by Keith Hilliard, DMD

A guide to upgrading your legacy technology

There’s a reason legacy computer systems are often referred to as “dinosaurs.” As digital technology evolves, it gets more compact and streamlined. It adapts to current market conditions and patient expectations. By contrast, the longer we stick with our older systems, the more dated and out-of-sync they seem.

Yet we often postpone upgrading as long as possible. Converting from legacy hardware and software is disruptive. There are risks involved. Often, we’re compelled to change how we run our practices.

Fortunately, the period of disruption is finite—and once the upgrade is complete, we can expect substantial benefits to practice standards of care and efficiency. Furthermore, as more orthodontists upgrade, we can learn from our colleagues; collectively, we’re amassing information that ensures that those who follow may benefit from our experience.

Last year, I moved from a UNIX-based practice management system to state-of-the-art Windows 2003 technology, including digital cephalometry and a dedicated datacommunications line to network my two offices. Looking back, I can now share a number of insights that may help other orthodontists as they plan to upgrade their legacy systems.

Why Upgrade? Why Now?

When we consider our financial and professional goals, it’s clear that technology can help play a substantial role in achieving them. In my case, I have a well-established practice and see an average of 90 patients a day. I’m comfortable with this number; I’m not interested in adding more patients. Therefore, my practice goals are twofold. My first goal is to make sure my patients are happy so that I continue to generate referrals and positive word-of-mouth at the same rate I have in the past. My second goal is to find ways to improve my bottom line. Since I’m not trying to expand my practice and don’t want to raise my fees unless absolutely necessary, my strategy is to improve efficiency and cut costs. 

While technology can help with goals like this, replacing legacy systems entails a certain degree of risk and stress. So one of the key issues is timing. When do the benefits of upgrading outweigh the inevitable disruption? In my case, here are the factors that suggested that the time to upgrade was at hand:

1) Windows 2003 system stability. As a UNIX system user, I viewed early versions of Windows systems with skepticism. When I became convinced that the Windows operating system was reliable, I felt confident that moving from our UNIX system to the Windows 2003 OS was a sensible option.

2) Improved hardware options. I knew I wanted to move to digital cephalometric and panoramic radiology, and my longtime imaging company introduced a digital cephalometric system last year. Another important factor: The graphics capabilities of Windows OS-based computers improved significantly—the Windows system now supports 16 million color images for displaying high-quality digital photographs.

3) Technology integration capabilities. At long last, true integration is now possible, from digital image acquisition through charting and patient record management.

4) Favorable taxation circumstances. Under the Jobs and Growth Tax Relief Reconciliation Act of 2003—better known as the 2003 federal tax act—businesses received accelerated expense deductions for equipment purchases. For example, under Section 179 of the code, businesses can deduct up to 100% of the cost of an equipment purchase. Needless to say, this was a key incentive to the timing of my upgrade.

5) Favorable interest rates. Another factor that played into my decision was low interest rates at the time, which made it relatively inexpensive to finance my equipment purchases.

The Plan’s The Thing

In retrospect, it seems that I caught some lucky breaks in the timing of my upgrade. I couldn’t have anticipated that President Bush’s tax break would come into effect at the same time Windows 2003 OS was released. But as the saying goes, luck is when preparedness meets opportunity—and the fact is, I’d begun planning my upgrade some 2 years before I implemented it.

Not all the planning was formal. For example, when I had the carpet replaced in one of my offices in 2001, I decided to prep the building for a computer network. I wanted to run it through the floor; and since our buildings here in central Florida are constructed on concrete slabs, that meant having PVC pipe laid in channels cut in the concrete. It’s a messy, dusty job, so it made sense to do it at the same time that the old carpet was being torn up anyway.

In my other office, I ended up going wireless when we ran into problems while trying to run cable through the PVC pipes I’d installed in the floor back when I’d originally had it built.

Much of my preparation involved reading articles on other orthodontists’ upgrade experiences. I talked to colleagues who had already replaced their legacy systems, looking for insight into what I might expect. I also followed industry news so that I would get a sense of what technology would be best supported in the future.

And I researched the technology itself.

