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ADOSI: The inside story
678 ■ JADA, Vol. 110, May 1985
■ ■ ecently, the Am erican Dental Association, through its wholly owned subsidiary, Am erican Dental Office System s, Inc (ADO SI), officially introduced its first for-profit venture: a com plete in-office com puter system for dental practices. The announcem ent, which cam e after alm ost 3 years of study and developm ent, has aroused consid erable interest in the professional com m unity. The Emphasis this month offers an in-depth look at the A ssociation’s contribution to the world of high technology.
ADOSI ■ 679
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From the beginning
n the beginning was the pegboard. From tim e im m em orial, d en tists have used this bookkeeping system of ledger cards and daysheets as a basis for m anag ing their practices. It still serves m any practices w ithin its lim itations of speed and flexibility; however, many dentists have found that they w ere spending too m uch of their ow n and staff tim e calculat ing, typing, and sending bills and recall notices. How could they speed up the work? A lthough the post-w ar develop m ent of the com puter seem ed to hold an answer, early com puters were too costly, m assive, an d te m p e ra m e n tal for any single practice to dream of buying its own. Thus was born data processing ser vices. The first service bureaus established large co m p u ter cen ters and p ro v id ed “batch processing,” that is, sim ilar kinds of inform ation grouped in batches for single processing. The practitioner’s staff w ould batch account inform ation and send it to the service bureau, usually by m ail. Days or w eeks later th e service bureau w ould m ail the bills, insurance claims, and recall notices. However, the practitioners could do little or nothing w ith the data until they received the ser vice bureau ’s report. T im e lin e ss an d access to d ata im proved w ith the introduction of the on line or tim e-sharing service bureau. In this system, the dental practice has an in-house term inal through w hich it can exchange data w ith the service bureau over telephone lines. The term inal may be “ intelligent,” allow ing the user to ma
nipulate data at the m ain com puter, or lege or professional school to practice “passive,” allow ing only the input and m a n a g e m e n t te c h n iq u e s ; a g ro w in g num ber have some experience or interest display of data. It w asn’t until the developm ent of the in com puters, especially among younger m icroprocessor in the late 1970s that the dentists. prom ise of a true in-house com puter sys tem began to be realized. This “com puter on a c h ip ” drastically cut the size and cost and increased the reliability of the com . «Ji The idea is born puter. Before the m icroprocessor, com puters dem anded constant care and were expensive—at a m inim um of $50,000 to J i t n 1982, the ADA Board of Trustees $150,000, far too costly for most practices. m ade a major decision: they agreed to G iven th e p ra c tic a litie s of th e m a r form a subsidiary corporation as a source ketplace, there was little or no software of nondues revenue for the ADA. Accord available for the average professional. ing to Dr. H. W illiam Gilmore, ADA Sev In the past few years, the professional enth District Trustee and chairm an of the market for com puters has exploded. One ADOSI board, the objective was twofold. fjr-i
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Before the microprocessor, computers demanded constant care and were expensive—at a minimum of $50,000 to $150,000, far too costly for most practices.
major reason has been the rapidly drop ping cost of com puter technology, p u t ting pow erful com puters w ith enorm ous memory w ithin the reach of m ost prac tices. A nother im portant factor has been the grow ing com plexity of practicing dentistry, the sometimes overw helm ing paperw ork generated by new tax laws, governm ent regulations, and insurance. According to the 1982 Survey o f Dental Practice, m ost p ractitio n ers sp e n d as m uch as 20% of their tim e on nonpatient care activities, most of w hich is in prac tice m anagement. Finally, a factor in increasing im por tance is the growing sophistication of the new generation of practitioners. More practitioners have some exposure in col
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“We w anted to expand m em bership services and program s,” he explained, “and we w anted to do it w ithout a major increase in m em bership dues. So w e had to develop a source of nondues income. Our solution was to form a w holly owned, for-profit su b sid ia ry —so m eth in g th at m any other associations have begun to do in the past few years.” In fact, the A m eri can H ospital A ssociation’s subsidiary, A m erican Hospital Publishing, Inc, rents space in the ADA headquarters building, and the A m erican M edical Association has been successful in its real estate ven tures. In deciding w hat activities—products or services—an ADA subsidiary m ight undertake, the Board of Trustees consid-
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680 ■ JADA, Vol. 110, May 1985
ered ideas ranging from a travel agency to an insurance brokerage, and from real es tate to continuing education by com pu ter, and all are possibilities for the future. But the idea that generated the m ost in terest was a com puter system for dental practice managem ent. Because the ADA M arketing Services D epartm ent was involved in m any of the business aspects of the A ssociation, its di rector at the tim e, Robert H ankin, PhD, c o n d u c te d an e v a lu a tio n of th e s u b sidiary’s possible ventures. “We w anted som ething that was rele vant to our m em bership and their needs, som ething that had a clear potential for s u c c e ss,” Dr. H a n k in e x p la in e d . “ A state-of-the-art d ental office com puter system fit both criteria. “ T h e ADA h a d h a d a s ig n if ic a n t num ber of phone calls on the WATS line from dentists seeking advice about w hat com puter system to choose or voicing concerns about ones they owned. We also received m any calls from private com p a n ie s se e k in g o u r e n d o rs e m e n t or partnership. Overall, it was evident that com puters had become a key considera tion in m any dentists’ m inds and that dentists are going to be buying com puters and autom ating their offices over th e next 10 years.” Dr. Gilmore agrees. “The dem and for com puters is high and getting hig h er,” he said, “and the com puterization of den tistry is a key goal of the ADA. Besides upgrading office systems, there is a huge p o te n tia l p a y o ff in c o m m u n ic a tio n among dentists, in education and sharing ideas, in ending the isolation of the solo practitioner.” Dr. H ankin, now vice-president, opera tions, ADOSI, also saw an opportunity to avoid the confusion often generated in the com puter market by the variety and in c o m p a tib ility of h a rd w a re and software. By standardizing the com puter systems in dental offices across the na tion, the ADA could make it easier for dentists to com m unicate w ith each other. “The result of these various lines of th in k in g ,” Dr. H ankin said, “was th at we decided to enter the com puter systems m arket, and, in fact, not to endorse an out side com puter system, but to acquire and develop one of our ow n.” The move was not unprecedented. His torically, the ADA has been involved, through its staff in the N ational Bureau of S ta n d a rd s a n d in its o w n r e s e a r c h facilities, w ith the developm ent of m any products that dentists now use, including the high-speed handpiece and panoram ic
Besides upgrading office systems, there is a huge potential payoff in communication among dentists, in education and sharing ideas, in ending the isolation of the solo practitioner. m H. William Gilmore, DDS, MDS
X-ray equipm ent. In the past, however, the A ssociation has given these products to private industry, w hich in tu rn has m arked them up for their own profit and sold them back to the dentist. This time, the A ssociation determ ined to acquire a state-of-the-art com puter package, de velop it by building its own program m ing and support staff, and provide it directly to practitio n ers. W ith profits directed back to th e national organization, the prim ary beneficiary w ould be the practi tioners themselves. This arrangem ent also has major ad vantages in pricing, service, and quality control. Because there are fewer links in the chain, developm ent and distribution are less costly and the system can be priced lower. Dr. Hankin considers this one of the com pany’s prim ary concerns: m ax im izin g th e perform ance-to-price ratio; that is, providing the practitioner w ith the best value for the dollar spent. A ccording to Dr. Hankin, it is a ques tio n of m o tiv atio n . “ You have to re m em ber,” he cautions, “ our customers are our members, so our incentives are som ew hat different from those of an out side vendor. If you look at ADOSI’s daily activities, y o u ’ll see a m uch heavier em phasis on service and support, and on re search and developm ent, than on adver tising, sales, and fast distribution. “If w e had sim ply endorsed or gone into partnership w ith an outside vendor, o u r m em bers w ould h av e b een c o n cerned, and not w ithout reason. Our obli gation to serve our m em bership could easily have come into conflict w ith the m otives of a private firm that d id n ’t share our com m itm ent to dentistry. From the beginning we knew that, as an arm of the
national organization for the profession, we had to set the highest standards and ensure the quality of our product—and the only way to do that was to m aintain com plete control.” Before starting, the Board asked Dr. H ankin to survey the existing market. Was th e m a rk e t s a tu ra te d or m erely crow ded and confused? Did the ideal product already exist? Was there a place for the ADA? Dr. H ankin found that some systems had excellent hardw are, others had w ell-designed software, som e had good service and support, others offered good pricing, but no single system com bined them all. Therefore, he concluded that ADOSI could fill that niche. Based on Dr. H ankin’s conclusion, the ADA Board of Trustees elected a board of directors for the new subsidiary, m em bership of w hich included A ssociation officers or trustees, three Association staff members, and several outside representa tives from business, banking, and law. The directors approved the business plan developed by the m arketing departm ent and presented it to the Board of Trustees, w hich agreed to capitalize the subsidiary corporation. ADOSI stock was then is sued to the Association, and the com pany established.
