SOLVING THE CHALLENGES: COMPLIANCE

Let’s start with patient compliance. If patients could see the results happening right in front of their eyes, they would be more pleased and would certainly be more compliant. That’s only human nature. We are all more likely to follow someone’s suggestion if we see proof that it is working.

Take-Home Bleaching

Most dental offices are still doing tooth whitening treating both arches at the same time. Unless there is an extreme time deadline, I never do that. We also do a few other things differently, and we are about to examine each of them.
First, make what you are doing important. Take pre-op photos, and plan on midway and post-op photos. Take a pre-op shade. Establish realistic expectations. Then quote a longer treatment time frame. In my office we say, “The average treatment time is about 2 to 3 weeks for the upper teeth, and another 2 to 3 weeks for the lowers, but it’s possible yours could take a little longer.” Set your fee so you don’t have to increase it if you need a little extra time or some extra materials. Then you can promise to “stick with it” even if this patient is a resistant case, and you are a hero if it takes less time to get the desired results.

Figure 1. Upper model.	Figure 2. Block out added.
Figure 3. Tray on model.	Figure 4. Reservoir tray showing gingival extension. Trays like these hold the bleaching gel intimately against the entire buccal surface of the teeth, but because the margin of the tray is extended on to the gingiva, there is no leakage at the gingival margin.

We also use reservoirs. Certainly, I have heard the same statements that you have—reservoirs are un-necessary—but that just doesn’t apply to this technique. (If you have a scalloped edge, those statements are correct: reservoirs don’t matter because the gel is going to escape no matter what you do since the tray can not be adapted well enough to the teeth.) However, since we have sealed the gingival margin of the tray against the gingival tissue, making reservoirs to hold the whitening gel against the teeth makes perfect sense. We place a thin layer of light-cured blockout material on the buccal surfaces of the teeth to be bleached. Then, we vacuum form a tray over the model and use a heat knife to cut the flat margin against the gingiva (no blockout there). Next, we smooth the cut tray edge by slightly heating it with a flame and then pressing it with a sliding finger against the stone model. The result is a pocket that holds the bleaching gel completely against the buccal surface of the teeth and disperses the gel right up to (yet stopping at) the gingival margin. In this way, the whitening gel is kept exactly where it needs to be during the entire treatment time. In the rare instance when the patient has sensitive gingival tissue, the tray is cut back in those areas into the more common scalloped shape (Figures 1 to 4).
(Here is a challenge to try on yourself: take an impression of your own mouth and make a bleaching tray. Construct one side as described above with block out, reservoirs, and the tray edge a few millimeters up on the gingiva; and then fabricate the other side in the “normal” [no reservoir, scalloped edge near the gingival crest] way. Put some whitening gel in the tray, insert it into your mouth, and look in the mirror. Watch the gel ooze out of the scalloped side. If you need further convincing regarding this design’s advantages, go ahead and use it personally for a couple of weeks. You will have to go back and help the scalloped side catch up to the “better-bleached” side done with the tray design fabricated using this method. You will be absolutely convinced of the effectiveness of this method.)

Bleaching Protocol

We then deliver only the upper tray, giving instructions, and asking the patient to return in one week for a check of how they are doing. If they have any problems in the meantime, they are to call and return to the office immediately. Within a week, the patient can see a difference between their upper and lower teeth. As each day progresses, they can see an even greater contrast. If both arches are done at the same time, the daily difference is too subtle for most patients to discern, so they may perceive there is no improvement and gradually quit. So, you can understand how you have ultimately caused their noncompliance in this way.

Figure 5. Midbleaching documentation photo. Upper teeth have been completed; the lower teeth are yet to be done.

After the one-week check, we then (usually) have the patient return 2 weeks later. The ever-increasing contrast between the arches in our patients is very obvious to them. Since they can see a difference, they have the incentive to keep bleaching as instructed so they can move on to the lower tray (which we withhold until we and the patient feel they have bleached to the desired level) as soon as possible. At this point, the patient will be a great ambassador for your office. They typically show everyone how their teeth are becoming brighter and more attractive and explain how you have helped them accomplish this goal. We then take a midtreatment photo with the upper teeth white and the lower teeth unbleached (Figure 5). The lower tray is then delivered. The patient is brought back once again for one week to monitor the progress of the lower teeth, and then typically a final check, 2 weeks later. At this final appointment, post-op photos are taken. The patient is reminded that touch-ups are inexpensive and are expected at about 6 month to one year intervals. (“Why not plan on it at each ‘cleaning’ appointment?”) With this method, you will get compliance, and your patients will get whiter teeth for life.

SOLVING THE CHALLENGES: SENSITIVITY

A significant number of patients develop temperature sensitivity during the whitening process. First, reassure them that it is transient. It always goes away within a couple of days of discontinuing the bleaching. Some patients develop such intense sensitivity that they would rather stop the process than to put up with the discomfort.

Chemical Treatments

There are many methods for dealing with sensitivity. One of the first methods was the use of fluoride applications, either in the trays or in prescription-level fluoride toothpastes. Potassium nitrate is an excellent desensitizer and is of enormous help. More recently, amorphous calcium phosphate has also proven to be quite an effective additive. All of these chemicals help to reduce bleaching-related sensitivity. They have also been incorporated in many of the currently available whitening products.

Preventing Sensitivity

How about preventing the sensitivity in the first place? In my opinion, dehydration is the primary cause of whitening sensitivity. Picture your last visit to the hygienist. They are trying to be extra careful and to remove even those tiny little specks of calculus just subgingival on the lingual surfaces of your mandibular anterior teeth. Then they blow some air on the area to better visualize the calculus, and then blow a little more. The teeth are dried out and they give you a “zing”—which you interpret as sensitivity to cold. When we bleach, the evaporation of the nascent oxygen produced from the peroxide dehydrates the teeth. That is why the teeth always look a little chalky right after bleaching—they are dehydrated.
To solve the dehydration problem, we use a prewhitener (Power Swabs [Power Swabs Corporation; also distributed under Power Start]) that performs 3 functions. First, Power Swabs include solvents that help clean the teeth (like prewash stain removers help in cleaning grass stains off trousers). It doesn’t take a rocket scientist to realize that clean teeth should get whiter faster than dirty teeth. Second, since there is less debris on the enamel, the bleaching can penetrate deeper—again resulting in faster and greater whitening. Third (and most important), the swabs contain a surfactant (wetting agent). The surfactant al-lows the bleaching gel to dissipate all over the teeth keeping them hydrated, and since the teeth are not allowed to dehydrate (keep bleaching times short) the teeth do not get sensitive. Thus, the simple use of this prewhitener produces results that are whiter and faster while eliminating a main cause of sensitivity.

Figure 6. The applicator.	Figure 7. Applying a prewhitener with a soaked swab (Power Swabs [Power Swabs Corporation]).

So, let’s go back to compliance for a moment. If you can show the patient that their teeth are getting whiter, they can see it every day, their time of application is reduced, and they have no sensitivity, why wouldn’t they do what you ask to help them improve their appearance?

POWER BLEACHING

The good news is that the prewhitener also works extremely well with power bleaching. Whether or not you use a light source, power bleaching involves a dental professional applying a stronger whitening agent for a shorter period of time than when using trays. To shorten the time even more while improving the results, just swirl the soaked Power Swab all over the surfaces to be bleached for 30 seconds immediately prior to each application. I typically cut my time for application of the whitening agent down to 3 sets at 10 minutes each. It is amazing, but when the final coat is rinsed off with cold water, the patients do not wince because the prewhitener prevented any sensitivity.
I typically follow power bleaching with a week of take home tray treatment, still using the prewhitener before every application. For maximum compliance, you can use the one-tray-at-a-time method, but I only do in-office power bleaching for those who are in a hurry—so they usually get both trays at once.
In rare instances, a few patients still get a little sensitivity with 30 minute tray applications of peroxide whiteners at home. If this happens, I reduce the time to 15, or even 10 minutes, and have the patient take one day off. This does extend the total time to get the whitening results we desire, but at least we can bleach these patients who would otherwise be unwilling to complete the process.

Figure 8. Before whitening.	Figure 9. After whitening.

Dr. Zase practices general dentistry with an emphasis on cosmetics, at the Colchester Dental Group in Colchester, Conn. He is an accredited member and past president (2006-2007) of the American Academy of Cosmetic Dentistry. He is also a master of the Academy of General Dentistry. He can be reached at (860) 537-2351 or martyzase@aol.com.

Disclosure: Dr. Zase is the professional advisor for Power Swabs Corp, the manufacturer of the Power Swabs, powerstart.com.