More Than a Couple of Boxes

It seems obvious, but as we transition to digital technology, we’re doing more than installing a computer here and a digital radiography system there. We’re installing a digital infrastructure. Everyone’s practice is unique, so there’s no “one size fits all” answer when a practice is ready to upgrade its technology. Nonetheless, certain factors will always be important.

1) Practice management software. Because this is the infrastructure component that determines how your patient and clinical data will be organized, presented, and accessed, it’s good sense to give it high priority. Make sure the practice management software you’re considering supports the functions you need and want.

You should also determine whether the software integrates directly with any hardware you’re considering. The fewer “bridge” software applications you need to ensure that data can move in and out of your practice management system, the less complicated your infrastructure will be. And the less complicated your infrastructure is, the lower the risk of instability or unexpected support hassles and costs. And finally, pay attention to who is offering the software. Products with large numbers of users are generating income for the vendors who develop them, which means those vendors are more likely to continue supporting and updating the software.

2) Computers. As the “engines” of the infrastructure, computers provide a processing platform that enables everything from access to digitized charts and patient information to data storage. Increasingly, computers are also used to run other digital devices. My digital cephalometric machine, for example, essentially functions as a computer peripheral.

When you consider computers, don’t confine your thinking to standard laptops or desktops. For example, I made use of a type of computer called a “thin client” in my clinic. These are relatively inexpensive, stripped-down computers. They aren’t used to store any data: their sole function is to access applications running on a network server. The thin clients I picked only cost me only about $450 apiece; since I’m using 21 of them, I only had to purchase a dozen full desktop systems. (They are also physically smaller than desktop systems, so they fit better in my clinics.)

3) Datacommunications. You also need to think about where your patient and clinical data has to flow, and how it’s going to get there. At the very least, you’ll want a site-wide network so that data can be transmitted among your practice computers. If you have more than one office, you also need to provide for the sharing of data between facilities. You will probably also want to send some files to third-party sites, and you may also want the capability to access your system while off-site yourself. For example, if you take a call from a patient while you’re at home, it’s nice to be able to view the patient’s record.

Don’t forget your patients, either. Mine can now log onto my system from home to check or update appointments. My patients being treated with clear plastic aligners can even run animations to see how their treatment will progress—or send the animations to their friends and family members.

Each of these issues requires research. Who needs access to your practice records? What’s the best way to make that access reliable, secure, and convenient? I know that some physicians with multiple offices transfer their patient databases to laptops so they can physically carry the information with them. This wouldn’t work for me, and I wouldn’t even recommend it, because I want my staff to be able to update patient records, schedule appointments, and make other changes to the data regardless of where I might be on a given day. So I opted for a dedicated, high-speed (T1) data line to connect my two offices. In effect, I now have a single network spanning both locations.

I could have done the same thing through an Internet connection or DSL line, but a T1 line, while more expensive, is also more reliable. The only service interruption I’ve experienced since it went live last year was due to last year’s extraordinary hurricane season—something we trust won’t recur any time soon.

4) Electric service. Some peripherals need 220-watt outlets. In my case, I needed 220 service for my digital cephalometric system, and for a surge protector and power backup system for my network server.

5) Storage and backup. The infrastructure must also provide for some sort of off-site data backup. It’s best to consult with your hardware vendor on the best backup and data-storage plan for your practice. Our hardware provider recommended that we back up on a daily, weekly, and monthly basis, and that we store our tapes somewhere off-site in a fire-safe location. 

The Intangibles

In addition to the physical components of the system, there are important intangibles to consider. One of the foremost of these is support. During a meeting to plan our upgrade, my staff argued strongly that we should not consider a particular company’s practice management software. The company had a history of being unresponsive to us in the past, and my staff was nervous—and rightly so—about being dependent on them in the future.

In my opinion, it’s better to pay a little extra than to be “penny wise, pound foolish” and end up with substandard support. That’s another reason why we chose to migrate to our current practice management software product. The company that makes it is known for their quality service and support, and it is well worth the investment to work with a company that orthodontists have trusted for years.