esigning softw are to fit J Dd entists’ needs
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c o m p u te r sy ste m re v o lv e s around its software; like a stereo system w ithout records, a com puter is no more than a boxful of silicon chips w ithout the program s that tell it w hat to do. ADOSI’s ADOSI ■ 681
'B h ip fa s i} first consideration, therefore, w as to de term ine w hat a dental office com puter system should do and then to find the best way of doing it. “In looking at den tists’ needs, w e fo cused on practice m anagem ent an d m ar keting,” Dr. H ankin said. “Dentists are by training and by interest excellent clini cians. But m ost dentists are not experts in practice managem ent; m ost have had lit tle or no training in running a business, and if they need help anyw here, it’s at the front desk. The principle of com parative advan tage says that if there are some things you do very w ell and others you do less well, you should concentrate your develop m ent energies on the latter. T hat is, if you're an excellent clinician b u t you’re not delivering as m uch dentistry as you’d like because of inefficiencies at the front desk, then you should shore up that end of the practice. But a dentist sh o u ld n ’t spend his or her ow n tim e balancing the books, w riting checks, and filling out forms. A dentist should be in the treatm ent area, practic ing dentistry. By the same token, an office m anager sh o u ld n ’t spend hours filling out insurance claim forms. Staff people should be calling patients to make sure appointm ents are kept, calling referring dentists to m aintain the d en tist’s linkage to his associates: doing the things that w ill ensure that the practice stays busy and the cash flow smooth. The routine, repetitive, m achine-like tasks of book keeping, accounting, and so on can be done m uch m ore quickly and m ore accu rately by a com puter, freeing th e staff to do the kinds of things only they can do.” To offer dentists the kind of software package that w ould allow them to prac tice the best dentistry of w hich they were capable, ADOSI hired Mr. Geoffrey Love. He and his colleagues in 1979 h ad begun to w rite the core program s of a dental of fice software system. The program s ad dressed the need for an affordable system designed specifically for dental offices. “We talked originally w ith about ten dentists, both general practitioners and specialists, and looked at how th eir prac tices w ere organized,” Mr. Love recalled. “ W ith the inform ation w e gathered, we did a systems analysis of a ‘ty p ical’ dental practice: How does the dental office h an dle paper flow ? Who generates w hich docum ents? W here does the p aper go? 682 ■ JADA, Vol. 110, May 1985
We talked originally with about ten dentists, both general practitioners and specialists, and looked at how their practices were organized.
Mr. Geoffrey Love
How are the various forms—insurance Choosing hardw are that claim s, treatm ent plans, general ledger, com plem ents software and so on—connected to one another? “ We also asked den tists w h at they w anted a com puter system to be able to do. We found that they w anted all the X ^ o m atter how good, software will standard things, of course: handling bill not run by itself. ADOSI’s next challenge ing, insurance, recalls, and so on. But was to select the com puter hardw are on each dentist also had particular needs. w hich those program s w ould run. Several For exam ple, some w anted to be able to systems were evaluated, including IBM, w rite their ow n recall letters and others Wang, and Convergent technologies, be preferred to use standard cards; some of fore ADOSI chose Altos com puters. “Al fices assessed late charges, and others tos is a leader in m ulti-user, small office d id n ’t. So w e knew we had to make the com puters—th at’s their strategic market, system both com prehensive and flexi so we know they’re going to be interested ble.” in it for a long tim e to com e,” explained T h ese w ere im p o rta n t fea tu re s for Dr. H ankin. “More dental offices have ADOSI because m any of the available A ltos com puters now th a n any other software packages were either m odified co m p u ter. T h e y ’ve b een aro u n d and physician or business packages. Because grow n stead ily since 1977; th e ir m a this package was specifically developed chines are highly reliable, and we know for d e n ta l p ra c titio n e rs , its in te rn a l that w ith Altos, w hat w e’re paying for is lo g ic — th e flo w of in s tr u c tio n s a n d good equipm ent, ra th er th an a brand com m ands—is consistent w ith the way nam e.” dental offices handle m anual recording A ccording to Mr. Phil W hite, vicesystems. “Billing is linked to recall, recall president, m arketing, Altos, the prim ary is linked to word processing, insurance is reason the Altos was chosen “ is that we designed for dental office patients, not offer a family of m ulti-user com puters, on hospital patients,” explained Dr. Hankin. all of w hich the ADOSI software operates “It’s a system designed specifically for identically. This m eans that as a practice dentists, and as a result it makes sense to grows, even from a single practitioner to them ; they find it com fortable.” an entire clinic, the dentist can upgrade, T h e A D O S I b o a r d a c q u i r e d th e th a t is, e x p a n d h is sy stem , w ith o u t software and hired its developers, bring changing the softw are, m odifying the ing them to ADA H eadquarters where docum ents, or retraining the staff. So h e’s they could apply their expertise to this lost none of his original investm ent in and other projects. In the past 15 m onths, tim e and money, but can accom m odate they have enhanced the program, built w hatever changes he makes in his prac tutorials and help aids, developed train tice.” ing procedures and support systems, and A n other im p o rta n t feature of A ltos w rote a detailed users’ m anual. c o m p u te rs is th e ir use of th e X enix
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operating system, an enhanced version of Unix (an earlier operating system) that has quickly becom e the indu stry stan dard. It is a flexible system specifically designed for m ulti-user, m ulti-task opera tions, enabling several different people to operate the system for a variety of func tions at the same time. “Xenix is broad-based, it’s supported by m any vendors, and there is a variety of software, in addition to ours, available for it,” Dr. H ankin said. “We thin k it’s an ideal system for standardizing com m uni cations among dentists and for protection a g a in st o b so lescen ce. B ecause w e ’re looking m any years ahead, these were very im portant considerations.” A lto s a ls o w o r k e d c lo s e ly w ith ADOSI’s program m ers, making hardw are m odifications to m eet the needs of the program s and to enhance the system ’s usefulness to practitioners. For exam ple, Altos added graphics capabilities to its com puters for “w indow ing,” a process that allows the user to call up one func tion in the m iddle of another or to zoom in and get more details on a specific area of data. They also added the ability to print any given screen at the touch of a key, a convenient and user friendly function all too rare in the com puter world. “Altos has been very cooperative,” said Dr. Hankin. “They have a real interest in dentistry, and w e’ve been able to develop a national agreem ent w ith them th at w ill be of great benefit to dentists. W e’ll be packaging their hardw are as part of the ADOSI system —testing it ourselves be fore it goes out, on top of th e ir ow n tests—and putting the ADOSI label on it. We stand behind it 100%. Mr. W hite agreed. “The ADA m ade our product theirs, and in return w e’ve m ade their interests our own. Altos plans to do everything we can to enhance research in the dental field and to help develop new technologies and new uses of com puters for dentists. W e’re very m uch com m itted to dentistry.”