Figure 1. Cancellous bone in which the trabeculae of bone and all the space that exists between them can be seen.	Figure 2. A bite-wing radiograph of the lower right quadrant. Notice the large area of cancellous space mesial to the molar. In addition, a retained root tip can be seen just distal to the premolar. This is an example of an anatomical anomaly that one must uncover before performing a perforation highlighting the importance of taking a preinjection radiograph.

Figure 4. The IOI device (IntraFlow) in position to perforate through the buccal plate of bone. The perforator is roughly perpendicular to the surface of the cortex and slightly pointing apically. This ensures that the perforator will travel where the operator wishes it to and not towards any root surfaces in the area.	Figure 5. The IOI device (IntraFlow) has perforated the buccal cortex and is inside the cancellous space. The operator now removes their foot from the rheostat to stop the perforator from rotating. This device will automatically switch to injection mode and the operator can now lightly step on the rheostat for a second time, and the device will inject solution.
Figure 6. A radiograph showing adequate cancellous bone between the lateral and central incisor.	Figure 7. The IOI device (IntraFlow) is in correct position and ready to perforate the cortex between the 2 teeth being treated.

Figure 8. The needle has just perforated through the cortex of bone and is sitting within the cancellous space. Local anesthetic can now be injected as previously described.

Next, a preparatory infiltration of approximately 0.3 ml of local anesthetic was slowly injected into the same buccal fold area. This was painless due to previous placement of the topical anesthetic, and because such a small volume creates little sensation from tissue expansion. An anesthetic with 1:100,000 epinephrine was chosen in order to achieve vasoconstriction and to avoid a small amount of bleeding that might occur following perforation. This injection ensured a painless perforation.
The IntraFlow handpiece system was then assembled (Figures 3a and 3b) and readied for use. The perforation site was within attached gingiva, just coronal to the mucogingival line (Figure 4). The rheostat was depressed at full speed (on the slow-speed line), and the perforator was pushed through the gingiva, cortex, and into the cancellous space with gentle pressure. When the cancellous space is entered, the resistance to push while perforating disappears and the perforator “pops” through the cortex (Figure 5). At this point, the foot is released from the rheostat. It should take no more than 3 to 4 seconds to perforate. There are situations where one may not feel that resistance disappear. This happens most commonly in the posterior mandible where the buccal plate of bone is thickest. In this situation, the operator must choose a different injection method since continually pressing on the cortex without perforating it can lead to heat buildup and the possibility of localized bony necrosis.
Next, to carry out the injection, the rheostat was depressed again, this time more lightly. 0.9 ml of local anesthetic (half a cartridge) was then slowly injected over a period of approximately 45 seconds. A solution containing 1:200,000 epinephrine was chosen for this procedure to limit heart palpitations and to maximize duration. The standard is to use this volume to achieve pulpal anesthesia for one tooth on either side of the perforation. If the operator decides to work in another area, there is enough volume to anesthetize 2 other teeth with a second perforation. One should not exceed one (full) cartridge of anesthetic per appointment due to the rapid uptake of the vasoconstrictor from the cancellous space and the risk of obtaining palpitations. The patient was warned about palpitations using the following calm language: “You might feel your heart racing a little bit. This will go away in a few seconds. It is a good sign that the anesthetic is in the right place.”
The dentistry was completed and the patient felt no pain or sensitivity during the injection or during the 45-minute treatment procedure.

CASE REPORT 2

A 67-year-old female was being treated for a crown and bridge prosthesis on her maxillary right lateral and central incisors (teeth Nos. 7 and 8). First, a preoperative radiograph was taken (Figure 6). This image showed a large amount of cancellous bone between the 2 teeth being treated. During the insertion phase of the treatment, it was decided that an IOI using the IntraFlow device would be used to provide pulpal anesthesia to closely match the duration of treatment. With this technique, the smile line can be more accurately assessed when anterior prosthetics are planned and tried in with no lip distortion present.
Next, topical anesthesia followed by a preparatory injection of 0.3 ml local anesthetic was slowly infiltrated into the mucobuccal fold between the central and lateral. Figure 7 shows the initial positioning of the IntraFlow handpiece before injection. Notice that the perforator is placed at the mucogingival line pointing slightly apically, sitting between the lateral and central incisor. In Figure 8, the needle has perforated the cortex and is now sitting inside the cancellous bone. The operator now can begin the injection phase using the methods described above.
Treatment began immediately after injection with the removal of the temporaries, followed by the try-in and finally the insertion of the new crowns. Treatment time took 25 minutes and the patient had no discomfort throughout the procedure.

CONCLUSION

This article has briefly reviewed the history of intraosseous anesthesia and presented 2 case reports describing how IOIs were successfully used. Studies demonstrating that the intraosseous delivery of local anesthetic has been shown to be an effective method of achieving pulpal anesthesia have been cited in this article. This technique has been available for many years via different systems. The author has found that the IOI method for achieving profound local anesthesia to be useful not only as a primary injection, but also in cases where supplementary anesthesia is required due to the failure of the standard techniques. In addition he has found that IOI devices, such as the IntraFlow (Prodex), are also easy to use and well-accepted by patients.

References

Dr. Isen’s dental clinic in Toronto is anesthesia-based, focusing on treating patients with special needs and dental phobia. He is past president of the Ontario Dental Society of Anesthesia and he lectures for the University of Western Ontario’s CE program and the University of Toronto Faculty of Dentistry. In addition, he has lectured internationally on topics related to local anesthesia and medical emergencies. He has acted as a consultant for numerous dental and pharmaceutical companies and serves as a peer reviewer. He can be reached at (416) 498-8484 or d.isen@rogers.com.

Disclosure: Dr. Isen has no financial interest in any company mentioned in this article.

With advancements in communication, the world has become a much smaller place. Through the use of cell phones, the Internet, and e-mail, one can easily communicate and consult with anyone, anytime throughout the world. These technologies offer great benefits, especially in the medical and dental fields. Doctors and patients not only use these tools for communication, but also as a means to transfer views and opinions. Despite these benefits, though, the aforementioned technological advancements have also brought forth many unforeseen problems. One of the latest and fastest-growing businesses in healthcare is medical/dental tourism. This is defined as the act of traveling to foreign, often underdeveloped countries to obtain medical, dental, and surgical care.1
The medical tourism market is estimated to grow by $2.2 billion, with a corresponding increase of $60 billion in the global healthcare market.2 A combination of various factors, such as the high cost of healthcare in industrialized nations, the increased ease of international travel, favorable currency exchange rates in the global economy, rapidly improving medical technology, the Internet, and the standard of care in many countries, have led to the recent increase in its popularity.3
In the case report that follows, a patient of record who was in the middle of treatment in the United States traveled to Argentina to have additional dental procedures done.
The work was completed within a period of approximately one week. It included the removal and replacement of all metallic restorations in the patient’s mouth. The reason for their removal was attributed to “toxic focal infections,” for which the believed cause was the patient’s metallic restorations.
The patient had completed a Huneke Neural Therapy test in Argentina, which not only supposedly tested the toxicity of the restorations, but also identified the specific organ that each “toxic tooth” was “affecting.” The Huneke Neural Therapy test is based on a concept of neural therapy that was developed by 2 German physician-dentists, Drs. Walter and Ferdinand Huneke, in the 1920s and 1930s. Neural therapy is the management of pain and other illnesses by finding and treating “interference fields” or “focal points” on the body. When these are manipulated, it is believed they can relieve pain in other sites in the body.4 To date, no scientific evidence supports any such claims.5

CASE REPORT

Figure 1. Radiograph of patient before implant placement.	Figure 2. Panoramic radiograph of patient after having previous metallic restorations removed.
Figure 3. Implant site with metallic restorations still in place.	Figure 4. Untouched implant after having all other metallic restorations removed.

