Orthodontic Software: A Candid Discussion
By Charles A. Lewis
Every day the successful operation and management of orthodontic practices becomes increasingly reliant upon computerized systems. This trend will continue to accelerate due to the rapidly growing movement toward paperless operation and the cost-effective efficiencies it provides. Operating in paperless mode means that, except for actual patient treatment, the management software essentially controls practice operations!
Despite its progressively important role in the practice, few doctors actually understand all the factors involved in implementing and operating the computer network controlled by orthodontic management software. These networks are becoming progressively more complicated, so this article will candidly discuss the critical functions required to enable efficient operation, although it will not go into detail by describing the functions. It will also talk about reasonable, and unreasonable, expectations in regard to these systems. As we begin, this caveat: some of the remarks about what orthodontists should - or should not - expect from the software and the company that provides it, are going to be brutally frank! Even so, they are totally true and users need to be aware of these realities.
Management Software
There are basically four categories of orthodontists when it comes to management software:
1. Those that have a system;
2. Those that have an obsolete program that must be replaced;
3. Those that have a system but are dissatisfied and want to replace it;
4. Those that do not have a system but realize they need to get one.
Although a majority of orthodontists now have management software, most of them report that (a) they are unhappy with it in some way; (b) they don’t truly understand the software or the hardware that operates it; (c) they don’t grasp the need for constantly upgrading their PCs; and (d) purchasing and operating a local area network (‘LAN’) can be (or is) expensive. Many would also say that they know they need to upgrade or change their system but are reluctant to do so because of the cost and/or disruption in the office. Actually, most seem to fear the interruption in the office more than the required investment.
The bad news is that 50-60% of these doctors still have outdated programs (such as DOS software) that need to be replaced! (The last Microsoft operating system that contained DOS components was Windows 98 Second Edition and no-charge incident support and extended hotfix support for Windows 98 Second Edition ended on June 30, 2003.) Besides the lack of an appropriate operating system, most companies that still have obsolete non-Windows software are phasing out their support because it is costly to support two different versions of software. Other doctors have programs that are being gradually phased out because the software company is trying to eliminate the marketing and support of multiple programs that are competing for sales.
Excluding recent graduates just entering practice, orthodontists who do not have a computer system usually try to purchase the most basic, inexpensive program available. These doctors are often nearing retirement and understand that it will be difficult to sell a practice that isn’t computerized. What they don’t take into consideration, is that most recent graduates purchasing a practice have been using PCs for years and want a comprehensive program that will allow them to incorporate all the latest computerized tools. Therefore, a basic system that will have to be replaced to make such operations possible can be a negative factor in their purchase considerations.
Mandatory Software Considerations
No orthodontist should seriously consider purchasing a new management program unless:
Other Important Software Concerns
§ Does the software provider have a history of providing consistently progressive programs?
§ Does the software provider have a history of furnishing prompt technical support?
§ Is the program regularly updated with state-of-the-art features?
§ Is it newly designed Windows XP-based software; or is it a DOS derivative?
More Software Issues
Because doctors don’t generally understand and, in many cases, don’t personally use management software, most do not carry out a real ‘due diligence’ investigation before making the purchase. The outcome is that they end up buying expensive programs that (a) aren’t state-of-the-art; (b) won’t really meet the needs of the practice (now or in the future); and (c) are poorly supported.
If you plan to operate a near-paperless office with 15-workstations, then checking user-references that only use 5-workstation systems for accounts receivable, scheduling, and letters isn’t going to be much help. In addition, orthodontists who operate multiple office locations have special problems / needs and should ensure that the software they purchase will accommodate these more complicated operations. The same is true of multi doctor practices.
The result of poorly investigating the programs under consideration is that doctors end up having to purchase more than one system during their practice years. In fact, most orthodontists in practice for 10+ years are now on their second system; many are on their third. One young doctor recently commented that he believed that he could only anticipate getting 5-7 years out of a system before having to replace it with another. That should not be the expectation of any doctor today that is willing to do a proper evaluation of software before purchasing it!
Hardware & Operating Systems
One of the biggest complaints from orthodontists (and anyone else that uses a PC) is the constant (and costly) need to upgrade the hardware components and operating systems of their networked PCs. The question is usually: why? The simple answer: the constant changes in technology.
Any software company whose program is kept up to date is continually using updated versions of a programming language and database. Usually, the resulting new version of management software requires the latest operating system and increased hardware capabilities such as greater processing power, additional RAM, a more powerful video card, and a larger hard drive. And given the current pricing of PCs, it is probably about as economical to purchase a new PC as it is to pay someone to upgrade an old one. You should anticipate changing your PC about every 3 years if you are operating leading edge software and want to make the most of its capabilities.