HH Service and support
T ■* ess ta n g ib le th a n h a rd w a re or software, but equally im portant, are ser vice and support. Dr.Hankin calls this the heart of the A m erican Dental A ssociation Office System. “W e’ve w orked harder at this than at alm ost anything else in the system ,” he said. “This system, w ith the ADA name
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2. Your paperw ork has increased to the point w here you w ill soon need to add front office staff. 3. You’d like to spend more tim e practice building, but first you need to analyze w here your practice is now. 4. You’d like your staff to spend more tim e on recalls and patient rela tions. 5. You’re serving m ore and more Is it time for a computer in your in s u r e d p a t i e n t s — o r w o u ld lik e practice? to—but the forms are overwhelm ing. 6. You’d like to speed up your cash The seven w arning signs that say you flow. could probably benefit from an office 7. You find yourself looking w ist com puter system. fully at com puter advertisem ents and 1. Your practice is grow ing, and reading every new com puter article that comes along. you w ant it to keep on growing.
on it, w ill be going into some sophisti cated practices and into others for w hich com puters are som ething entirely new. It w ill be used by m any people w ho may never have sat dow n at a term inal before. A nd we have a responsibility to see that every user gets as m uch help and support as he needs—from the beginning and all dow n the lin e.” The support begins w ith ADOSI’s care ful, deliberate m ethod of d istrib u tio n through a netw ork of authorized agents th ro u g h o u t th e U nited States. “ ‘A u thorized agent’ is the key term ,” Dr. H an kin explained. “T hey’re not dealers and th e y ’re n o t franchisers; they are local facilitators for ADOSI. The practitioner is purchasing the system from us, not from the agent. The agents m ust follow our guidelines for training and installation; they come to Chicago and spend several weeks w ith us, in hands-on sem inars and training sessions, learning those proce dures. “ Because w e ’re being very careful, m aking sure every agent satisfies our criteria for both capability and quality control, w e’re m oving slowly and sequen tially, on a state-by-state and region-byr e g i o n b a s i s . W e s t a r t e d in M a s sachusetts, New York, and Illinois, and so far w e’ve focused prim arily on the 15 or 20 installation sites betw een here and the Atlantic; by late sum m er we should have authorized agents throughout the West Coast, the West, and the South.” M ost of the agents are systems houses, com panies th at have solid experience
dealing w ith m icrocom puter-based in s ta lla tio n s in p ro fe s s io n a l e n v iro n m e n ts —fo r e x a m p le , d e n ta l, m edical, legal, and accounting. “ State dental societies are also being given an opportunity to participate,” said Dr. Gil m o re , “ a n d s e v e r a l — O h io , fo r exam ple—have form ed authorized agents in th eir ow n subsidiary corporations. Others have affiliated w ith our agents in their states.” Through the authorized agent, ADOSI w ill sell and install the system, configur ing it to the needs of the individual prac tice, and train the practitioner and staff in its use. “We have a three-pronged ap proach to train in g ,” Mr. Love explained: “ a user-oriented training guide, sem i nars, and on-site consultation to help the practice convert from a m anual to a com puterized system .” C ontinuing support is built into the user friendly software itself. For example, there are clear “error m essages” to let the user know w hen he has m ade a mistake; a unique “h e lp ” key that gives the user an im m ediate solution to m ost problem s; sim ple m ethods for correction of typo graphic and other m istakes; w arnings w hen disk space is running low; and a sim ple, built-in procedure that virtually forces the user to m ake back-up copies to ensure no data can be lost. Still, there may come a tim e w hen m ore help is needed than the system can offer. This help is available through ADOSI’s unique tele phone support service. “The telephone provides every user ADOSI ■ 683
w ith an um bilical cord connecting him to the home office,” Dr. H ankin explained. “Not only do we offer hotlines, we also provide a link-up by m odem, a device that lets our technical staff take over the users’ system from their ow n keyboards and cor rect operator errors on th e spot. The m odem connection also provides a w ay to transm it updates and enhancem ents to al ready installed system s as we develop them , so w hile [we are] continually ex p an d in g , no ADOSI u se r n eed w orry about being left behind. All custom er calls are follow ed by a sophisticated tracking system that en su res no p ro b lem is u n a tte n d e d . A l though there are few actual problem s, the technical staff knows how to evaluate and respond quickly to alm ost any question. To date, m ost of the calls are about opera tive questions: Can I do this? W hat if I do that? “W hat h appens,” said Dr. H ankin, “is that after the practice has had the system for a w hile, they begin to get creative w ith it, and they w ant to use it in new ways. They start thinking about the kinds of re ports they’d like to generate, th e different ways they’d like to analyze their data, and they call us with those questions.” The ADOSI staff actively solicits users’ feedback and keeps a detailed record of questions and requests. These are incor porated into training sem inars and w ill become the basis for enhancem ents in later versions of the software. “As a subsidiary of the Association, we w ant to have the very best support in the b u sin e ss,” said Ms. M anon F ie ld in g , ADOSI’s te c h n ic a l s u p p o rt m an ag er. “The Association is a service organiza tion, and it is im portant to us to be re sponsive to d en tists. We have to see things from the users’ perspective. Our philosophy is simple: a problem is solved only w hen the user thinks it’s solved.”
t The future: w here do w e go from here?
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JL J L DOSI’s plans do not end w ith the cu rren t system . “ The p o ssib ilities for com puter applications in dentistry are alm ost lim itless,” said Dr. H ankin. “One of the m ost exciting areas of develop m ent, one in w hich ADOSI is very m uch involved, is the work being done by Dr. Howard Bailit and his colleagues, w ith 684 ■ JADA, Vol. 110, May 198S
The ADA made our product theirs, and in return w e’ve made their interests our own.