A 39-year-old Hispanic woman was referred to the Howard University Dental School clinic for restoration of a recently placed Bränemark 4×15-mm titanium implant at the position of tooth No. 4. The initial visit consisted of a review of the patient’s medical history, intraoral and extraoral exams, and radiographs (Figure 1). The patient’s medical history did not have any positive findings, and all vital signs were within normal limits.
Examination did not reveal anything remarkable extraorally. The intraoral exam revealed a full complement of teeth with existing dental work. Teeth Nos. 2 and 14 presented with large but serviceable silver amalgam restorations. Porcelain-fused-to-metal (PFM) crowns were noted on teeth Nos. 3, 15, 18, 19, 29, and 30; with metal posts present in teeth Nos. 3, 18, and 30. The patient also had 2 PFM bridges from teeth Nos. 5 to 9 and teeth Nos. 11 to 13. All the restorations were checked with a sharp dental explorer and passed the inspection for integrity of the margins.
The periodontal evaluation indicated a generalized, mild, soft-tissue inflammation with isolated bleeding upon probing. A neuromuscular evaluation and occlusal analysis revealed no abnormalities; the patient reported that she did not have any TMJ pain. Radiographic examination of the implant placed 6 months prior to her visit revealed signs of proper osseointegration.
Second-stage surgery to uncover the implant was performed under local anesthesia using a 5-mm-diameter punch biopsy kit. The corresponding healing abutment was subsequently attached. The patient was dismissed with instructions to return in 3 weeks. This would allow time for proper adaptation of the surrounding tissue around the healing abutment.
The patient returned with a favorable soft-tissue response. At this appointment, final impressions were taken using the corresponding impression coping with a closed-tray technique. An opposing model, bite registration, and shade were taken. The patient was then told to return in approximately 2 weeks for placement of the permanent implant crown.
On the day of the final cementation, the patient’s sister called the clinic and explained that the patient had left for the week to have dental work done in Argentina. Her appointment was rescheduled for the following week.
The following week, after returning from Argentina, the patient came in for her appointment to have her implant crown cemented. After the patient was seated, she told us that she brought a medical and dental consultation review statement of the work that had been completed in Argentina. After the document was translated from Spanish to English, it was revealed that the patient had participated in a Huneke Neural Therapy test. This report detailed an analysis of every tooth previously restored with metal, with its respective and alleged systemic repercussions. These ailments included back, stomach, and muscle pains supposedly due to the patient’s metallic restorations. When the patient was questioned as to why she did not report these ailments during the review of our initial health questionnaire, the patient responded, “I was not aware of these problems before I had my teeth tested.”
New soft- and hard-tissue exams were performed on the patient. Examination also included full-mouth radiographs, a panoramic radiograph (Figure 2), photos, and the examination of any new dental work. Radiographic examination revealed that all previously placed metallic restorations (including all amalgam restorations, core buildups, metallic posts, and PFM crowns) had been removed except the implant (Figures 3 and 4). The treatment report that the patient provided stated, “The Huneke test was positive to the indicated teeth showing evidence that the cause of the described symptoms (is due to) the metallic restorations found in the mouth. Treatment shall consist of removal of all metallic restorations and the replacement with non-metallic restorations.” New restorations were checked for contacts, occlusion, and marginal integrity. Using a sharp dental explorer, several open margin areas were noted around the newly placed bridgework and crowns. When asked if the patient noticed any changes in her health after treatment was completed, she responded, “I’m not sure. I have not noticed any changes yet.”
She was not informed in Argentina that any alterations to her current metallic restorations might affect restorations in progress in the United States. The teeth the implant crown would have contacted (teeth Nos. 3 and 5) and the occluding teeth (Nos. 29 and 30) had been replaced with new all-ceramic restorations. Attempts to seat the implant crown were unsuccessful. The patient was informed that either the implant crown must be remade or attempts could be made to adjust the crown to see if it could be seated.
Due to the added time that would be required to remake the crown and the concomitant financial considerations, the patient opted simply to have the crown adjusted. She was then informed of the possibility that after adjustments the crown may still not fit properly and a remake might still be needed. Adjustments were made to both the interproximal contacts and occlusal surfaces with a high-speed diamond under copious water irrigation. After this, the crown was seated and the interproximal contacts and occlusion were checked. During the adjustments, perforation of the porcelain, exposing the zirconium substructure, had occurred. However, the crown was able to be seated without discomfort to the patient. The patient was then shown the crown, color was compared to the new dental work (Figures 5 and 6), and she approved the cementation procedure. The crown was cemented with Fuji Plus (GC America) glass ion-omer cement, and a final radiograph was taken.
The patient was seen 6 months later for follow-up and a prophylaxis. When questioned, she reported that she had no changes in any ailments or her quality of life after having had the new dental care completed. She did report that she was happy with how her new crowns and bridges looked. She was made aware of the potential problems that may occur with the open margins. She reported that she spent close to $3,000 (USD) for all of her dental work in Argentina. The patient was placed on a 4-month continuing care schedule, and she was given a guarded prognosis for several of the newly restored teeth. It should be noted that she had no desire to replace any of the crowns found to have open or questionable margins.

DISCUSSION

The concept that oral conditions can significantly influence events elsewhere in the body is not new, and it has undergone a number of transformations over the years.6 While this may be foreign to most physicians in the United States, dentists have known for quite some time about the importance of oral heath and its effects on systemic health. The possibility that events in the oral cavity can influence systemic disease has been mentioned in the Surgeon General’s report7 in 2000 and in various other studies. These studies report a link between oral disease and such systemic diseases as coronary heart disease, stroke, adverse pregnancy outcomes, diabetes, and bacterial pneumonia.6 However, these conditions have nothing to do with “interference fields.” Instead, they are related to periodontal pathogens affecting the body through 2 proposed pathways.8,9
When people travel to foreign countries (especially underdeveloped countries) for dental work, they either ignore or are unaware of the obvious differences in training, infection control, sterilization, and materials standards in clinics. Furthermore, there can be differences between countries in the philosophy of care and various treatment modalities. Government and basic medical insurance, and sometimes extended medical insurance, often fail to cover those medical and dental procedures.
Most countries that offer these services have little or no follow-up care, weak oversight agencies to monitor the quality of care, and little or no legal action available for patient recourse, if needed. While this may help keep healthcare costs down in other countries, it allows for the possibility of less-than-ideal care to be given without ramification. Complications, side effects, and postoperative care are then the responsibility of the medical and dental care system in the patient’s home country.
Dentists in the United States may be reluctant to care for patients who have been treated outside of the country because the patient may blame them for complications related to treatment. The patient’s local dentist is placed in the ethical dilemma of informing these patients that less-than-ideal care was performed, and then must decide whether to retreat. The ADA’s Principles of Ethics and Code of Professional Conduct addresses the issue of “Justifiable Criticism” in Code Section 4.C, stating, “Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services.” This becomes a gray area when dealing with these types of situations, since most “reviewing agencies” are from underdeveloped countries. In the 2006 ADA House of Delegates meeting, the association addressed dental tourism for the first time in its history. By doing so, the ADA recognized the grow?ing trend of United States residents traveling outside the border for healthcare.10

CONCLUSION

As dental tourism continues to grow, dentists will be faced with difficult decisions. When patients who have had dental work completed in a foreign country return to their dentists in the United States, those professionals will now have to determine the best way to manage the treatment that was done elsewhere. While this issue was identified much earlier in the medical field, many dentists are still not fully aware of this issue or the repercussions. The lack of knowledge about this issue makes dealing with it difficult. By the ADA formally addressing this problem in 2007, it marked the beginning of a possible solution. The answer, however, will be difficult to determine. This difficulty is due to the complex nature of why certain people choose to have sensitive medical and dental care done away from home. As the ADA spreads awareness about this situation, not only will the dental community have a better understanding on how to deal with these complex issues, but the patients who seek this care in foreign countries might also begin to understand the ramifications as well.

References

Dr. Vaughn is a full-time associate in a family practice focusing on cosmetic dentistry in northern Virginia. He earned his DDS degree from the University of Michigan School of Dentistry and his AEGD certificate from Howard University School of Dentistry. He can be reached at parisvaughn@gmail.com or at (703) 580-1443.

Ms. Whitley is a full-time dental hygienist in a cosmetic dental practice in Silver Spring, Md. She earned her RDH degree from Howard University and her BA degree from Trinity University. She can be reached at (202) 641-4201.

Disclosure: The authors have no financial interest in any of the companies mentioned in this article.

Last month in Part 1, the author re-viewed the life cycle of a typical dentist and explained why life planning is more important than ever for today’s practitioners. Part 2, which follows, discusses the nuts and bolts of a comprehensive life plan, and how asking yourself the right questions can lead to a discovery process that will bring you peace of mind for the short term and the long term.

ASKING THE RIGHT QUESTIONS

“The quality of one’s life is in direct proportion to the quality of the questions one asks,” a philosopher once said. I would argue that the quality of one’s life plan follows the same rule. We begin the life planning process by asking our clients the magic-wand question: “If you had a magic wand and could have life any way you wanted, how would it be?” This is such an important question, but it is amazing how difficult it is for people to answer. We are conditioned to create limits for ourselves around what we believe is possible (or impossible), so we have trouble imagining life in an ideal way, even with the proverbial magic wand in our hands!

