Installation and Integration of Radiographic Technology
Proper planning and staff commitment are essential
As clinicians select the radiographic system most suitable for the dental practice, a key factor that must be addressed is where the various components will be placed and how the system will be installed. However, thanks to advances in computer technology, data storage, and networking—as well as the lower cost of high-definition monitors and computer hardware—installing digital radiography systems and integrating them into a dental office’s current practice management system is no longer the daunting process it once was. Nevertheless, proper planning is still crucial and requires that the following be established: the location of the equipment and its components, networking infrastructure, Internet access, security, the routine workflow and movement of both the patients and staff, and by whom and how the system will be installed and maintained.
Installing Digital Radiography Systems
One of the perceived drawbacks dentists initially anticipated with converting to radiographic systems was the cost of installation related to office computers. Dale A. Miles, DDS, MS, FRCD, an oral and maxillofacial radiologist in private practice, says that this is no longer a problem now that virtually all offices already have at least one computer in place. No matter what system is being installed, one consideration, according to Miles, is that if the dentist wants to have access to digital files in multiple operatories and at multiple workstations (which most do), the practice needs a server to move the data within the office environment.
Installing and Maintaining the Office Computer Network
Viewing the same information on different computers or workstations requires a computer network that enables the sharing of information on multiple machines. The value of having a properly designed and installed network, along with proper maintenance and security procedures for the network, cannot be overstated. Unfortunately, this value is often minimized, and all too often an improperly designed and installed network is the cause of many of the problems that are encountered as the system is used on a daily basis.
It is imperative that a practice establish and maintain a close relationship with a dependable, qualified information technology (IT) technician or company that understands the true needs of the dental practice and can not only properly install the necessary hardware, but provide integration and support services as well. This ongoing IT relationship is imperative and must include the ability to provide ongoing support—both onsite and online—when needed in a timely and efficient manner. A major consideration is the cost to the practice, both financially and organizationally, if the system is in a nonfunctional state. The practice also needs to develop a contingency plan of how to operate and correct the problem when a disruption does occur.
A general rule to use with computing is that faster is always better, and there never seems to be enough memory—but it comes with a price. Dependability and consistency are also an essential consideration, especially when designing and installing a digital imaging system and network. While using wireless networking might appear to simplify the process, whenever reasonably possible, installing a wired Ethernet connection, which is not only faster, but more secure and reliable, can minimize the potential for networking problems for that device in the future.
When it comes to storing and sharing data with digital radiographic systems, it is essential to follow HIPAA regulations. All patient health information and data, especially radiographic images, need to be maintained and protected. When the image is being acquired and saved, it needs to be immediately stored in multiple locations to prevent the loss of the data in the event of a hardware (disk) failure. The server where the images are being stored should be set up with multiple drives with a “RAID” configuration—Redundant Array of Independent Disks, or sometimes referred to as Redundant Array of Inexpensive Disks. This configuration allows the saved data to be stored on multiple disks at the same time, as a form of protection.
However, the RAID configuration will not protect the data from a catastrophic loss (such as a fire or a flood, or software corruption); therefore the data protection process needs to include a daily method of creating additional secure off-line and off-site copies. This cannot be done with traditional acetate film and is an additional advantage of a digital system.
The cost of data storage and backup to a removable storage or cloud system is very low, Miles explains. Data can be backed up off-site or placed on an external hard drive that is taken home from the office at the end of each day, or it can be done through online or cloud-based options.
Space Considerations and Workflow
Intraoral systems typically fit in the operatories much in the same way film-based systems did; however, there are some additional considerations to be addressed. With direct-wired systems, due to the expense of the sensors, the same sensor is often used in multiple operatories. This requires the use of a quick connection/disconnection interface that should be placed in a location to facilitate ease of use and efficient workflow. Determining where to store the sensors when not in use for convenient access should also be established.
With an indirect system using computed radiology (CR) utilizing phosphor storage plates (PSP), the workflow is very similar to film. The main difference is that the digital scanner that processes the image must be attached to a computer workstation. Often the ideal location for this process is in the same area where the chemical processor was placed.