Mr. Phil White
the support of the Kellogg Foundation.” Dr. Bailit, who heads the departm ent of health adm inistration, Columbia Univer sity, School of Public Health, is working on a major project that, w hen integrated w ith ADOSI, could bring com puters into the treatm ent rooms of dentists across the nation. “I’d been w orking in the area of quality assurance for a long tim e,” Dr. Bailit said, “and it had become apparent to me that im provem ents in the quality of care come about not through the efforts of regulatory a g e n c ie s, b u t th ro u g h sc ie n tific and technological advances. I was convinced that com puterized inform ation systems, once they becom e affordable to in d i vidual dentists, could have a major im pact on dental care.” Dr. Bailit is working on a system that
has tw o major aspects, the first of w hich is a com puterized recordkeeping function that w ill enable practitioners to collect, store, and retrieve clinical inform ation on every patient in the practice. The record w ould include everything from the h is tory and exam ination to treatm ent plan ning and treatm ent notes, in effect replac ing the w ritten dental record. The practi tioner w ould be able to retrieve inform a tion alm ost instantaneously, sw itching from one patient to another or tracking the history of a particular patient, a given service, or even a particular tooth. The second aspect of the system would bring a com puterized inform ation base into the practitioner’s office, including sum m aries of current know ledge in many areas of diagnosis and treatm ent. Up- : dated regularly, by a m odem connection
to the A ssociation’s m ain com puter, the in fo rm a tio n c o u ld h e lp p ra c titio n e rs diagnose w hite lesions or odontogenic p ain, review th e latest treatm ents for periodontal disease, or check drug in teractions. “The potential for this kind of system is just staggering,” Dr. Bailit said. “ We can com bine the aggregate know ledge of den tists and give the smallest, m ost remote practice access to as m uch expertise as any major practice in the country. We can, for the first tim e in dentistry, gather in form ation on a huge aggregate of patients, analyze it dem ographically, and find out just how effective specific treatm ents are for any segm ent of the population. We can offer dentists an opportunity to compare their practice m anagem ent to that of sim i lar practices, give them a way to make higher-order decisions about cash flow, and so on. And this is just the tip of the iceberg.
I’d been working in the area of quality assurance for a long time and it had become apparent to me that improvements in the quality of care come about not through the efforts of regulatory agencies, but through scientific and technological advances. Howard Bailit, DMD, PhD
We already have the m eans to generate a trem endous am ount of information. The
Through the authorized agent, ADOSI w ill sell and install the system, configuring it to the needs of the individual practice, and train the practitioner and staff in its use.
. . What a computer will—and won’t— P* do for your practice A realistic assessm ent of w hat you can expect from a com puter in your prac tice.
A computer will: • perform boring, repetitive tasks consistently and w ithout com plaint; • provide you w ith inform ation and reports—w hich w ill be precisely as valuable as the uses to w hich you put them;
• give you access to inform ation on w hich to base decisions; • be as accurate as the data you feed it; • fre e y o u r t i m e — a n d y o u r staff’s—for c lin ic a l w ork, p ractic e building, collections, and other n e glected tasks; • have o c c a sio n a l m a in te n a n c e needs—like your typew riter or tele phone; and • take tim e to learn—and then make you w onder how you got along w ith out it.
A computer will not: • manage your practice; • make business decisions for you; • dehum anize your practice; • replace your current office staff; • turn a disorganized, inefficient practice into an efficient, organized practice; and • change your personality or your social life.
question now is, w hat do w e do w ith that information: how do w e make sense of it and use it to im prove the practice of den tistry? The next step, clearly, is a system that w ill not only provide data, b u t w ill assist the dentist in making clinical and m anagem ent decisions.” Dr. Bailit w ill be testing his system in a handful of practices this sum m er and p red icts it w ill be available, th ro u g h ADOSI, in 2 years. M eanwhile, said Dr. H ankin, ADOSI is also w orking w ith the Am erican Dental Network, sim ilar to the existing American M edical Network and A m erican O ste o p ath ic N etw ork. T he netw ork w ill offer access, by modem, to clinical and practice inform ation, pre scription drug inform ation, references and abstracts to current literature, and in formation about upcom ing Association m eetings and events. It w ill also enable practitioners to send messages and re ports directly to one another and to com m unicate w ith their state dental societies, and it w ill probably be used for continu ing education programs, electronic jour nals and new sletters, and m uch more. “This is the future of dentistry,” Dr. H ankin concluded. “Because of com put ers, the dental office 10 years from now w ill be very different from today’s prac tice. Dentists w ill be linked w ith their col leagues and w ith state-of-the-art d en tistry. T hey’ll be m uch more sophisti cated m anagers, able to analyze cash flow, productivity, costs, and tim ing of accounts payable. Their practices w ill be m uch more organized, more efficient, and more productive because dentists w ill be freed from the burdens of adm inistration, free to be the best dentists they can possi bly be, and able to dedicate them selves ADOSI ■ 685
fully to w hat they really w ant to do— im prove the dental health of the A m eri can public. A nd ADOSI w ill help them do it.” “ADOSI is going to have m ajor reper c u ssio n s for d e n tis tr y ,” Dr. G ilm ore added. “It’s only the beginning. There is great potential in for-profit ventures, and we are determ ined to keep th e risks low and the benefits high. One of m y top goals in oganized dentistry is to see this become a major success for our m em bership.”
Because of computers, the dental office 10 years from now w ill be very different from today’s practice.
Robert Hankin, PhD
A GLOSSARY OF COMPUTER TERMS
Applications programs: Program s de signed to perform specific business functions, such as accounts receiv able or w ord processing. Back-up: Copies of data m ade and kept as protection against loss. CRT: Cathode ray tube. The video ter m inal, usually w ith keyboard, used for entering and receiving data from a com puter. CPU: Central processing unit. The part of the com puter w here instructions are interpreted and carried out. Data: Inform ation entered into or re ceived from the com puter.
686 ■ JADA, Vol. 110, May 1985
Disk: Floppy disk (diskette) or hard
S ecu rity code: A p a s s w o r d th e
disk. M agnetic devices used to store data. H ard disks g en erally hold m u c h m ore d ata th a n flo p p ie s. Floppy disks are inserted into a “ disk drive” for use w ith the com puter. Hard copy: Printed m aterial produced by the computer. Hardware: T he c o m p u te r a p p a ra tus—that is, the com ponents of the m achine. Memory: The part of the CPU that holds inform ation being processed. Modem: A dev ice th a t co n n ects a com puter or term inal to a telephone line for transm ission of data. Multi-tasking: The ability of a system to ru n m ore than one job or task si m ultaneously. Multi-user: The ability of a system to allow more than one person to use the com puter at the same time. Operating system: The program s, usu ally provided w ith a com puter, that p erform its basic fu n ctio n s and allow other programs (such as ap plications programs) to be used. Peripherals: H ardw are other than the CPU: p rin te rs, keyboards, CRTs, disk drives, modems.
operator m ust type into the com pu ter in order to execute a program. (A security m easure to protect against u n au th o riz ed access to in form a tion.) Service bureau: A data processing facility that provides services such as billing and accounting, based on data provided by the client. Software: The set of instructions or programs used by the com puter and the operator to perform specific functions. Storage: E x tern al devices su c h as disks, tapes, cassettes, and cards, w hich store data and software. System: The w hole set-up: hardw are and software, peripherals and ap p licatio n program s, w orking to gether in a practice. Terminal: A device to transm it or re ceive data, usually consisting of a keyboard an d CRT. “ In te llig e n t term inals” also have some built-in com puting power. Time sharing: A m ethod by w hich a com puter facility (usually a large “m ainfram e”) can be shared by sev eral users, often at remote term i nals, apparently at the same time.