Here is a simple example of how drastically things change. Doctors in practice in 1994 who had the latest hardware will recall that the average PC they used had a hard drive with 80-120 Megabytes of storage. Ten years later, the Microsoft Windows Server 2003 operating system alone requires almost 2 Gigabytes (2,000 MB) of hard drive space!
Another illustration is the improvements in network transfer speed capabilities. Affordable 100BASE-T became available in 1996, allowing 100 mbps transfer speeds. Three years later, in 1999, 1000BASE-T became available, allowing 1gbps transfers; a speed that is ten times faster!
From these two examples it is easy to see that state-of-the-art networks require continual upgrades to hardware, operating systems, and any ancillary software such as Microsoft Office, if they are to be maintained at optimum operating levels. In addition, the need for these upgrades cannot be blamed on a software provider that is simply providing what most of its users want: a system that is always up to date.
Data Conversions
The agreement to purchase the software you have chosen should clearly spell out the data that is electronically convertible from your existing system for use in the new program. If the software company has never converted data from the system you are using, it should offer to do a trial conversion to provide you with an answer before you sign the agreement.
If a software company tells you that it can electronically convert all your existing data for use in their program, pretend that you are from Missouri and ask them to 'Show Me' before signing on the dotted line! In thirteen years in the orthodontic software industry, I have yet to see anyone electronically convert all the data from a program for use in totally different software.
Reasonable User Expectations
Every orthodontist who purchases management software after doing a complete evaluation of the program has every reason to expect the following:
ª The software will perform as advertised, promised, or demonstrated;
ª The program will be stable – operating without frequent software-related system crashes;
ª The software will be promptly supported and regularly updated (for an additional fee);
ª Reported program errors will be fixed as quickly as possible;
ª The company will have a procedure for users to submit program improvement suggestions;
ª Access to senior management regarding problems unresolved after a reasonable period of time.
Unreasonable User Expectations
The following has been accumulated and condensed from 13 years of conversations with disgruntled orthodontists looking for new software. Most of them had ample reasons and justifications for wanting to change systems; but these particular issues should not be included in that category. With these expectations, a doctor will never find his/her ideal software and the resulting relationship with the software company is likely to be a rocky one. Remember, I warned that these remarks would be blunt.
Expectation: The new software should do everything you want it to do and in exactly the way you want it done, which is, ironically, usually the way your old software did it. A secondary expectation is that you can contact the software company and they will change the software to make all this possible.
Reality: To be commercially successful, a software company must find a combination of functions that meet the needs of most users. While evaluating the software, you and the staff should determine whether or not the program’s operation is suitable for your particular office and method of operation. If it isn’t, either don’t purchase it or be prepared to change the way you operate. For a software company to alter a program simply to conform to the desires of a particular client would be both impractical and financially ruinous; custom programming would make it nearly impossible to support. As a result, these are unreasonable expectations.
Expectation: If you submit a suggestion for a change or enhancement to the program, you (a) have a right to talk directly with the programmer(s) about the suggestion; and (b) the company should give you some kind of time frame as to when your suggestion will be added to the program.
Reality: Most companies welcome program suggestions from users and prospective users and provide a method for their submission. After all, many program features come about in this manner. However, programming time is very valuable (and expensive) and a company will not usually allow programmers to take time to discuss suggested improvements. In addition, companies will usually not give any indication as to whether or not a submitted change will be included in a future upgrade. Even if a suggestion is expected to eventually be included, rarely would a time frame be given. Because of the drastic programming that can be required for what seems (to a layman) to be a very minor change, program revisions have to be carefully planned in advance. In addition, changes to the program require that all users be updated to avoid support issues. Therefore, these expectations are not reasonable.
Expectation: If a problem is encountered with the network, it is the software company’s responsibility to find and resolve it, since the management software probably caused the problem.
Reality: Normally, the first thing the company’s support technician will do is take whatever measures are necessary to determine whether the issue is related to the management program, and if it is, fix the problem. However, unless you have a really faulty management program, most problems that affect an entire network, or particular workstations, are not going to be caused by the system. For instance, if you have a 10-workstation local area network and only 2-3 of your workstations are experiencing problems in using the program, you have a network issue – not a program issue.
