HOW TO PROFIT FROM...Solid-state digital radiography imaging

David Gane, DDS

Dentistry has seen a significant increase in the number of digital-imaging technologies that have become commercially available during the past year. Of all the new imaging technologies that are currently being offered, CCD-based digital radiography has the biggest potential to positively impact patient care and to favorably affect overall work flow, practice efficiencies, and most importantly, a practice's overall profitability.

Figure 2

CCD-based intraoral and extra-oral digital X-ray systems can produce striking, high-resolution, diagnostic-quality digital images that rival, and in some instances, even exceed film in diagnostic quality. These solid-state-based digital radiograph systems are rapidly becoming the way of the future in the dental profession, and will no doubt soon be the adopted standard of care in our profession. (See Figures 1 and 2.)

Digital radiographs already have proven to be an invaluable resource to the dental team for diagnosis, treatment-planning, and case presentation. These images also are proving to be fundamental in optimizing communications with specialists, physicians, insurance companies, and patients.

This article will provide a look at the diverse number of ways that solid-state digital radiography can enhance patient care. It also will provide you with some compelling business reasons — based on sound economic principles — why you should be taking a very close look at digital radiography for your professional practice. Because not all of the economic advantages and efficiencies discussed in this article are common to storage- phosphor or PSP-based systems, I will limit my discussion to CCD-based systems.

Digital diagnosis and treatment-planning

One advantage digital images hold over film images is in the area of diagnosis and treatment-planning. A benefit that is often overlooked is the easy-to-view, large-format-size of the digital-image files when they are displayed on a CRT or LCD monitor.

Such a large image display allows for full-resolution viewing at a comfortable angle, which is conducive to a thorough and complete diagnosis. A large display provides for an easier X-ray viewing process, increases the likelihood of viewing X-rays in a more comprehensive fashion, and promotes a more thorough radiographic examination. A more thorough examination frequently will lead to increased diagnostic capabilities, both qualitatively and quantitatively. This will lead to a more complete and thoughtful treatment plan, ultimately resulting in increased treatment and the associated revenue it brings. This larger-image format is a major benefit when compared with viewing a standard No. 1- or No. 2-size film.

Because the image is binary code and not analog, software algorithms can enhance dentists' diagnostic abilities, enabling them to easily "extract" certain features from the digital image with the click of a mouse. Many digital images have a very wide dynamic range, containing as many as 4,098 shades of gray (or 12-bit). Even though Windows only can display 256 shades and the human eye is limited to even less (16 to 20 gray shades), these software tools present the 16 to 20 shades that are best-suited to what you are looking for, whether it be caries, lamina dura, trabecular bone, DEJ, calculus, radiolucencies, etc.

The advantages of digital radiographs in treatment-planning include the large-format image, feature extraction "software tools," and the image-management aspects of digital radiography. Imagine never having to worry about losing an image again, as well as the ability to make historical-image comparisons with ease. As digital radiographs are stamped with time and date and automatically incorporated into the patient's records, they are never lost and easily coordinated with digital photos and other clinical information. The treatment-planning process becomes faster and more comprehensive. There is no doubt that the more thorough and efficient we become as clinicians in using radiographs in the diagnosis, treatment-planning and conservative treatment of dental disease, the better it will be for both patient and practitioner from an economic point of view.

Optimized case presentation

Behavioral scientists have long informed us that as much as 75 percent of all human learning is visual. The other senses of hearing, smell, and taste account for much less in comparison. There is no better way to educate and to communicate a patient's treatment needs than to visually educate them using their own images. If patients cannot see the problem, they will be less inclined to accept the solution.

Digital radiographs displayed on a CRT or LCD monitor allow for full-resolution viewing at a comfortable angle. This is conducive to a thorough and complete diagnosis and optimized patient communication.

Fortunately, the converse is also true — patients who are effectively educated and understand their treatment needs are far more likely to accept the treatment you recommend. High-resolution, large-format, digital-radiographic images — optimized to display what you want to show — are far easier for the patient to view and understand.