■ ■ ecently, the Am erican Dental Association, through its wholly owned subsidiary, Am erican Dental Office System s, Inc (ADO SI), officially introduced its first for-profit venture: a com plete in-office com puter system for dental practices. The announcem ent, which cam e after alm ost 3 years of study and developm ent, has aroused consid erable interest in the professional com m unity. The Emphasis this month offers an in-depth look at the A ssociation’s contribution to the world of high technology.
ADOSI ■ 679
A
From the beginning
n the beginning was the pegboard. From tim e im m em orial, d en tists have used this bookkeeping system of ledger cards and daysheets as a basis for m anag ing their practices. It still serves m any practices w ithin its lim itations of speed and flexibility; however, many dentists have found that they w ere spending too m uch of their ow n and staff tim e calculat ing, typing, and sending bills and recall notices. How could they speed up the work? A lthough the post-w ar develop m ent of the com puter seem ed to hold an answer, early com puters were too costly, m assive, an d te m p e ra m e n tal for any single practice to dream of buying its own. Thus was born data processing ser vices. The first service bureaus established large co m p u ter cen ters and p ro v id ed “batch processing,” that is, sim ilar kinds of inform ation grouped in batches for single processing. The practitioner’s staff w ould batch account inform ation and send it to the service bureau, usually by m ail. Days or w eeks later th e service bureau w ould m ail the bills, insurance claims, and recall notices. However, the practitioners could do little or nothing w ith the data until they received the ser vice bureau ’s report. T im e lin e ss an d access to d ata im proved w ith the introduction of the on line or tim e-sharing service bureau. In this system, the dental practice has an in-house term inal through w hich it can exchange data w ith the service bureau over telephone lines. The term inal may be “ intelligent,” allow ing the user to ma
nipulate data at the m ain com puter, or lege or professional school to practice “passive,” allow ing only the input and m a n a g e m e n t te c h n iq u e s ; a g ro w in g num ber have some experience or interest display of data. It w asn’t until the developm ent of the in com puters, especially among younger m icroprocessor in the late 1970s that the dentists. prom ise of a true in-house com puter sys tem began to be realized. This “com puter on a c h ip ” drastically cut the size and cost and increased the reliability of the com . «Ji The idea is born puter. Before the m icroprocessor, com puters dem anded constant care and were expensive—at a m inim um of $50,000 to J i t n 1982, the ADA Board of Trustees $150,000, far too costly for most practices. m ade a major decision: they agreed to G iven th e p ra c tic a litie s of th e m a r form a subsidiary corporation as a source ketplace, there was little or no software of nondues revenue for the ADA. Accord available for the average professional. ing to Dr. H. W illiam Gilmore, ADA Sev In the past few years, the professional enth District Trustee and chairm an of the market for com puters has exploded. One ADOSI board, the objective was twofold. fjr-i
I T'
Before the microprocessor, computers demanded constant care and were expensive—at a minimum of $50,000 to $150,000, far too costly for most practices.
major reason has been the rapidly drop ping cost of com puter technology, p u t ting pow erful com puters w ith enorm ous memory w ithin the reach of m ost prac tices. A nother im portant factor has been the grow ing com plexity of practicing dentistry, the sometimes overw helm ing paperw ork generated by new tax laws, governm ent regulations, and insurance. According to the 1982 Survey o f Dental Practice, m ost p ractitio n ers sp e n d as m uch as 20% of their tim e on nonpatient care activities, most of w hich is in prac tice m anagement. Finally, a factor in increasing im por tance is the growing sophistication of the new generation of practitioners. More practitioners have some exposure in col
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“We w anted to expand m em bership services and program s,” he explained, “and we w anted to do it w ithout a major increase in m em bership dues. So w e had to develop a source of nondues income. Our solution was to form a w holly owned, for-profit su b sid ia ry —so m eth in g th at m any other associations have begun to do in the past few years.” In fact, the A m eri can H ospital A ssociation’s subsidiary, A m erican Hospital Publishing, Inc, rents space in the ADA headquarters building, and the A m erican M edical Association has been successful in its real estate ven tures. In deciding w hat activities—products or services—an ADA subsidiary m ight undertake, the Board of Trustees consid-
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680 ■ JADA, Vol. 110, May 1985
ered ideas ranging from a travel agency to an insurance brokerage, and from real es tate to continuing education by com pu ter, and all are possibilities for the future. But the idea that generated the m ost in terest was a com puter system for dental practice managem ent. Because the ADA M arketing Services D epartm ent was involved in m any of the business aspects of the A ssociation, its di rector at the tim e, Robert H ankin, PhD, c o n d u c te d an e v a lu a tio n of th e s u b sidiary’s possible ventures. “We w anted som ething that was rele vant to our m em bership and their needs, som ething that had a clear potential for s u c c e ss,” Dr. H a n k in e x p la in e d . “ A state-of-the-art d ental office com puter system fit both criteria. “ T h e ADA h a d h a d a s ig n if ic a n t num ber of phone calls on the WATS line from dentists seeking advice about w hat com puter system to choose or voicing concerns about ones they owned. We also received m any calls from private com p a n ie s se e k in g o u r e n d o rs e m e n t or partnership. Overall, it was evident that com puters had become a key considera tion in m any dentists’ m inds and that dentists are going to be buying com puters and autom ating their offices over th e next 10 years.” Dr. Gilmore agrees. “The dem and for com puters is high and getting hig h er,” he said, “and the com puterization of den tistry is a key goal of the ADA. Besides upgrading office systems, there is a huge p o te n tia l p a y o ff in c o m m u n ic a tio n among dentists, in education and sharing ideas, in ending the isolation of the solo practitioner.” Dr. H ankin, now vice-president, opera tions, ADOSI, also saw an opportunity to avoid the confusion often generated in the com puter market by the variety and in c o m p a tib ility of h a rd w a re and software. By standardizing the com puter systems in dental offices across the na tion, the ADA could make it easier for dentists to com m unicate w ith each other. “The result of these various lines of th in k in g ,” Dr. H ankin said, “was th at we decided to enter the com puter systems m arket, and, in fact, not to endorse an out side com puter system, but to acquire and develop one of our ow n.” The move was not unprecedented. His torically, the ADA has been involved, through its staff in the N ational Bureau of S ta n d a rd s a n d in its o w n r e s e a r c h facilities, w ith the developm ent of m any products that dentists now use, including the high-speed handpiece and panoram ic
Besides upgrading office systems, there is a huge potential payoff in communication among dentists, in education and sharing ideas, in ending the isolation of the solo practitioner. m H. William Gilmore, DDS, MDS
X-ray equipm ent. In the past, however, the A ssociation has given these products to private industry, w hich in tu rn has m arked them up for their own profit and sold them back to the dentist. This time, the A ssociation determ ined to acquire a state-of-the-art com puter package, de velop it by building its own program m ing and support staff, and provide it directly to practitio n ers. W ith profits directed back to th e national organization, the prim ary beneficiary w ould be the practi tioners themselves. This arrangem ent also has major ad vantages in pricing, service, and quality control. Because there are fewer links in the chain, developm ent and distribution are less costly and the system can be priced lower. Dr. Hankin considers this one of the com pany’s prim ary concerns: m ax im izin g th e perform ance-to-price ratio; that is, providing the practitioner w ith the best value for the dollar spent. A ccording to Dr. Hankin, it is a ques tio n of m o tiv atio n . “ You have to re m em ber,” he cautions, “ our customers are our members, so our incentives are som ew hat different from those of an out side vendor. If you look at ADOSI’s daily activities, y o u ’ll see a m uch heavier em phasis on service and support, and on re search and developm ent, than on adver tising, sales, and fast distribution. “If w e had sim ply endorsed or gone into partnership w ith an outside vendor, o u r m em bers w ould h av e b een c o n cerned, and not w ithout reason. Our obli gation to serve our m em bership could easily have come into conflict w ith the m otives of a private firm that d id n ’t share our com m itm ent to dentistry. From the beginning we knew that, as an arm of the
national organization for the profession, we had to set the highest standards and ensure the quality of our product—and the only way to do that was to m aintain com plete control.” Before starting, the Board asked Dr. H ankin to survey the existing market. Was th e m a rk e t s a tu ra te d or m erely crow ded and confused? Did the ideal product already exist? Was there a place for the ADA? Dr. H ankin found that some systems had excellent hardw are, others had w ell-designed software, som e had good service and support, others offered good pricing, but no single system com bined them all. Therefore, he concluded that ADOSI could fill that niche. Based on Dr. H ankin’s conclusion, the ADA Board of Trustees elected a board of directors for the new subsidiary, m em bership of w hich included A ssociation officers or trustees, three Association staff members, and several outside representa tives from business, banking, and law. The directors approved the business plan developed by the m arketing departm ent and presented it to the Board of Trustees, w hich agreed to capitalize the subsidiary corporation. ADOSI stock was then is sued to the Association, and the com pany established.