Digital Illustration by Nathan Zak

From this broad question we start to get more specific. What would the ideal practice be like? Most of us don’t have a choice about whether we work. As discussed in Part 1, we’ll likely be working longer than our parents did. However, we do have a choice about where and how we work. What would your facility look like if you could have it any way you wanted? What technology would you incorporate? What kind of cases would be your focus? How many days would you work each week and how many weeks each year? Naturally, we must consider the same thing with your lifestyle outside the practice—your home, your car, your vacations, your commitments and activities outside the office.
Once this ideal life is clearly envisioned, we help our doctors look at how it can be achieved. Then we begin to piece together the economic puzzle, beginning with the most important pieces and working backward until we have a clear understanding of the ideal income needed to support your ideal lifestyle.
Economic Freedom. At some point, you will want the choice either to continue or to stop working altogether. When will that be? What will your life-style be like? How much will you need to have saved to sustain that lifestyle for the rest of your life? You must also think about your current lifestyle and the economics needed to give you a sense of stability and choices today. We look at all these questions and come up with an economic game plan for how much you need to be earning and saving annually and the best investment strategy for your goals.
The Essentials. Next we look at your spending needs on an annual basis for the non-negotiables. This covers the basics like your home, cars, children’s education, food, utilities, etc; but it also includes things like charitable giving, vacations, entertainment, and recreation—things that you want to ensure are funded up front, and not subject to whatever is left at the end of the year. We come up with a detailed spending plan based on your current needs and in anticipation of any major changes in the coming years.
The “Adds-Meaning” List. On top of the essentials are things that add meaning to your life above and be-yond the everyday. This is where the magic-wand question comes into play again. What have you always wanted to do, but stopped yourself because of time or economics? With proper planning, we can also build in things like a dream car, a second home, or world travel.
The Practice. Since the practice is the economic engine that fuels your life plan, we also take a comprehensive look at its unique economics. We look at the essentials (production, collections, overhead expenses, etc) as well as the “adds-meaning” list for the practice—technology or facility upgrades that would make your lifestyle within the practice ideal.
With these areas understood, we are able to zero in on the income needed to support your ideal lifestyle now while protecting your future at the same time. I know it sounds simple—and naturally, to be completely comprehensive we also look at pension, estate, tax, and other factors—but just this basic exercise creates more clarity than most people have ever had about their economic situation.
In most cases, we discover a gap between the current income and the amount needed to afford this ideal life—and that’s okay! The beauty of an integrated life plan is that it takes into account the practice and your ability to generate income. When the gap is understood, it is surprisingly easy to find areas of opportunity in the practice that can very quickly generate the needed income to close the gap. When you consider that in the average practice just a $100 improvement in hourly production can yield an additional $131,200 in net income annually, it becomes clear that you really are in control of the income that fuels your total life plan.

THE 365-DAY MINDSET: CALENDAR PLANNING

So let’s review. We know that we are going to live and work longer, and we want choices about how we go through life. We’ve waved the “magic wand” and asked the right questions. We are clear about our ideal lifestyle inside and outside the practice. We have understood the economics of that ideal lifestyle and created a plan to meet our income needs. What’s left? Time, of course! Fully understanding calendar planning would require an additional article, so I will just touch on the most important aspects here.
I have always believed we think about time incorrectly. We get attached to labels: weekdays, weekends, work time, personal time, overtime, time off, etc. We try to sequester our activities into these labeled categories, and then we feel resentful or guilty when one area leaks over into another. Instead, I challenge you to think about time this way: there are 365 days in a year with 24 hours in each day. No matter what we do, we cannot somehow get more or less time than the hours given to us, nor can we get more or less than anyone else. In this way, time is the great equalizer.
Given that we have 24 hours in a day and 365 days in a year, I believe that we need a spending plan for those days and hours just like we need a spending plan around our economics. It is not about 9 to 5 or Monday through Friday; it’s about ensuring that we set aside time for our non-negotiables and the things that add meaning to our lives, just like we do with our money. If we do not schedule the most important things, time gets spent here and there. Before we know it, we have spent it all.
We teach clients to think of time in 4 major areas: vision time, on time, in time, and personal time. Vision time is the time you spend creating your life plan, including your practice vision and mission. It is the time that you use just to dream by yourself or with your spouse about the future. On time is time you spend working on your business, taking clinical or leadership education, spending time align-ing your team, reviewing practice data, and creating growth strategies. In time is your revenue-generating practice time. Personal time is the time you spend at home, and with family and friends.
When creating your calendar plan for the year, I would recommend that you take the following approach:
Block out your personal time. This includes vacations, weekends you want to protect, special family events, and things that you know about well in advance like golf tournaments and school plays.
Block out vision time. Usually I recommend a block of several days, either at the beginning or end of the year. In addition, block out another day devoted to vision time about every 4 months. When tied into a weekend, these vision-time days need not take significant production time away from the office.
Block out “on” time. How you structure your on time is up to you, but I recommend at the very minimum a day a month away from your day-to-day practice responsibilities. Some practitioners also like to block out an hour each evening, or a half day per week for on time.
Be clear about your “in” time. Know that as an entrepreneur you will naturally do what it takes to meet your in time objectives, but as long as your other non-negotiables are already scheduled, you will not have to make tough sacrifices.
If this sounds like a lot of time, it is! But it is time you are spending anyway, organized in a way that allows you to protect the activities that mean the most to you. I have always said that if I am going to be doing nothing, I want to feel great about doing nothing, and I want to do it at the highest level. Thinking about your time in these areas and planning your calendar this way allows you to increase the value of your time in each area so that it is truly optimized.

WHEN CHOICES REALLY MATTER

All of this might sound like a lot of planning. If you are one of the many dentists who has settled into a comfortable routine, it may even sound like more trouble than it’s worth to put your life plan in place. That’s because when life is good and things are going our way, it is easy to be seduced by the path of least resistance. However, it is when things go wrong that having a plan in place is most important. In 2003, my wife of 25 years was diagnosed with a cancer that required us to seek treatment at the Mayo Clinic in Arizona; we were living in Vancouver, Canada, at the time. I took weeks away from the office and also found myself with unplanned medical expenses. Because we had been disciplined about our economics and were clear about our life plan, we were able to make those decisions without a second thought. Because our calendar was structured to protect precious time together and with our children, I was able to enjoy the additional flexibility I needed to spend time with my wife in her final months. In addition, because my business partnership was also aligned around a vision and a comprehensive plan, I had the support of my partners in the weeks leading up to and following her passing.
Life planning is not about sticking to a rigid set of principles or following a series of steps toward a goal. It’s not about budgeting or investing. It’s not about trying to predict the future or prepare for every possible scenario. Life planning is about knowing what is important to you, putting pieces in place to have and enjoy those things, and living each day on purpose with peace of mind.
I encourage you to take time away from your everyday commitments to look at your life comprehensively and ask yourself the really important questions. I can promise you that life will not always go according to your plan, but that having a plan will allow you to experience the best life has to offer, with choices and freedom at every step of the way.

Mr. Manji is founder and CEO of the Scottsdale Center for Dentistry, the continuation of his longtime goal to provide a world-class facility where dentists and teams can receive comprehensive, evidence-based, patient-centered learning. For more than 20 years, he has been educating and motivating dentists across North America. Mr. Manji’s newest workshops, “Dental Office Design,” “BreakThrough Practice,” and “CEREC Experience,” and his classics, “Leadership and Team Alignment” and “Transitions and the Business of Dentistry,” combine his endless energy and inimitable style with his practical teachings to make these programs a “must-see.” He can be reached at imtiaz.manji@scottsdalecenter.com or at (866) 781-0072.

The Internet is having a profound effect on how we practice dentistry. More and more consumers (your patients) are relying on the Internet for ease and convenience in obtaining information and communicating with their health professionals. Statistics show 8 in 10 Internet users (113 million adults) have looked for health information online (Pew Internet & American Life Project, pewinternet.org, accessed on October 29, 2006).
As more dental practices are seeking to go paperless, or just trying to streamline office procedures and save time, communication with patients via e-mail, providing anytime, readily accessed information on a Web site, and/or completing questionnaires and forms online have taken on more dramatic importance. For the purposes of this article, I will focus on how patients can complete their HIPAA agreement, business registration, insurance information, and their medical and dental histories online.

ONLINE SERVICES AVAILABLE FOR YOUR PATIENTS

Several companies provide this type of service. The Dental Record (dentalrecord.com), created by the Wisconsin Dental As-sociation, has become affiliated with the American Dental Association. A dental practice may license a software package from them for between $3,395 (5 terminals) to $4,395 (10 terminals). There is a $350 annual charge to have online access after the first year and an additional $350 for support and upgrades. Also, the Dental Record system has direct integration with some of the practice management software available for dental offices.
Many design and development companies for dental practice Web sites include PDF forms that patients can download, complete, and bring to the office during their first appointment. While this is more convenient for patients than filling out these questionnaires in the reception area, the dentist still receives forms that are often illegible with the need to retype the information or to scan the forms in order to store them electronically.

Figure 1. SubmitPatientForms.com Web site home page.

The service Submit Patient Forms (SubmitPatientForms.com) is another on-line service (Figure 1) that requires a minimal financial investment. The cost is $25 per month for an unlimited number of patients. This includes both e-mail and telephone support and any updates to the system. If a practice wants to use its own custom forms, there is a one-time charge of $399 to convert the forms.