Another key issue is data conversion. When you switch from a legacy to a new digital infrastructure, you’ll want to make sure your data makes the move with you. This is important enough that it should figure significantly in your choice of practice management software vendors. Choose one who understands the conversion process and is committed to making sure your data will be intact.

It may also make sense to keep a copy of your legacy database around for awhile. We’ve kept one UNIX system box on-site to let us look up patient records if we see an apparent discrepancy of any kind. We rarely use it anymore—we went live with our new system in May 2004—but it’s an extra measure of security to have it there for now.

The Installation

Once you’ve decided on the infrastructure components, you need to figure out how to get them installed. In my case, this involved coordinating several different contractors. I used a local contractor to reconfigure the physical space as needed: For example, to reclaim my darkroom to enlarge my lab. I brought in a Kentucky-based systems integrator who had been certified by my practice management software vendor to install my computers and oversee the configuration of my network cabling. Two other contractors installed the cabling and set up my T1 line and related hardware.

In addition to managing contractors, I needed to get my staff trained on the new practice management software and my new digital radiography systems.

We did all this by closing the office to appointments for 1 week at a time, on two separate occasions. In addition to training, my staff used this time to catch up on inventory and other tasks.

Once the Dust Has Settled

So was it worth it?

In a word, yes.

The total cost of upgrading my practice for both offices—including the renovations, my digital cephalometric system, computer equipment, cabling, installation and training—came to about $180,000. But because I borrowed to finance it, and received a significant tax write-off, my cash flow was actually strengthened.

And now that the system is in place, I’m beginning to see some significant cost reductions.

For example, when two part-time employees decided to move on, I didn’t need to replace them because we’ve eliminated so many low-level, time-consuming tasks. The main time savings have come from the following areas:

1) Patient inquiries about appointments. Approximately 100 queries a month, such as questions about an appointment time, are now handled online instead of through direct calls to my offices.

2) Charting. With 90 patients per day coming through my practice, my staff was spending a lot of time handling charts. They’d have to manage one chart for each person with an appointment that day, plus all the charts they needed to pull for the next day’s appointments. Integrating charting software alone saves us about four person-hours per day.

3) Trimming, labeling, boxing, and storing models. With integrated third-party software, I now do all my modeling on the computer.

4) Checking in patients. Patients now check themselves in using a touchscreen system in the waiting room. And our patient flow module allows us to know where our patients are in the office at all times.

5) Managing outgoing patient correspondence. With letters to patients now all tracked in the electronic patient record, it’s easier for staff to keep track of what letters have been generated for which patients.

6) Managing photography slides. We do all our photography digitally now, so the staff no longer has to take film to be developed, or to label and file slides.

With these tasks gone, I can run my practice using 1.5 fewer people, saving me (conservatively) $40,000-45,000 a year in salaries and benefits.

Because I’m now capturing my x-rays and photographs digitally, I expect to save significantly on film, processing, and development costs.

Our patient care has improved as well. With our technology handling more low-value tasks, we can spend more time with our patients, and keep ourselves more focused on them when we are with them. I’ve found that I have more time to interact on a personal level with my patients, educating them on hygiene and other aspects of their care.

I’ve also gained new space. I used to have separate panoramic and cephalometric systems. Now I have one digital panoramic and cephalometric system instead. Switching to digital radiography also let me get rid of my darkroom; that space is now part of a larger lab, where I have room to work on my device-design projects.

And finally, the atmosphere of the practice has improved. Because we’re more efficient and productive, everyone’s stress levels seem to be reduced. We’re more relaxed with our patients. The tasks we’ve eliminated were all things my staff felt were mundane—everyone is glad they don’t have to do them anymore. Yes, there was a month or so of disruption, but the benefits have made it well worth it. z

Keith Hilliard, DMD, a member of the AAO and the Southern Association of Orthodontists, has been a pioneer in the application of computer technology to orthodontic practice management and diagnosis. He designed the first commercial orthodontic video imaging station and specialized imaging software, demonstrated at the 1987 national meeting of the AAO. He has also designed and holds patents for a number of orthodontic instruments that are in wide use. His private practice in Lakeland, Fla, is now entering its 30th year. He can be reached at (863) 644-0430 or [email protected].