esigning softw are to fit J Dd entists’ needs
A
JL JL n y
c o m p u te r sy ste m re v o lv e s around its software; like a stereo system w ithout records, a com puter is no more than a boxful of silicon chips w ithout the program s that tell it w hat to do. ADOSI’s ADOSI ■ 681
'B h ip fa s i} first consideration, therefore, w as to de term ine w hat a dental office com puter system should do and then to find the best way of doing it. “In looking at den tists’ needs, w e fo cused on practice m anagem ent an d m ar keting,” Dr. H ankin said. “Dentists are by training and by interest excellent clini cians. But m ost dentists are not experts in practice managem ent; m ost have had lit tle or no training in running a business, and if they need help anyw here, it’s at the front desk. The principle of com parative advan tage says that if there are some things you do very w ell and others you do less well, you should concentrate your develop m ent energies on the latter. T hat is, if you're an excellent clinician b u t you’re not delivering as m uch dentistry as you’d like because of inefficiencies at the front desk, then you should shore up that end of the practice. But a dentist sh o u ld n ’t spend his or her ow n tim e balancing the books, w riting checks, and filling out forms. A dentist should be in the treatm ent area, practic ing dentistry. By the same token, an office m anager sh o u ld n ’t spend hours filling out insurance claim forms. Staff people should be calling patients to make sure appointm ents are kept, calling referring dentists to m aintain the d en tist’s linkage to his associates: doing the things that w ill ensure that the practice stays busy and the cash flow smooth. The routine, repetitive, m achine-like tasks of book keeping, accounting, and so on can be done m uch m ore quickly and m ore accu rately by a com puter, freeing th e staff to do the kinds of things only they can do.” To offer dentists the kind of software package that w ould allow them to prac tice the best dentistry of w hich they were capable, ADOSI hired Mr. Geoffrey Love. He and his colleagues in 1979 h ad begun to w rite the core program s of a dental of fice software system. The program s ad dressed the need for an affordable system designed specifically for dental offices. “We talked originally w ith about ten dentists, both general practitioners and specialists, and looked at how th eir prac tices w ere organized,” Mr. Love recalled. “ W ith the inform ation w e gathered, we did a systems analysis of a ‘ty p ical’ dental practice: How does the dental office h an dle paper flow ? Who generates w hich docum ents? W here does the p aper go? 682 ■ JADA, Vol. 110, May 1985
We talked originally with about ten dentists, both general practitioners and specialists, and looked at how their practices were organized.
Mr. Geoffrey Love
How are the various forms—insurance Choosing hardw are that claim s, treatm ent plans, general ledger, com plem ents software and so on—connected to one another? “ We also asked den tists w h at they w anted a com puter system to be able to do. We found that they w anted all the X ^ o m atter how good, software will standard things, of course: handling bill not run by itself. ADOSI’s next challenge ing, insurance, recalls, and so on. But was to select the com puter hardw are on each dentist also had particular needs. w hich those program s w ould run. Several For exam ple, some w anted to be able to systems were evaluated, including IBM, w rite their ow n recall letters and others Wang, and Convergent technologies, be preferred to use standard cards; some of fore ADOSI chose Altos com puters. “Al fices assessed late charges, and others tos is a leader in m ulti-user, small office d id n ’t. So w e knew we had to make the com puters—th at’s their strategic market, system both com prehensive and flexi so we know they’re going to be interested ble.” in it for a long tim e to com e,” explained T h ese w ere im p o rta n t fea tu re s for Dr. H ankin. “More dental offices have ADOSI because m any of the available A ltos com puters now th a n any other software packages were either m odified co m p u ter. T h e y ’ve b een aro u n d and physician or business packages. Because grow n stead ily since 1977; th e ir m a this package was specifically developed chines are highly reliable, and we know for d e n ta l p ra c titio n e rs , its in te rn a l that w ith Altos, w hat w e’re paying for is lo g ic — th e flo w of in s tr u c tio n s a n d good equipm ent, ra th er th an a brand com m ands—is consistent w ith the way nam e.” dental offices handle m anual recording A ccording to Mr. Phil W hite, vicesystems. “Billing is linked to recall, recall president, m arketing, Altos, the prim ary is linked to word processing, insurance is reason the Altos was chosen “ is that we designed for dental office patients, not offer a family of m ulti-user com puters, on hospital patients,” explained Dr. Hankin. all of w hich the ADOSI software operates “It’s a system designed specifically for identically. This m eans that as a practice dentists, and as a result it makes sense to grows, even from a single practitioner to them ; they find it com fortable.” an entire clinic, the dentist can upgrade, T h e A D O S I b o a r d a c q u i r e d th e th a t is, e x p a n d h is sy stem , w ith o u t software and hired its developers, bring changing the softw are, m odifying the ing them to ADA H eadquarters where docum ents, or retraining the staff. So h e’s they could apply their expertise to this lost none of his original investm ent in and other projects. In the past 15 m onths, tim e and money, but can accom m odate they have enhanced the program, built w hatever changes he makes in his prac tutorials and help aids, developed train tice.” ing procedures and support systems, and A n other im p o rta n t feature of A ltos w rote a detailed users’ m anual. c o m p u te rs is th e ir use of th e X enix
N
J
-i
^
-i
operating system, an enhanced version of Unix (an earlier operating system) that has quickly becom e the indu stry stan dard. It is a flexible system specifically designed for m ulti-user, m ulti-task opera tions, enabling several different people to operate the system for a variety of func tions at the same time. “Xenix is broad-based, it’s supported by m any vendors, and there is a variety of software, in addition to ours, available for it,” Dr. H ankin said. “We thin k it’s an ideal system for standardizing com m uni cations among dentists and for protection a g a in st o b so lescen ce. B ecause w e ’re looking m any years ahead, these were very im portant considerations.” A lto s a ls o w o r k e d c lo s e ly w ith ADOSI’s program m ers, making hardw are m odifications to m eet the needs of the program s and to enhance the system ’s usefulness to practitioners. For exam ple, Altos added graphics capabilities to its com puters for “w indow ing,” a process that allows the user to call up one func tion in the m iddle of another or to zoom in and get more details on a specific area of data. They also added the ability to print any given screen at the touch of a key, a convenient and user friendly function all too rare in the com puter world. “Altos has been very cooperative,” said Dr. Hankin. “They have a real interest in dentistry, and w e’ve been able to develop a national agreem ent w ith them th at w ill be of great benefit to dentists. W e’ll be packaging their hardw are as part of the ADOSI system —testing it ourselves be fore it goes out, on top of th e ir ow n tests—and putting the ADOSI label on it. We stand behind it 100%. Mr. W hite agreed. “The ADA m ade our product theirs, and in return w e’ve m ade their interests our own. Altos plans to do everything we can to enhance research in the dental field and to help develop new technologies and new uses of com puters for dentists. W e’re very m uch com m itted to dentistry.”