Displaying the images on a large monitor also helps to optimize communication. This type of visual communication increases education and trust, leading ultimately to patient agreement. Patient agreement leads to increased treatment acceptance, which , in turn, leads to increased revenue.

The large-screen monitor and visual education clearly help to explain vertical or horizontal loss of crestal bone. The patient begins to better comprehend the insidious process and its treatment and, as a result, is more amenable to a periodontal-treatment plan. At an average treatment cost of $400, one new case per week would generate $20,000.

Facilitating efficiency

It does not take much for most dentists to grasp the incredible benefits of time- and motion-savings afforded from the "real-time" nature of CCD-based intraoral and panoramic radiographs. The instant gratification and time-savings associated with an immediate image are probably the main reasons that most dentists are initially drawn to digital radiography.

Endodontists were the early adopters of digital X-ray technology, with penetration of that market at approximately 40 percent now. As a result, endodontists were the early benefactors of the dramatic time- and money-savings the technology brings. This should come as no surprise at all when you consider the number of working films that endodontists take in the course of a day.

For example, let's look at the time-savings for surgical procedures, such as root canals or implants, where more than one X-ray is taken at different times. If each X-ray involves five minutes of actual processing time and four X-rays are taken during the procedures, that amounts to 20 minutes spent in processing X-rays. If you multiply that 20 minutes by three procedures, you come up with a total of one hour of doctor time each week tied up with waiting on X-rays to be processed. While that doesn't sound like a great deal of time, if you put the doctor's billable time at $200 per hour, then $200 a week spent waiting on X-ray-processing amounts to $10,000 a year in lost income.

Digital radiography is extremely comfortable for both the patient and the doctor, especially when a radiograph needs to be retaken. It is liberating for the patient to know that he or she will never again have to endure a double (or triple) dose of radiation. For the doctor and staff, there is no longer the laborious exercise of taking and processing a film, only to find out that the patient moved just prior to the exposure or that the projection was not quite right. Additionally, solid-state digital radiography can have a dramatic and positive effect on total staff productivity. Staff members often recognize that the investment benefits them in their work place, which can lead to increased enthusiasm and effort.

Everyone wants to excel. Digital radiography allows doctors and staff members to save time and communicate more effectively. The very process of advancing your education and learning new skills is motivating. A 5 percent increase in motivation in a $400,000 practice equals a $20,000 increase in productivity.

What's wrong with film?

At an average price of $1 per processed-based intraoral image, including labor, most offices are spending in the range of $700 to $900 per month on film and film-related costs. In many cases, the amount of money spent on film- based imaging frequently can finance your entire digital radiography purchase!

Despite having to navigate an initial learning curve, not one office I have spoken with that has made the transition to digital imaging has missed the chemical smell, the inventorying of film, the darkroom and mounting process, or the time spent duplicating film-based X-rays. Time previously spent on film-processing, retrieving X-rays from charts, moving X-rays from room to room, duplicating X-rays, and transferring X-rays to others can be far more efficiently used for expanded duties and other patient services. Do the math — how many films do you take?

For example, if a staff member takes films on 10 patients a day, the average time-savings per X-ray processing run is six minutes (4 1/2 minutes for the processor, 30 seconds to get to it, 30 seconds to put the film in mounts, and 30 seconds to bring them back to the operatory). Six minutes x 10 patients per day equals one hour of staff time.With an average labor cost of $20 per hour and $20 per day, the labor cost equates to $100 per week and $5,000 per year (250 hours x $20). Using that time for expanded duty procedures is far more valuable.

Practice-building and marketing

Digital radiography has been shown to increase referrals from within an existing client base. Patients are amazed with this technology. Whether we like it or not, patients often equate the use of high technology with high quality. Many offices using digital technology send patients home with prints of their digital X-ray series, reminding them of their experience with high technology and low radiation. The prints contain the dentists' name, address, and phone number, making them very effective internal-marketing tools and a conversation piece when patients recount their experience with employers, friends, and family.

