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The Chartless Dental Office

May 1, 2003
Practicing the art and science of dentistry integrates basic biology, chemistry, physics, and other scientific disciplines to provide optimal patient care. Likewise, an understanding of business disciplines is also important.

Is chartlessness a fact or fantasy? Stop feeding that "Wall-O-Charts" monster and start thinking digital chart.

Written by Allen Jorgensen

Practicing the art and science of dentistry integrates basic biology, chemistry, physics, and other scientific disciplines to provide optimal patient care. Likewise, an understanding of business disciplines is also important. Although unseen by patients, these skills are essential to the smooth operation of a dental office. Basic accounting, chart review and management, patient flow analysis, staff management, leadership skills, and accounts receivable management are the disciplines of the business of dentistry.

Historically, individual patient charts have served as a record of diagnosis, treatment, and resolution. Recently, instead of a simple tool to provide patients with better care, the chart has multiple purposes: a legal protection or government regulation tool; an insurance tracking and processing method; a HIPAA compliance document; a billing and receivables management system; and a free-standing, bloated, inefficient entity that requires catering from multiple staff! To merge the simple act of caring for patients with the demands of modern-day realities, electronic charts are the answer. The revolution in utilizing electronic charts incorporates today's best business techniques and technologies.

Then and now

Over the last 50 years, businesses of all types (retail, utilities, manufacturing, etc.) have undergone significant changes in processes by embracing new technology to deliver better goods and services at a lower cost. In the early 1900s, the business office of a bank resembled a dentist's business office. Each depositor had an individualized ledger card by name and a folder with all signed documents, such as loans. More than 100 years later, modern-day banking has changed with the use of Internet banking, ATMs, and availability of funds at multiple branches. Technology did not come to the banking process overnight. As technology evolved, technological applications were updated and even these have changed over time to remain competitive. Your dental practice deserves a similar update to a chartless office.

How to start

By reading this article, you are already on the road to "chartlessness." For offices starting from scratch, congratulations! By starting as a chartless office, you can achieve life-long cost savings by minimizing wasted staff time. For established practices with charts, set a goal and time frame for conversion to a chartless office. Phase in these changes over an 18-to-24-month period to be efficient and effective. Your road map for this journey will be described in the next article in this series.

Can a computer screen replace a paper chart?

If you are starting a practice, go modern and begin chartless. If you own a practice, do you have a "Wall-O-Charts" monster that can stop being fed? While a paper chart can be touched and held, those rows and rows from floor to ceiling take up valuable space and require attention. Like modern banking, you can eliminate that monster. Your dental business data can be stored in a fraction of the space with today's tools. You can eliminate the hassle of chart retrieval; the frantic search is over.

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Once you decide to convert to a chartless system, develop a plan and set a start date. You may be surprised by the space savings when you get rid of those expensive rotating file cabinets. You will be pleased with the money and time you save in labor, fruitless searches for a lost chart, and more efficient use of office resources.

Other questions remain: Can paperless charts be customized to suit your needs? Will patients be served better? Is the office both protected and relieved from nonclinical-related work? Even if you choose to convert, will the office be disrupted?

Your data can be stored and viewed on a computer screen. The computer is designed for data storage, retrieval, and processing. Data contains "fields" for name, address, date of birth, allergies, medical history, etc. These fields can be physically encoded into the chart for future use, with the data "captured."

Data collection and retrieval is easy, and you can perform various permutations and combinations with the data. Unlike a paper chart containing multiple data points "wrapped" together in a single place at a time, the computer allows multiple people to do multiple things in parallel with the same information. The computer formats the data into subsections, delivering insurance information and providing important clinical information simultaneously. You can share data with your staff while the office processes insurance claims. You also can isolate data so that a referring specialist sees only certain fields.

While paper charts have a limited number and pocket size, computer data is expandable to meet your needs. You can use the digital charts in multiple places, while protecting patient information. Since the computer has expandable "pockets," any information formerly part of a paper chart can be encoded digitally.