TYPICAL OFFICE PROCEDURE FOR A NEW PATIENT

A new patient calls and makes an initial appointment for next Thursday at 4 PM. Instead of saying to the patient, “You must come at 3:30 PM to fill out the paperwork,” you now have the option of offering an alternative. Tell the patient your office now offers convenient, private, and secure registration online. If he or she has access to a computer and the Internet, and would like to take advantage of this convenient service, ask for an e-mail address. Emphasize that the patient must complete the forms prior to coming in for the first visit.

Figure 2. Staff can log onto the password-protected management account to view billing history, view patient progress, send patients links to their forms, or to view, print, or download a patient’s completed forms.	Figure 3. Patients are invited to fill out paperwork online by a prepared e-mail letter that contains instructions and the link to get them started.

The office manager then logs onto the practice management account that was created when the dental office originally signed up (Figure 2). When the next page is displayed, she clicks on “Refer a Patient” and then types in the patient’s name and e-mail address and clicks on “Submit” (Figure 3). This automatically sends a prepared e-mail letter from the office to the patient. When the patient clicks on the enclosed link, it brings them to the HIPAA document with the doctor’s name and contact information already inserted.
Until the patient clicks on “I have read, understand, and agree to the consent provisions set forth above…,” no other forms will appear. This electronic “click-through” is acceptable under HIPAA guidelines. (Submit Patient Forms [SPF] conforms to the HIPAA regulations for privacy, and all the online information is secure with advanced Internet encryption. An article at the SPF Web site describes in great detail how all the data is secured and protected. Only the patient’s dentist will have access to personal data via a username and password. Once the dentist has downloaded the patient’s records, he or she has the option of deleting the information. SPF periodically purges the patient records from the server, so they don’t remain in the database indefinitely.)
SPF then records and saves the time and date of the patient’s consent. The patient will type in the appropriate information. The patient may take a break, save the information, and go back to filling out the forms any time later by logging on with the e-mail address and password. He or she has ample opportunity to review what was written, and may print or download a personal copy of the records before submitting.

Figure 4. When the patients complete the forms, the forms will then appear in the management account in 3 convenient formats. Any or all can be utilized by the practice. The PDF can be easily printed as a hard copy, the JPEG can be downloaded into practice management software instead of scanning the forms, or the Excel format can be used to save time by copying and pasting.

When the patient completes the process and clicks “Submit,” the participating dental office gets auto-matic e-mail notification that a patient has registered. A staff member then logs on and may view the forms online, print a hard copy of the forms, and/or download the forms in PDF, JPEG, and/or Excel format (Figure 4) directly into the office computer or patient document center of the practice management software. There are huge advantages for new patients, existing patients, and the dental practice.

NEED SPECIAL EQUIPMENT? IS IT DIFFICULT AND TIME CONSUMING?

Figure 5. HTML script can be copied from the office management account to install a direct link to the patient registration page from your practice Web site.

Having your own dental office Web site is not required for this service. For those who already have a Web site, once the practice registers, a code can be copied from the SPF Web site. This code is then used to install a link from the dental practice Web site to the patient registration page (Figure 5).
How much time does it take the hygienist to update each current patient’s medical history at the recall appointment? I recommend that you print some business-size cards with your office contact information and the direct link to the patient registration page. Then, at each recall appointment, have the hygienist say, “We would like to update your medical and dental records. Please go online at your convenience to this site (the hygienist hands them your card) and fill out the appropriate information.”

ADVANTAGES FOR YOUR PATIENTS AND YOUR OFFICE

Patients will love this service. They go online without concern about other patients sitting nearby looking over their shoulders, without concern of where to prop up a clipboard, without concern for watching their children, and without concern about fumbling for their insurance or Social Security cards. Also, they will not be interrupting your office manager with questions about the questions. Sometimes it is these little things that count in building your reputation and practice. Many patients do not understand medical/dental terms and have problems filling out forms in an office setting. With SPF, they can have a friend or family member help them, in the privacy of their homes. SPF will also help to remove potentially negative emotional tension from the office setting, leaving your patient more relaxed and better able to communicate with you and your staff.
Since these are legible, computer-generated forms, practices save time and money by eliminating careless clerical errors and having to scan or retype information from handwritten forms. This frees up your professional dental staff to work on health-related topics. Before your patient even arrives, your office staff can verify the patient’s insurance and identify potential medical problems or conditions. Allergies and/or the necessity for premedication can be red-flagged in the chart. Follow-up questions can be asked at the patient’s first appointment. Information on how a patient perceives his or her mouth or smile or any immediate dental problems can be ascertained before the first appointment. Your patient’s health will benefit and can be protected from the improved record-keeping accuracy and being able to plan ahead better.

Dr. Rossein is a consultant, author, and lecturer. He is president of International Dental Consultants and a partner in WebDentalMar-keting.com and SubmitPatientForms.com. He is the editor of Implant News & Views, is listed in the Seattle Study Clubs Speaker’s Bureau, and has been a speaker for ADA Seminar Services. He presents the following lectures and hands-on courses: “Increase Income and Reduce Stress With Electrosurgery/Radiosurgery,” “Narrow Body Implants to Retain,” “Stabilize and Cushion Mandibular Dentures,” “Care and Maintenance of Dental Implants,” “Patient and Personal Stress Assessment and Management,” and “Is Your Practice Internet Friendly?” He can be reached at (888) 385-1535 or (516) 593-3806), krossein@optonline.net, or by visiting implantnewsandviews.com, webdentalmarketing.com, and submitpatientforms.com.

Disclosure: Dr. Rossein is a partner in SubmitPatientForms.com.

In my educational workshops I talk a lot about the importance of life planning: the idea that dentists need a comprehensive plan that integrates practice and personal economics within the context of a clear vision (Figure). It always amazes me how this simple concept resonates so deeply with many very successful practitioners. I am often approached by dentists who say they feel a “void” despite years of practice and that they want to rediscover their passion for dentistry…and for life. There is a real need in our industry to bring clarity, passion, and engagement back into the lives of dentists who are successful, but unfulfilled; busy, but feeling incomplete; established in their careers, but looking for a way out.
Is the profession really that bleak? I don’t think so. I know many practitioners who are absolutely in love with dentistry and would not choose any other business in which to be. But could it be better? I am 100% sure that it can be. In fact, I am so convinced that this profession is among the best that I have devoted my career to helping dentists see what is possible in dentistry and giving them a plan to achieve their practice and personal goals.
Most of us start out full of hope and possibility, but then let circumstances interfere along the way. The primary reason for choosing dentistry as a career, according to a 2001 survey1 of dental students, was the “ability to control time at work in relation to personal and family interests.” “Service to others” and “self-employment” was tied at second. They may be young, but the dental students in this survey were right on! I don’t know of another profession that offers the entrepreneurial flexibility and personal fulfillment that dentistry does, and with almost no upper limit to the amount of income one can earn.

Illustration by Brian Green

THE LIFE CYCLE OF A DENTIST

So where along the way does this clarity get lost? Why do only some practitioners actually experience all that dentistry has to offer? It is easy to see how it happens. After graduation, most new dentists go into what I call “survival mode,” with their sole objective being to find and acquire a practice by starting from scratch, joining an existing practice, or purchasing one outright. They make personal and financial sacrifices willingly in an effort to make a small dent in their huge accumulation of school and practice debt, as well as to hone their fragile clinical skills in a trial-by-fire fashion. In short, they exist only to get through each day and hope the next is a little easier, a little more profitable, and a little more fun.
Somewhere along the line, these young practitioners gain their footing, and the focus turns to growing their practice. Demands of practice ownership still require some personal sacrifices. Paying down debt remains a priority, but often profitability will have reached a point where personal economics are less strained. Dentists in this phase are often still working long days, and some struggle to balance the added commitments of a growing family.
As they become further established in practice and more comfortable with the demands of ownership, many dentists start looking for ways to balance their work commitments with more time for family and vacation. The practice may be “successful” by this point, but it does not run by itself.
Often, mid career dentists begin to worry about future economic realities, such as paying for a child’s education and funding their own retirement. They must also continue to invest in their practice and clinical skills in order to remain current and competitive.
This “established” phase can go on for years, and for many dentists it takes them right up until the twilight of their career. With the realization that they cannot practice forever, many begin looking for exit solutions, only to find that the scarcity of graduating dentists does not favor the selling doctor and that their practice value falls short of fully meeting their retirement needs. Notwithstanding their economic needs, these dentists often have a staff and patients who are also approaching retirement, and they feel an obligation to continue to practice long after they reach burnout.
I have purposely painted a rather dim picture here of the life cycle of a dentist, not because it is like this for everyone, but because I have seen far too many practitioners go through their careers in this way. They hide in their comfort zone year after year, and before they know it, decades go by. It is a life dominated by worry: they worry about paying down their school debt and then about paying off the loans from the purchase of a practice. They worry about affording their children’s education, and then about whether they can afford to retire. They worry about the daily realities of running a practice—not enough patients, not enough time (or too many patients, too much time)—and they worry about the things they don’t have time to worry about—keeping their facility current, maintaining team alignment, and making time to improve their clinical skills.
If I have learned one thing in 25 years helping dentists, it’s that it does not have to be this way. It’s not only possible to have the life in dentistry you envisioned as a dental student, it’s actually easier, more profitable, and more fun to do so. And that is what life planning is about for me. Its about asking the question, “If I could have it any way I wanted it, how would it be?” and then working backward through a series of further questions until you arrive at a plan that allows for choices and freedom in every phase, choices that protect your future at the same time. A life plan replaces anxiety with peace of mind, burnout with passion, and unhealthy stress with a healthy tension between what is and what can be.