Conservatively, you can estimate that you will receive at least 20 referrals from your existing patient base if you see 1,000 patients in a year's time. These referrals would all be word-of-mouth, based on what your patients are telling their friends and family about their positive experience in your office with high technology and low radiation. According to the ADA, each new patient spends an average of at least $400 per year on dental services, so 20 new referrals from 1,000 patients (spending a minimum of $400 per year) plays out to $8,000 in additional revenue.

I also have seen very successful public relations campaigns, articles, and newsletters by dentists describing their investment in digital radiography. They all emphasize improved patient communications, reduced chairtime, and lower exposure to radiation — sometimes by as much as 90 percent lower.

Many offices have placed news releases in local neighborhood newspapers about their new digital-radiography technology. Most can trace a number of new patients to that articles. Unlike advertising, news coverage costs you nothing. So if you gain only two new patient per month (a conservative estimate) at $400 per patient, that will yield $800 a month or $9,600 a year in additional income! These articles may generate 20 referrals a month!

In most practices, at least 2 percent of patients are totally averse to X-rays. Since most digital systems lower radiation by up to 90 percent, educating these patients on the benefits of digital radiology can produce additional income through additional treatments. Again, as an example, let's say you have a patient base of 2,000 and 2 percent (or 40) of your patients are averse to X-rays. If those 40 patients now agree to treatment because you are using digital radiography, you have gained $16,000 in production (40 x $400). Still other practitioners use digital radiography to justify a price increase. If you add just $1 to the amount your bill your patients per X-ray, and each patient has four X-rays, that amounts to an additional $9,600 per year in revenue. It's so easy to justify! Which would you choose for your own son or daughter — films or digital radiography?,

Although harder to quantify,. it also is important to realize the value of providing your patients with a reduced-stress environment and a safer, cleaner work space for ourselves, our patients, and our staff. It's also a good feeling to know that we are doing our bit to create a safer and cleaner environment.

Recognizing that all practices are different and that some would put more emphasis on certain areas than others, I have included the following checklist to help you determine your own return on investment.

Using this article as a guide, calculate your own expected return on investment (ROI). Let's assume that your digital-radiography network will cost you $30,000 at 0 percent financing. Deduct your investment tax break (Capital Asset Depreciation, Section 179) and calculate your anticipated return on your investment for the first year. We find the ROI often falls into the triple-digit range — and it would be hard to find a better return on investment.

The positive return on investment on digital radiography through the benefits of "real- time" image acquisition and the cost savings from not using film and film- related supplies are exceptional. When you add to this the additional benefits to the practice of improved diagnosis and treatment-planning, increased treatment acceptance, efficiencies in time and motion, supply savings, and additional marketing strategies, a picture starts to emerge of a sound investment that will hopefully create a desire within you to take a long, hard look at solid- state digital radiography.

Finally, before you decide on the system that's right for your practice, do your homework. All is not equal, despite what you might hear in the marketplace. You should not make a purchasing decision solely on sales information, or by learning vicariously through the experience of others. To maximize your digital imaging experience you need to receive an in-office demonstration. In my estimation, there are only a few important things to consider:

1 Image quality — Purchase the highest-resolution system that you can so the finest clinical details will be visible. The image is everything!

2 Training, product reliability and warranty — There is great comfort in knowing you have a reliable product, backed by a comprehensive warranty, and that you have been trained by professionals.

3 Integrates with practice-management software — Make sure that the system you choose works well with your practice-management software. Purchase it from a company with digital X-ray experience that will be there to back you with their product in the years to come.

If you follow these guidelines and do your homework, your choice will be a relatively easy one.

1. Increase in diagnostic capabilities
2. Increase in treatment acceptance
3. Time-savings
4. Decrease in operating expense
5. Referral increase (internal marketing)
6. News features (external marketing)
7. Increase in productivity
8. Fee increase
9. Treatment of X-ray averse patients
10. Tax incentives

Add up the dollar savings and/or increased production in each of these areas to come up with your own return on investment with digital radiography.