Unless the software company’s contract with the client specifically specifies that it is providing hardware and/or network support and is charging a fee for such services, it will rarely attempt to diagnose or resolve a non-software related problem. The primary reason for this is that salaries for technicians with hardware and networking expertise are much higher than for software helpdesk personnel. It is very expensive to maintain sufficient staff to provide hardware and networking support and no company is going to furnish such services without payment. Expecting a software company to provide hardware and software support, gratis, so you can avoid the expense of hiring someone to do it, is unreasonable.
Expectation: Your Pentium 4, 2GHz server and eight 10BASE-T equipped Pentium II workstations are going to operate your new leading edge Windows XP-based database software at fast speeds. If the software is slow and the network encounters problems, it is the fault of the management program.
Reality: Unless your software delivery is Internet-based and using a fast broadband connection, obtaining quick speeds with this kind of hardware simply isn’t possible. A server with a Pentium 4 processor attempting to operate this many active workstations using a comprehensive Windows XP-based database software would be running at 100% capacity at all times, creating terrible network data conflicts and ‘time out’ problems. And these problems would not be the fault of the software; although its use would be the root cause. It is unreasonable to use inadequate hardware and networks and then expect optimum results.
Expectation: The features in your new Windows XP-based software will function similarly to those of your old DOS or COBOL-based program.
Reality: If you are converting from DOS or COBOL-based software, the change to a Windows XP-based program is going to be radical! Trainers commonly hear, "But our old program did it this way." Keep this in mind; just because your old program functioned a certain way did not mean that was the correct way - it's just how it did things and you and the staff got used to it. Also, those old programs usually did things in a certain manner because that was the only way they could do them! The Windows XP operating system offers programmers greater flexibility in designing program functions and they will be different! Expecting a new Windows XP-based program to operate just like your old program is unreasonable – and illogical.
Expectation: You purchase new software but elect not to be trained, or to pay only for minimal training, because your staff is ‘sharp’ and will learn to use it on their own. And if they need help on how to use the system, they can always call for support (which is usually included at no cost during the first year). After all, if the staff cannot learn the program on their own; it is the fault of the software for not being ‘easy to use.’
Reality: Regardless of how intuitive or easy to use the software might be, if the program is comprehensive the staff will require training to use it properly. Further, if you are transitioning from an old program, the staff is inevitably going to be confused at first because the new software operates much differently than what they have been using. These factors, combined with the fact that the staff has to try to learn the software while working with patients, is going to create tremendous stress. As a result, they will begin to hate the new software, although it is not at fault and works as advertised and/or demonstrated.
Most software companies do not mind their support staff answering questions about how to use the software, especially in the early weeks after installation. However, when an office staff begins taking an inordinate amount of the support team’s time with what are clearly issues resulting from a lack of training, the software company is probably going to demand that training be purchased. The same is true when support technicians are consistently asked to clean up mistakes made by a clearly untrained staff. It is not reasonable for a doctor to expect to avoid paying training fees by transferring the burden (and cost) to the software company's support staff.
Summary
Practice management software is playing an increasingly important role in the orthodontic office. The networks of software, hardware, and the ancillary systems they incorporate, grow more sophisticated every day. These systems are expensive and must be set up with all the right components and then maintained properly if they are to provide efficient, trouble-free operation. As it is with orthodontics, you cannot skimp on the treatment and/or quality of materials and then expect outstanding results. Obtaining the necessary training on how to operate the software is absolutely essential.
An appropriate evaluation of available orthodontic software should enable you to select the program that best meets the needs of your practice. (No doctor should ever purchase software that he/she believes might require replacement at a later date.) Evaluating the company that provides the software is equally important, because the software installation is only the beginning of what needs to be a long, positive association between you and the vendor. However, such a relationship is unlikely unless each of the parties understand what is expected of them; what they are to provide; and know all the ground rules. If either the company or the doctor is unreasonable, the relationship will likely be terminated.
A recent article, “The Road to Paperless Nirvana” written by Dr. Hugh R. Phillis and published by the Orthodontic Cyberjournal (http://www.oc-j.com/dec03/Paperless.htm) did an excellent job in discussing how to create and sustain a good relationship with a software company. I highly recommend taking time to read it.
About the Author: Charles A. Lewis is the Chairman and CEO of CPI Technologies Corporation and CEO of its subsidiary companies; Advanced Ortho Systems, LLC and Advanced Dental Systems, LLC. He has many published articles on paperless operations and practice automation. Charles lectures at seminars and colleges on increasing practice efficiency through paperless operation and on Internet-based delivery of management software. He can be contacted at 877.803.4412.