THE LONGEVITY FACTOR

There is another central flaw in the life cycle of a dentist. The established practitioner that I talked about will likely reach his comfortable plateau sometime in his forties, at which point practice growth has slowed or leveled off completely. A generation ago, retirement at age 55 or 60 would mean this dentist could “coast” comfortably for 10 to 15 years before closing his doors for good. Today, however, demographic and economic factors make this scenario impossible.
As the average life expectancy creeps well into the 80s for both men and women, and as medical advances continue to accelerate at unprecedented rates, we have additional reasons to think about having a comprehensive life plan. The Employee Benefit Research Institute estimates that a typical husband and wife will need $295,000 to cover out-of-pocket healthcare costs after retirement, assuming an average life expectancy (82 for men, 85 for women). Should the couple live to be 95, they will need $550,000. And remember, this is not about luxury and lifestyle; we are just talking about covering basic healthcare costs.
But let’s forget economics for a minute. Living longer (and healthier, for the most part) also means that retirement at age 65 could leave you with 25 years of blank pages in your date book. That is a long time to do nothing! In fact, a recent survey showed that 7 million previously retired Americans returned to work after an average “hiatus” of just 18 months. About one third returned because their economic position could not support their retirement, but most did so by choice, probably because they needed to do something that continued to give meaning and purpose to their lives.
The reality is that we are living longer, and most of us will need to work longer. Assuming that part is a given, we now get to choose how we spend those working years. With proper planning, it is possible to continue to earn income long into your 60s and even 70s without sacrificing the lifestyle expectations that you have for those years. Having a life plan in place allows you to start making choices about how you work long before you get to the established phase of your practice. That’s when the question shifts from “When can I retire?” to “How long can I stay?”

Note: In Part 2, to be published in next month’s issue of Dentistry Today, the author will discuss the nuts and bolts of a comprehensive life plan, and how asking yourself the right questions can lead to a discovery process that will bring you peace of mind now and into the future.

Reference

Mr. Manji is founder and CEO of the Scottsdale Center for Dentistry, the continuation of his longtime goal to provide a world-class facility where dentists and teams can receive comprehensive, evidence-based, patient-centered learning. For more than 20 years, he has been educating and motivating dentists across North America. Mr. Manji’s newest workshops, Dental Office Design, BreakThrough Practice, and CEREC Experience, and his classics, Leadership & Team Alignment and Transitions & the Business of Dentistry, combine his endless energy and inimitable style with his practical teachings to make these programs a “must-see.” He can be reached at (866) 781-0072 or imtiaz.manji@scottsdalecenter.com.

At first, a commitment to the interdisciplinary approach to patient care can be intimidating for many dentists and practices. You may think that it will take up too much time, be too complicated, or overwhelm your patients. In reality, it is exactly the opposite. By taking the initiative to create an interdisciplinary team, you will save time and energy in the long run by streamlining and simplifying the process of referrals and working with other specialists. Most importantly, you will be ensuring that your patients receive the best possible care at every step of the treatment process.

WHAT IS THE INTERDISCIPLINARY APPROACH?

llustration by Cheryl Gloss

We already know that the dentist alone cannot always solve some of the more complex oral, cranial, and facial problems from which patients suffer. This is when the dentist will traditionally refer his or her patient to a specialist in order to seek additional expertise. In a particularly complex case, there may be several referrals to several different specialists over the course of treatment. This multidisciplinary approach to treatment can be very effective, as one specialist cannot deal with all aspects of a complicated problem. However, it can be a bit one-sided, since information travels between the dentist and the specialist(s) without any time or place dedicated to collaboration. The interdisciplinary approach brings in that missing collaborative element and allows all specialists involved to conduct a dialogue concerning patient care.
Interdisciplinary dentistry focuses on interaction, not only between the primary dentist and the specialists, but also between the interdisciplinary team and the patient. The patient should always be included in the process as a member of the team and should be updated regularly on incoming information and decisions. Including the patient in this way not only brings treatment to a new level, but it also provides optimal customer service from the dental practice.
The interdisciplinary team creates a network of shared skills and expertise, open communication, and trust. The ultimate goal is to create and perpetuate an ideal treatment environment in which the patient feels comfortable and doctors can work effectively.

HOW DOES THE INTERDISCIPLINARY APPROACH WORK?

As we know, a dentist already wears many hats within his or her practice: business owner, boss, clinician, customer service provider, manager, and leader. With these responsibilities already in place, it is easy to view interdisciplinary dentistry as extra work that could be handled just as well with simple referrals. Even though establishing the interdisciplinary team may require an extra time investment up front, once the team is in place it provides a much more effective framework for treatment. It also opens the lines of communication, reducing stress and confusion for all members of the team, including the patient. Clear expectations of the intended treatment outcome are built into the interdisciplinary team’s framework. As a result, and by its very nature, the team approach allows for more efficiency and a better treatment outcome.
The initial formation of the ideal interdisciplinary team can require a considerable amount of time and energy. However, it will be worthwhile to your practice to create that valuable network of specialists on whom both the dentist and the patient can rely. Team members should meet at the beginning to discuss the patient’s diagnosis and treatment plan together. By combining the individual skills and expertise of all the specialists, a comprehensive treatment plan can be developed. As with any sort of collaborative effort, the interdisciplinary team can benefit from a written agreement delineating all responsibilities, expectations, and financial compensation.
The team should discuss every aspect of the treatment plan in detail and ensure that the plan is customized to the patient’s needs. Then, at every step of the process, all members of the team will follow the treatment plan. It is important to remember that the patient is an essential part of the team and should be included in the development and execution of the treatment plan. Once an atmosphere of open communication has been established, it is much easier to avoid mistakes and confusion during the treatment process. The key is to start the interdisciplinary process before problems arise and not after. Rather than making referrals and then subsequently engaging in dialogue with specialists should a problem arise, be sure to collaborate actively with the other members of the team at the onset of treatment. Be sure that all members of the team are working together on all the steps of the treatment plan.
The beauty of collaborative work is that everyone can give each other advice and build on each other’s ideas. Rather than passing down orders, team members can ask for input and suggestions. Again, be sure to engage the patient in the dialogue. Instead of commanding your patient to do something, ask the patient if he or she would be comfortable with a given method of treatment. Do not hesitate to consult other members of the team if a problem arises. Overlooking something or misdiagnosing a patient can lead to a lack of treatment or unnecessary multiple treatments, which can be ineffective at best and harmful at worst.

CUSTOMER SERVICE AND THE INTERDISCIPLINARY APPROACH

Once your interdisciplinary team is in place, it will be a valuable resource for both your practice and future patients. Learning about alternative treatments and options will allow you to greatly increase your level of patient care. Sometimes traditional dentistry is not the only solution, and in those cases your established interdisciplinary team can be available to help develop a personal treatment plan for your patient.
The interdisciplinary approach to dentistry can have a major impact on your practice, not only in treatment of your patients, but also in your level of customer service. By including your patients in the dialogue and development of their treatment plans, they will begin to develop personal relationships with the dentist and specialists. Trust will grow from these relationships, and the patient’s level of trust in the team will steadily increase as long as the lines of communication remain open and as the ex-pected outcomes of the treatment plan are met. The objective is to make your patients feel secure in their treatment, and that by working together to create highly individualized treatment plans, their goals will be met. Your patients will feel valued and respected, and in turn they will value and respect their treating clinicians. These patients will be sure to return to the practice and the team for future treatment.
Once your practice fully embraces the interdisciplinary approach, you will reap the benefits. Not only will your treatment plans for complex problems be more comprehensive and effective, but your patients will be receiving optimal care and customer service, as you will be anticipating their every need. Ultimately, the interdisciplinary team is not about what fellow specialists can do for you, but what you can all do collaboratively for your loyal patients.