With both direct-wired and indirect (PSP) systems, the images are routinely viewed and utilized on workstations other than the one acquiring and processing the image. All images need to be saved and stored in a central location—usually on the system’s networked server. This procedure should be configured as part of the initial image processing and saving. Storing all images in a central location not only facilitates access and retrieval, but also enables the appropriate RAID protection, as well as simplifying data backup and protection.
Another major consideration is determining the location of the monitor for viewing the images in the operatory. Where and when are the images viewed, and by whom? If images are to be viewed by the dentist while performing a procedure such as an examination or endodontic therapy, then the monitor should be placed in a location where they can be easily viewed at that time. If images are going to be viewed by the patient for education and consultation purposes, that also must be considered when determining monitor placement.
Installing 21-inch-wide or larger monitors allows for better viewing of radiographs, compared to the standard No. 2- size film. The minimum contrast ratio of the monitor, should be 500:1, advises Donald Tyndall, DDS, MSPH, PhD, FICD, an oral and maxillofacial radiologist at the University of North Carolina School of Dentistry.
Allan G. Farman, BDS, PhD, MBA, DSc, professor of radiology and imaging science in the department of surgical and hospital dentistry at the University of Louisville, adds, “You want to have a good-quality screen, and now good-quality screens aren’t expensive. We don’t have the problems we saw years ago with resolution and memory issues.”
Panoramic and cone beam computed tomography (CBCT) will require a dedicated area and workstation to control the acquisition device. However, the space needed is often similar to that required for panoramic film machines, and offices switching to digital will no longer need space for the chemicals and processing used for film-based systems. One option that many clinicians are taking advantage of is buying a panoramic unit to which cone beam technology can later be added. This option is not available on all panoramic systems, but such hybrid systems that allow for traditional panoramic and CBCT are popular, Tyndall says. “Many people are buying 3D systems because it makes it easier to perform implants, and if the dentist does five to six implants a month, the machine is paid for in about 2 years.”
If a practice is considering a CBCT system in the future, planning for the appropriate space and wiring when installing the imaging system might be a prudent investment.
When purchasing a new system, clinicians need to decide whether to integrate the system software with their practice management software or a separate database. Because imaging software bridges to existing practice management software, these decisions should be based on the clinical preference for software.
Farman recommends asking about DICOM (Digital Imaging and Communications in Medicine) file format possibilities when purchasing a new radiographic system. Even if proprietary files are being used, there should be an import and export option for DICOM files, which contain headers that have patient information as well as information about procedures and if the images have been altered.
“There should be a way to read DICOM files, because dentists don’t work in isolation and they may get referrals from other practitioners or images sent back from specialists they referred patients to,” Farman explains, adding that is particularly important with CBCT, because a dentist might want to have models made for surgical procedures or surgical stents and would need to have interoperable file formats to send to third parties.
In addition, Farman recommends that when buying a CBCT system, it is important to be sure that the software allows for exporting images to a CD or digital drive, so a copy of the radiographic image can be burned for the patient.
Tyndall agrees that when integrating software for a new system with an existing practice management system, there should not be any issues. “In terms of integration, for example, any sensor, as a general rule, integrates with any practice management system.”
It is important to consider support, maintenance, and upgrades that may be provided for the digital system purchased, Tyndall explains. “Don’t just make a decision based on the machine. Consider the company making it. Do they provide good support, do they provide upgrades from time to time so your software gets better and better? This is crucial. You want good support and good maintenance, and there is a wide variation from company to company. There are some companies that are just outstanding and others that don’t return phone calls for more than a week. If you depend on this system and you don’t have backup, that’s a major problem,” he says.
The successful implementation of a radiographic imaging system involves more than simply selecting the sensor or imaging device. It requires a team of knowledgeable, dedicated, and dependable professionals both from within the practice and from outside sources that understand the practice’s true goals. Furthermore, it takes proper planning and time commitment from everyone involved, utilizing the correct systems, hardware, software, and personnel to achieve a successful outcome.
Dr. Benjamin is a consultant for Sirona.