HH Service and support
T ■* ess ta n g ib le th a n h a rd w a re or software, but equally im portant, are ser vice and support. Dr.Hankin calls this the heart of the A m erican Dental A ssociation Office System. “W e’ve w orked harder at this than at alm ost anything else in the system ,” he said. “This system, w ith the ADA name
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2. Your paperw ork has increased to the point w here you w ill soon need to add front office staff. 3. You’d like to spend more tim e practice building, but first you need to analyze w here your practice is now. 4. You’d like your staff to spend more tim e on recalls and patient rela tions. 5. You’re serving m ore and more Is it time for a computer in your in s u r e d p a t i e n t s — o r w o u ld lik e practice? to—but the forms are overwhelm ing. 6. You’d like to speed up your cash The seven w arning signs that say you flow. could probably benefit from an office 7. You find yourself looking w ist com puter system. fully at com puter advertisem ents and 1. Your practice is grow ing, and reading every new com puter article that comes along. you w ant it to keep on growing.
on it, w ill be going into some sophisti cated practices and into others for w hich com puters are som ething entirely new. It w ill be used by m any people w ho may never have sat dow n at a term inal before. A nd we have a responsibility to see that every user gets as m uch help and support as he needs—from the beginning and all dow n the lin e.” The support begins w ith ADOSI’s care ful, deliberate m ethod of d istrib u tio n through a netw ork of authorized agents th ro u g h o u t th e U nited States. “ ‘A u thorized agent’ is the key term ,” Dr. H an kin explained. “T hey’re not dealers and th e y ’re n o t franchisers; they are local facilitators for ADOSI. The practitioner is purchasing the system from us, not from the agent. The agents m ust follow our guidelines for training and installation; they come to Chicago and spend several weeks w ith us, in hands-on sem inars and training sessions, learning those proce dures. “ Because w e ’re being very careful, m aking sure every agent satisfies our criteria for both capability and quality control, w e’re m oving slowly and sequen tially, on a state-by-state and region-byr e g i o n b a s i s . W e s t a r t e d in M a s sachusetts, New York, and Illinois, and so far w e’ve focused prim arily on the 15 or 20 installation sites betw een here and the Atlantic; by late sum m er we should have authorized agents throughout the West Coast, the West, and the South.” M ost of the agents are systems houses, com panies th at have solid experience
dealing w ith m icrocom puter-based in s ta lla tio n s in p ro fe s s io n a l e n v iro n m e n ts —fo r e x a m p le , d e n ta l, m edical, legal, and accounting. “ State dental societies are also being given an opportunity to participate,” said Dr. Gil m o re , “ a n d s e v e r a l — O h io , fo r exam ple—have form ed authorized agents in th eir ow n subsidiary corporations. Others have affiliated w ith our agents in their states.” Through the authorized agent, ADOSI w ill sell and install the system, configur ing it to the needs of the individual prac tice, and train the practitioner and staff in its use. “We have a three-pronged ap proach to train in g ,” Mr. Love explained: “ a user-oriented training guide, sem i nars, and on-site consultation to help the practice convert from a m anual to a com puterized system .” C ontinuing support is built into the user friendly software itself. For example, there are clear “error m essages” to let the user know w hen he has m ade a mistake; a unique “h e lp ” key that gives the user an im m ediate solution to m ost problem s; sim ple m ethods for correction of typo graphic and other m istakes; w arnings w hen disk space is running low; and a sim ple, built-in procedure that virtually forces the user to m ake back-up copies to ensure no data can be lost. Still, there may come a tim e w hen m ore help is needed than the system can offer. This help is available through ADOSI’s unique tele phone support service. “The telephone provides every user ADOSI ■ 683
w ith an um bilical cord connecting him to the home office,” Dr. H ankin explained. “Not only do we offer hotlines, we also provide a link-up by m odem, a device that lets our technical staff take over the users’ system from their ow n keyboards and cor rect operator errors on th e spot. The m odem connection also provides a w ay to transm it updates and enhancem ents to al ready installed system s as we develop them , so w hile [we are] continually ex p an d in g , no ADOSI u se r n eed w orry about being left behind. All custom er calls are follow ed by a sophisticated tracking system that en su res no p ro b lem is u n a tte n d e d . A l though there are few actual problem s, the technical staff knows how to evaluate and respond quickly to alm ost any question. To date, m ost of the calls are about opera tive questions: Can I do this? W hat if I do that? “W hat h appens,” said Dr. H ankin, “is that after the practice has had the system for a w hile, they begin to get creative w ith it, and they w ant to use it in new ways. They start thinking about the kinds of re ports they’d like to generate, th e different ways they’d like to analyze their data, and they call us with those questions.” The ADOSI staff actively solicits users’ feedback and keeps a detailed record of questions and requests. These are incor porated into training sem inars and w ill become the basis for enhancem ents in later versions of the software. “As a subsidiary of the Association, we w ant to have the very best support in the b u sin e ss,” said Ms. M anon F ie ld in g , ADOSI’s te c h n ic a l s u p p o rt m an ag er. “The Association is a service organiza tion, and it is im portant to us to be re sponsive to d en tists. We have to see things from the users’ perspective. Our philosophy is simple: a problem is solved only w hen the user thinks it’s solved.”
t The future: w here do w e go from here?
A
JL J L DOSI’s plans do not end w ith the cu rren t system . “ The p o ssib ilities for com puter applications in dentistry are alm ost lim itless,” said Dr. H ankin. “One of the m ost exciting areas of develop m ent, one in w hich ADOSI is very m uch involved, is the work being done by Dr. Howard Bailit and his colleagues, w ith 684 ■ JADA, Vol. 110, May 198S
The ADA made our product theirs, and in return w e’ve made their interests our own.