Pokémon® and the dental office

If you have school-age children, you are probably familiar with the Pokémon® cartoon and trading card craze of the last few years. In this fictional world, various sorts of creatures are able to "hop" out of their digital holding ball and fight various battles for their trainers, and then, on demand, "hop" back into digital storage. While this seems to be a child's fantasy, the digital dental chart possesses this same characteristic!

Imagine a perfect day in the office. You would have essential information to meet and greet each patient, the most current X-rays, and any referral information. You would have current drug therapies and any medical alerts, lab slip information, and before-and-after images that document treatment results. Gone are the time spent assembling specially colored forms with key hole punches and the aggravation of handling films in their mount, or that fuzzy Polaroid.

When a digital chart appears on the screen chairside, the results are everything you imagined:

  • All current hard tissue and soft tissue charting with historical versions
  • Personal information with screensaver reminders to ask about the baby or the graduation
  • Digital X-rays with computer applications to use for treatment planning, treatment consultations with specialists, or patients for co-diagnosis and education
  • Every referral completely documented and reproducible with the specialist's response/resolution
  • Every prescription logged and printed for signature
  • Detailed lab scripts in the chart with computer-generated duplicates for the laboratory
  • A reproducible digital image of every intraoral and extraoral image documenting the initial patient presentation and results of your treatment

You have peace of mind knowing that you can retrieve information and that it will be retained for future use. The computer can alert you to all endodontic referrals who have not returned for crowns. It can track your historical success with different labs over a period of time, instead of when that one crown will not seat. The computer can alert you to standard treatment, such as repeat radiographs. The list is endless once the information is digitized and unleashed. With a little training, your own "dental Pokéman®" will be winning at every task you assign it!

'Chartlessness' is not 'paperless'

"Chartlessness" doesn't mean that you totally eliminate paper in your office. Pen and paper should be used for many purposes: original health history, health history update, financial information, informed consent, confidentiality, etc. Keep these "original ink" items at least as long as state and federal laws dictate. While any piece of paper can be turned into a digital image, know which items must be stored by law. Even though a document is collected with ink, it does not require an individual chart. Rather, the existence of the document can be entered into the computer and then you can document the whole day chronologically. You can store items on a disk or CD or other media.

Stop feeding the monster and start thinking digital chart. Watch that Wall-O-Charts disappear!

The next article in this series will address which items to consider for your computer-maintained "chart."

Technology Acquisition

To become "chartless," you must be able to digitally access a chart in all of the locations that you currently use a physical paper chart. A typical five-treatment-room office will need a network of approximately 10 computers -- one for each treatment room, check-in, check-out, doctor's office, sterilization, and back-office/staff area.

Since most offices have one or two computers, this seems like an insurmountable obstacle just to get started. However, today's computers are much less expensive than they were just a few years ago. If you shop wisely — without "overbuying" — you can easily get the infrastructure you need.

Server — This is the machine that "holds" the data and that the other machines talk to. This is the area that is usually grossly overbuilt and overspent. In a typical corporate environment, a server can and should be "beefed up" to support the work environment of office staff. Since volume is low, the server in a typical dental office can be any average machine (with the addition of a disk-mirroring card to protect your data from a head crash). Cost: $600 - $1,500.

Workstation — Rather than "specialized" machines that are different for business workstations vs. clinical workstations, try "universal" computers. With today's computing power, these can serve all functions. Cost: $400- $800.

Backup — This is mandatory. Use a drive; don't use tape backup systems that are slow, error-prone, and obsolete. Historically, tapes were the most cost-effective solution. Hard-drive capacity used to be smaller, expensive, and not portable. Today, drive capacities are 100 times greater, and the cost of drives are a fraction of the cost of a quality tape drive. Depending on how you configure your environment, off-site backup could be free (part of your notebook computer) or very inexpensive (less than $200) if you use portable hard drive technology.

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Allen Jorgensen
Mr. Jorgensen is a principal in the Lighthouse Practice Management Group, which offers consulting services to dental practices with a focus on PracticeWorks software users. He conducts seminars to help dentists implement high technology in their practices. Contact him at hitechteeth@