Sources

Israel HA, Scrivani SJ. The interdisciplinary approach to oral, facial and head pain. J Am Dent Assoc. 2000;131:919-926.

Murphy MT. Collaborative interdisciplinary agreements: a new paradigm in laboratory and specialist communication and patient care. J Am Dent Assoc. 2006;137:1164-1167.

Spear FM. Forming an interdisciplinary team: a key element in practicing with confidence and efficiency. J Am Dent Assoc. 2005;136:1463-1464.

Hanley Y. Inter-disciplinary dentistry persists as a challenge for rural dentists. Dent Econ. 2005;95(2).

Varallo M, Varallo V. Killer customer service: beyond satisfaction. Dent Today. Oct 2007;26:142-144.

Dr. Varallo is a 1980 graduate of Farleigh Dickenson Dental School in New Jersey. He is a member of the International Academy for Dental-Facial Esthetics, an AGD-trained speaker, an associate fellow of the World Clinical Laser Association, and serves on the Clinical Advisory Board for DENTSPLY. He owns and operates the Nantucket Dental Society. Dr. Varallo runs a patient-centered practice in Ho Ho Kus, NJ. He can be reached at (201) 670-9076.

The team members jumped out of their seats and shared high-fives all around the dental office. Celebratory back slaps were exchanged in the treatment area. Elation was the feeling among all team members after their big win in the consult room. This Tennessee-based dental team had already scored 2-for-2 in its “pay today” attempts. That’s right, the first 2 patients this dental team took through Next-Level Practice’s case-closed system not only accepted the entire treatment presented, but signed the treatment agreement and paid in full, utilizing what my team and I refer to as the pay today courtesy (a 5% discount for patients who pay for treatment in advance). After researching payment terms such as accounting courtesy, bookkeeping dis-count, and prepay, we found that using the verbal language of pay today makes a dramatic statistical difference in closing a case.

Photograph by Nathan Zak

Let’s visit this successful practice 48 hours before the celebrations began. This one-doctor-one-hygienist practice was earning $75,000 a month by offering general dentistry, sedation, Invisalign, and aesthetic services. It was successful by many business standards; however, this doctor knew she could do better. Her team, consisting of front office personnel with more than 20 years of experience, a few crackerjack assistants, and a terrific hygienist, all had been successfully trained in the past by several nationally recognized dental consulting firms. Our Next-Level Practice team spent invaluable time getting acquainted with this progressively thinking dental practice, earning its trust, and handling its concerns. Once everyone was 100% on-board and willing to cause action, all the team members got on the “basketball court” as we stood “on the sidelines” watching the practice in motion. Throughout “the game,” my staff pulled team members aside one-by-one to zero-in on their current beliefs, attitudes, and skill sets.
I knew that this team had great potential once I spoke to the treatment coordinator and had asked why the biggest case she’d ever presented was $5,000. She shared her belief that it is the patients’ responsibility to know their own insurance coverage and she did not think they should have to prepay for service before it is delivered. In these one-on-one discoveries, we found additional opportunities for the practice: the hygienist used intraoral pictures on only 20% of patients. Most treatment was presented from the front desk, with a handful of patients in earshot. The doctor always offered options as she rose from her chair, leaving patients with the feeling that they would need to go to dental school themselves in order to make the right decision.
These beliefs and practices are commonplace in most dental offices across the United States, and I’ve recently learned they are basic truths in Canada and the United Kingdom as well. You see, when the world has been doing something the same way for generations, it can be hard to create change. My favorite quote on change is this: “For things to stay the same around here, we have to make ongoing changes.” I am on a mission to positively alter the way dentists do business as usual. It bothers me to see the same recurring problems exist in practice after practice—this resembles insanity. Suffering is optional in dentistry, and there is a way out. You must trust in a philosophy that makes sense to you. If you understand it, secure it within yourself, and engage your team in accepting it, you will win. So will your team and your patients! The following is one possibility for you to shift how you approach your case acceptance system.

THE KEYS TO POSITIVE CHANGE

Consider that you and your team’s thoughts and beliefs are at the core of it all, and that the source of real change begins between your ears. If your belief is that it cannot be done, then you are limiting yourself, closing the door on possibility, and you might choose to save the time and effort by not reading the rest of this article. If, however, you are tired of feeling that you have to work harder to gain more, or that you do not think you deserve success, I encourage you to stop here and work this through. Get a coach. Work on your core beliefs before taking this on. When you know that you deserve success and prosperity, then take this on. Only at this point will your career become effortless and your practice evolve into a world-class customer service ATM machine, making a real difference to those you serve.
Before we move on from thinking to doing, consider this question: When was the last time you purchased something that you didn’t think you needed, was going to cost you thousands of dollars, take up valuable time, and cause you pain? This closely defines what many doctors currently offer their patients. And, if you think about it, this question hasn’t truly been addressed. Do you ever wonder why patients have become insurance-dependent? Ponder this a bit and create a new world of willingness and passion to conquer this issue—make it your mission. Okay, we’ve now built a solid foundation to allow you to get it done. Let’s begin. First, I will distinguish how to set up your team structure, and then I’ll give you 3 tools that can be implemented right away.

BUILDING YOUR TEAM FOR MAXIMUM RESULTS

For a scratch-start practice, you must start with a team of three: the front office, assistant, and hygienist. For an existing practice, with one doctor and one hygienist, you will ideally want 2 people in your front office—one who manages time (ap-pointment coordinator) and one who manages money (treatment coordinator). Money and time are commodities that responsible persons must manage proactively throughout the day.
Let’s assume you want to create a million-dollar practice working 4 days a week. To do this, you must produce $5,500 per day—$1,000 for your hygienist and $4,500 for the doctor. This is an accountability system, or what I call the daily primary outcome (DPO) for the appointment coordinator. This team member’s job is to make sure that the schedule is financially productive every day and to eliminate any roller-coaster-type fluctuations. The treatment coordinator then focuses on a DPO to present at least $7,000, achieving an acceptance rate of at least 67%. The hygienist’s DPO is to generate at least $1,000 in daily production and at least $7,000 in treatment for the treatment coordinator to present. Finally, the assistant has a DPO to ensure that the doctor produces at least $4,500 chairside each day. Your practice is now structured to manage with facts rather than emotions. Everyone is now attached to a scoreboard, so they know whether they are winning. And if they are not, then they know they can rally the team around for support. Of course, these numbers can be adjusted to create larger goals for practices with more team members. (Details on this topic can be found in my book, Million Dollar Dentistry).

THREE PRIMARY TOOLS TO CLOSE A CASE

NextLevel Practice has developed more than 26 tools to help close a case. However, for the purpose of this article, I will focus on 3 primary, no-miss tools used to transform case acceptance in the practices we have worked with. These tools are (1) the patient qualifier, (2) personal motivators, and (3) the CCWare financial options presenter (CareCredit).

The Patient Qualifier

Do you ever find yourself not really knowing how much treatment to present, especially to a new patient? Or maybe an existing patient has brainwashed you into thinking she has no money, even though she just got back from an around-the-world cruise in a first-class cabin, toting a new designer handbag. This little tool may be your big solution. Envision 4 quadrants on a piece of paper that are divided by 2 axes. The X axis represents the range of low trust to high trust, and the Y axis ranges from low dental values to high dental values. Most patients start out in the lower left quadrant: low trust, low dental value. These are the patients who think your purpose, as a dentist, is to acquire the most toys in Tennessee. They are also the ones that want you to pull their teeth instead of restoring them. This is what frustrates most dental teams.
The key to using this tool is to always start in the same place as your patients. If they fall within the lower left quadrant, don’t try to sell them a roundhouse. Build up to it. From the initial phone conversation to the trust exam, make sure you reiterate that you will address their chief complaints. Start thinking beyond just teeth and gums. Expand outside of the office space you usually work in and realize that you are caring for an emotional human being.

Personal Motivators

This brings us to the second tool: personal motivators. Patients buy on why. They want to know why it is that they need what you are recommending and how it will affect their emotional attachments. Many dentists have been presenting dentistry to patients from a logical position: “You need 2 crowns and 3 fillings.” Here lies an immediate problem in using this approach: Those who are receiving the message are listening for “why I need it” and “how it fulfills my highest values.”
Here’s an example: I was listening in on a new-patient interview between a patient and a treatment coordinator. The patient was explaining how he had not visited a dentist in 15 years and that he’s a hardworking cable guy. His medical doctor, who told him he has an infection moving into his throat possibly from his teeth, referred him to the dentist. This patient described that he was getting older and wanted to be around to see his 3 children grow up. He also shared that he had confided in his wife that he was going to the dentist to have his missing tooth fixed. His wife had told him that she noticed he really hadn’t smiled since losing his tooth. His smile was one of the things his wife loved most about him.
After this patient went to another room for radiographs, I asked the treatment coordinator what she had heard. She said that this patient was typical: he hated the dentist, probably couldn’t afford all the care he needed, and wanted to get that missing tooth fixed to make his wife happy. You see, this treatment coordinator was listening through a filter of brainwashed belief systems, which created her general reality about patients. According to her thoughts, every patient came from the lower left quadrant of the patient qualifier…I decided to transform her belief systems. This treatment coordinator needed to see that this guy was ultimately buying more time with his kids and a reconnection with his wife.
The NextLevel Practice team showed this dental practice how to tie the dentistry (the means) to the emotional ties (the end). As a result, this patient walked out a $15,000 pay today patient, and I can pretty much guarantee that he will not be breaking any of his future appointments.