Mr. Phil White
the support of the Kellogg Foundation.” Dr. Bailit, who heads the departm ent of health adm inistration, Columbia Univer sity, School of Public Health, is working on a major project that, w hen integrated w ith ADOSI, could bring com puters into the treatm ent rooms of dentists across the nation. “I’d been w orking in the area of quality assurance for a long tim e,” Dr. Bailit said, “and it had become apparent to me that im provem ents in the quality of care come about not through the efforts of regulatory a g e n c ie s, b u t th ro u g h sc ie n tific and technological advances. I was convinced that com puterized inform ation systems, once they becom e affordable to in d i vidual dentists, could have a major im pact on dental care.” Dr. Bailit is working on a system that
has tw o major aspects, the first of w hich is a com puterized recordkeeping function that w ill enable practitioners to collect, store, and retrieve clinical inform ation on every patient in the practice. The record w ould include everything from the h is tory and exam ination to treatm ent plan ning and treatm ent notes, in effect replac ing the w ritten dental record. The practi tioner w ould be able to retrieve inform a tion alm ost instantaneously, sw itching from one patient to another or tracking the history of a particular patient, a given service, or even a particular tooth. The second aspect of the system would bring a com puterized inform ation base into the practitioner’s office, including sum m aries of current know ledge in many areas of diagnosis and treatm ent. Up- : dated regularly, by a m odem connection
to the A ssociation’s m ain com puter, the in fo rm a tio n c o u ld h e lp p ra c titio n e rs diagnose w hite lesions or odontogenic p ain, review th e latest treatm ents for periodontal disease, or check drug in teractions. “The potential for this kind of system is just staggering,” Dr. Bailit said. “ We can com bine the aggregate know ledge of den tists and give the smallest, m ost remote practice access to as m uch expertise as any major practice in the country. We can, for the first tim e in dentistry, gather in form ation on a huge aggregate of patients, analyze it dem ographically, and find out just how effective specific treatm ents are for any segm ent of the population. We can offer dentists an opportunity to compare their practice m anagem ent to that of sim i lar practices, give them a way to make higher-order decisions about cash flow, and so on. And this is just the tip of the iceberg.
I’d been working in the area of quality assurance for a long time and it had become apparent to me that improvements in the quality of care come about not through the efforts of regulatory agencies, but through scientific and technological advances. Howard Bailit, DMD, PhD
We already have the m eans to generate a trem endous am ount of information. The
Through the authorized agent, ADOSI w ill sell and install the system, configuring it to the needs of the individual practice, and train the practitioner and staff in its use.
. . What a computer will—and won’t— P* do for your practice A realistic assessm ent of w hat you can expect from a com puter in your prac tice.
A computer will: • perform boring, repetitive tasks consistently and w ithout com plaint; • provide you w ith inform ation and reports—w hich w ill be precisely as valuable as the uses to w hich you put them;
• give you access to inform ation on w hich to base decisions; • be as accurate as the data you feed it; • fre e y o u r t i m e — a n d y o u r staff’s—for c lin ic a l w ork, p ractic e building, collections, and other n e glected tasks; • have o c c a sio n a l m a in te n a n c e needs—like your typew riter or tele phone; and • take tim e to learn—and then make you w onder how you got along w ith out it.
A computer will not: • manage your practice; • make business decisions for you; • dehum anize your practice; • replace your current office staff; • turn a disorganized, inefficient practice into an efficient, organized practice; and • change your personality or your social life.
question now is, w hat do w e do w ith that information: how do w e make sense of it and use it to im prove the practice of den tistry? The next step, clearly, is a system that w ill not only provide data, b u t w ill assist the dentist in making clinical and m anagem ent decisions.” Dr. Bailit w ill be testing his system in a handful of practices this sum m er and p red icts it w ill be available, th ro u g h ADOSI, in 2 years. M eanwhile, said Dr. H ankin, ADOSI is also w orking w ith the Am erican Dental Network, sim ilar to the existing American M edical Network and A m erican O ste o p ath ic N etw ork. T he netw ork w ill offer access, by modem, to clinical and practice inform ation, pre scription drug inform ation, references and abstracts to current literature, and in formation about upcom ing Association m eetings and events. It w ill also enable practitioners to send messages and re ports directly to one another and to com m unicate w ith their state dental societies, and it w ill probably be used for continu ing education programs, electronic jour nals and new sletters, and m uch more. “This is the future of dentistry,” Dr. H ankin concluded. “Because of com put ers, the dental office 10 years from now w ill be very different from today’s prac tice. Dentists w ill be linked w ith their col leagues and w ith state-of-the-art d en tistry. T hey’ll be m uch more sophisti cated m anagers, able to analyze cash flow, productivity, costs, and tim ing of accounts payable. Their practices w ill be m uch more organized, more efficient, and more productive because dentists w ill be freed from the burdens of adm inistration, free to be the best dentists they can possi bly be, and able to dedicate them selves ADOSI ■ 685
fully to w hat they really w ant to do— im prove the dental health of the A m eri can public. A nd ADOSI w ill help them do it.” “ADOSI is going to have m ajor reper c u ssio n s for d e n tis tr y ,” Dr. G ilm ore added. “It’s only the beginning. There is great potential in for-profit ventures, and we are determ ined to keep th e risks low and the benefits high. One of m y top goals in oganized dentistry is to see this become a major success for our m em bership.”
Because of computers, the dental office 10 years from now w ill be very different from today’s practice.
Robert Hankin, PhD
A GLOSSARY OF COMPUTER TERMS
Applications programs: Program s de signed to perform specific business functions, such as accounts receiv able or w ord processing. Back-up: Copies of data m ade and kept as protection against loss. CRT: Cathode ray tube. The video ter m inal, usually w ith keyboard, used for entering and receiving data from a com puter. CPU: Central processing unit. The part of the com puter w here instructions are interpreted and carried out. Data: Inform ation entered into or re ceived from the com puter.
686 ■ JADA, Vol. 110, May 1985
Disk: Floppy disk (diskette) or hard
S ecu rity code: A p a s s w o r d th e
disk. M agnetic devices used to store data. H ard disks g en erally hold m u c h m ore d ata th a n flo p p ie s. Floppy disks are inserted into a “ disk drive” for use w ith the com puter. Hard copy: Printed m aterial produced by the computer. Hardware: T he c o m p u te r a p p a ra tus—that is, the com ponents of the m achine. Memory: The part of the CPU that holds inform ation being processed. Modem: A dev ice th a t co n n ects a com puter or term inal to a telephone line for transm ission of data. Multi-tasking: The ability of a system to ru n m ore than one job or task si m ultaneously. Multi-user: The ability of a system to allow more than one person to use the com puter at the same time. Operating system: The program s, usu ally provided w ith a com puter, that p erform its basic fu n ctio n s and allow other programs (such as ap plications programs) to be used. Peripherals: H ardw are other than the CPU: p rin te rs, keyboards, CRTs, disk drives, modems.
operator m ust type into the com pu ter in order to execute a program. (A security m easure to protect against u n au th o riz ed access to in form a tion.) Service bureau: A data processing facility that provides services such as billing and accounting, based on data provided by the client. Software: The set of instructions or programs used by the com puter and the operator to perform specific functions. Storage: E x tern al devices su c h as disks, tapes, cassettes, and cards, w hich store data and software. System: The w hole set-up: hardw are and software, peripherals and ap p licatio n program s, w orking to gether in a practice. Terminal: A device to transm it or re ceive data, usually consisting of a keyboard an d CRT. “ In te llig e n t term inals” also have some built-in com puting power. Time sharing: A m ethod by w hich a com puter facility (usually a large “m ainfram e”) can be shared by sev eral users, often at remote term i nals, apparently at the same time.