as make major inroads into the conservation of time. I can store my series of standardized clinical notes in the form of a computerized digital template and make modifications specific for each patient as necessary for any variations to my template. Why do so many dentists continue to tolerate this obvious bottleneck? It has become accepted behavior because we have been doing it for so long the same way — "If it ain't broke, don't fix it." Nevertheless, when a superior method is available, the old way becomes ill-advised.
Becoming paperless often strikes fear into dentists and staff members alike because it is a concept that is beyond their everyday thoughts. They still rely heavily upon paper formats and dental charts for storage. The changes that must take place both physically within the office, as well as the emotional ties attached to these time-tested formats and procedures, can make the transition difficult. The more items on paper that can be transformed to a digital format will inherently eliminate the bottlenecks they create by their mere existence.
Converting the paper-driven office to a computerized digital office will allow for not only better control of the practice, but also for you to become a more efficient manager of information within the office. This results in greater efficiency in controlling the use of your time.
Win-win advantages of digital images
With increasing demands by third-party insurance carriers for diagnostic documentation for services planned or performed, digital extraoral and intraoral cameras are becoming common instruments in dental offices. Instead of placing these photographs onto photographic or regular paper and mailing them to insurance carriers, doctors are able to e-mail or forward them in digital formats to intermediary clearinghouses for this documentation. With this computer-driven, digital format, images can be directed to the clinical monitors for viewing by the patient at chairside. The saying, "A picture is worth a thousand words," cannot be truer than when viewed by a patient sitting in the clinical operatory during a treatment-plan presentation. This is another example of a digital format that aids in the elimination of another bottleneck.
Digital dental radiography imposes the biggest decision dentists will contemplate now or in the near future. First, implementing digital X-ray equipment is a costly investment. In round figures, the minimum expenditure is about $25,000. The next decision is the type of digital X-ray equipment and computer software that is most appropriate for the specific type of practice. Whatever type is selected is a moot point once radiographs become a computerized digital format. Just now, I have eliminated a major bottleneck in the clinical area by:
• eliminating prolonged film development time
• establishing the ability to access the radiograph from anywhere in the office with a computer terminal — without fumbling through a paper chart
• enhancing my X-ray with image-enhancement tools to improve my diagnostic abilities
• ridding the office of developing solutions and bio-hazardous waste-removal procedures, as well as film processor cleaning and maintenance
• gaining the ability to replicate and store the image within the patient's computer records.
The side benefit to this is that the patient is exposed to less radiation with digital radiography. As with extraoral and intraoral images, digital radiographs can be magnified and enhanced on a computer monitor at chairside so patients can see what is happening in their mouths. When patients can see their dental conditions, they are in a greater position to own their problems and be more accepting of treatment recommendations. One can easily realize the tremendous advantages gained by eliminating one of the major bottlenecks in the dental practice. What always strikes the doctors and staffs of these offices is this — the only thing they really changed to gain this efficiency was a technology with a very small thumbprint of training.
Challenges of change
During our discussion of bottlenecks, one can easily see that their elimination is important if a practice wants to achieve optimum efficiency and improve on time management. In my experience, practices that have made the transition to maximize the use of digital formats are always amazed at their own evolutions. They all comment that they wished that they had changed a lot sooner than they did. Most of them had the technological capabilities, but had to get over the psychological and emotional hurdles they had imposed on themselves.
A poignant question is this — Doctor, can you make the necessary changes to eliminate bottlenecks and provide optimum patient care and service? Oliver Wendell Holmes said it best:
"Greatness is not in where we stand, but in what direction we are moving. We must sail sometimes with the wind and sometimes against it — but sail we must and not drift, nor lie at anchor."
Look at what we can transform to nonpaper formats:• Patient-information forms
• Medical histories
• Insurance forms and EOBs
• Scanned correspondence from referrals, insurance companies, colleagues, etc.
• Recall systems
• Clinical charts, clinical notes, and clinical exams
• Periodontal probing evaluations