CCWare Financial Options Presenter

The final tool that I recommend is the CCWare Financial Options (CareCredit) presentation sheet. It can be found on the resource center of the Web site carecredit.com and downloaded onto your computer. Install this on every computer. We ask treatment coordinators to display intraoral pictures and fill out this worksheet prior to releasing the patient from the treatment room. Once patients understand their recommended treatment and you have tied these needs to their personal motivators, you may then present the associated investments that will be required to accomplish their goals. We refrain from using the dental software presenter because we find that it can be overwhelming and confusing.
The CareCredit software makes it easy to present cases and enforces a less-is-more mindset. I particularly like the language that is used in this form. I train coordinators to say, “Your total investment is…” instead of “Your cost is…” I also prefer saying, “Your responsibility is…” instead of “Your out-of-pocket is…” You can also enter the utilities option on this worksheet and change the words accounting courtesy to pay today courtesy. The real genius behind this tool is that it calculates the “pay today” and shows patients the final total. It lends more value for patients to see the discounted figure versus telling them you’ll give them a 5% discount.
People with money tend to love saving their money. For those who purchase in monthly increments to fit their budget, use the 3, 6, 12 interest-free plan, where the doctor pays the interest. This can melt a $5,000 case down to a $333 monthly payment for 12 months after insurance. Most teams never give patients a chance to agree to a $333 easily doable monthly payment. Either they didn’t qualify them, or they neglected to tie the treatment to those patients’ highest values that would drive them to take action. Lastly, many teams rely on old-school case presentation sheets that do a great job of overwhelming patients, and as a result treatment is not accepted.

Conclusion

It takes a team to close a case. So spur your team members onto the court, give them the fundamentals, and everyone will win. Every day you can play an exciting game. It will feel like you’re winning the NCAA of dentistry with slam dunks, chest bumps, and high-fives all around!

Mr. Kadi transforms successful dentists into highly successful dentists: financially secure, professionally respected, and deeply satisfied with their practices and their lives. He created the Next Level methodology and is one of America’s leading dental practice developers. His 12 years of transforming and developing dental practices are captured in his newest book, Million Dollar Dentistry. He can be reached at (480) 361-9955, gary@nextlevelpractice.com, or by visiting the Web site next-levelpractice.com.

Last month we looked at some of the challenges facing the health professions, and dentistry in particular, as we transition into electronic record keeping and the storage of other vital information. This month we will look at HIPAA privacy recommendations, national provider identifier (NPI) numbers, and patient record essentials, whether paper or digital.

HIPAA PRIVACY RECOMMENDATIONS AND GEORGE CLOONEY’S MEDICAL RECORDS

Illustration by Nathan Zak

Wherever records are compiled and housed, HIPAA provides general privacy recommendations for their confidentiality. One of these recommendations is that each office, hospital, or clinic have a written Notice of Privacy Practices that, among other things, typically spells out which employees are allowed access to patient records, whether paper or computer. To simplify matters, many medical/dental locations specify that all health personnel may have access to a patient’s record. Therefore, employees may look at paper charts and/or electronic records whenever necessary. Regardless of whether it is specified in a Notice of Privacy Practices, does this mean that all health personnel in a particular location may have a legitimate reason to look at a particular record? Maybe, maybe not!
Several months ago George Clooney, the famous actor, was involved in a motorcycle accident and was treated at the Palisades Medical Center in North Bergen, NJ. According to the medical center’s Notice of Privacy Practices, any med-ical employee of the hospital has the right to access a patient’s record. So, 27 employees looked at George Clooney’s electronic chart. While no one apparently violated HIPAA, why were all of these people looking at George Clooney’s record? (Paper charts could probably have been accessed as easily, however a record of who looked and when they looked would probably not have been as evident or accurate.)
As far as privacy goes, HIPAA regulations do little or nothing to protect privacy within a hospital or dental office. However, a digitized system can at least make it possible to uncover “peekers” at a facility. Privacy beyond the confines of a facility is important, but can it really be consistently implemented? Could George Clooney’s electronic health record also have been accessed outside of the hospital? The answer probably is “Yes!” Many such systems have been hacked into before.

PRIVACY AND NPI NUMBERS

Whether private facilities, the Internet, or another type of repository (as we discussed in Part 1 of this article) is ultimately used for private information storage, the NPI number for dentists is a reality right now. The deadline for obtaining this number was May 23, 2008. According to the ADA, the NPI is a “unique, standard identification number for healthcare providers” to use on all HIPAA transactions. The NPI number is said to replace “legacy” identifiers such as license numbers and social security numbers on electronic claims and other patient encounters. The NPI number supposedly does not provide details about a dentist such as his or her name, location, specialty, or qualifications. However, at least one “sales lead and mailing list” supplier is advertising labels that contain provider NPI numbers in addition to names, addresses, and degrees. (This implies that in the future, additional confidential provider identifier numbers will be required in order to access patient records in a repository or Internet location. Otherwise anyone who purchased such a mailing list would also know that provider’s identifier number.)
The current version of the ADA dental claim form (2006) provides a section for NPI numbers, legacy numbers or other numbers previously used by the dentist, license numbers, and social security or tax ID numbers. All bases are covered. Treating dentists or individual practitioners need a NPI Type 1. Hospitals, clinics, group practices, and corporations, including individual corporations, need a NPI Type 2. Dentists who treat patients and who have individual corporations need to have two numbers: a NPI Type 1 and NPI Type 2. (Note: It is important for dentists to remember that some dental plans base their payments on the network status of the treating dentist, not the billing entity. This means that they may not pay in-network amounts and/or may send the reimbursement check directly to the patient, if the treating dentist is not participating.)

MANAGING DIGITIZED RECORDS

The ADA provides standards and reports for records software that can be found at ADA.org. The ADA Council on Dental Practice and the Division of Legal Affairs has also produced a 37-page document that gives general guidelines on dental records, both paper and digital. However, digitized records do have their own special concerns.
Of interest to many dentists is the current status of the “written signature” requirement on a patient’s record. Previously, in most states, if a dentist had not provided his or her signature, or initials in some cases, on a written record of progress notes, any notations made by others were not considered legal documentation. Some states continue to require a written signature by the dentist or authorized provider on progress notes. However, many states have devised parameters for electronic signatures, “stamps,” or “keys” that can be associated with a patient’s dental record and given the same “force and effect” as a hand-written signature. You can look up your own state requirements by using an Internet search engine such as Google and typing in “regulations for electronic signatures.” (The American Health Information Management Association (AHIMA) used to provide a general Web site for this information, but recent inquiries show that it has been changed.)
Suggested features for computerized systems include time-sensitive lock-out elements, automatic terminal log-outs, password parameters, and fingerprint identification. Time sensitive lock-out features may include an automatic, full-system lock on the ability for anyone to make changes to a digital record, or simply a special password that is required to make such changes after a certain amount of time. Special passwords may also be required for activities such as taking a payment, making an appointment, or making entries into a patient record. Frequent password changes are recommended as well as consistent logging off by individuals once they are finished working on a certain computer terminal. If all office personnel have access to all terminals, the use of an automatic log-off function that goes into effect after a designated time period may be preferred. It is also possible to utilize a USB biometric fingerprint scanner to determine who is logging in and out.
Even if progress notes are digitized or “packaged,” it is important that adequate notations be provided to address important details of diagnosis, treatment, and recommendations. Standardized progress notes are not adequate, and may even be dangerously incorrect. For example, standardized notes may indicate “#3MOD-composite, 2 carpules of anesthetic.” What happens if #2-crown preparation, #3MOD, #4MOD, #5MOD, #14MOD, and #15MOD are performed at the same appointment, and each standardized entry includes 2 carpules of anesthetic? The patient’s record will indicate that 12 carpules of anesthetic have been injected! Treatment-specific and patient-specific notes are essential, no matter the method used to make the notes.
Digital records as a part of a computerized management system may be expensive. While many dentists are aware of software packages for purchase that include management, charting, e-insurance claim filing, and others, they may not know that there are companies who can provide all these types of programs for download off the Internet. Typically dentists pay for whatever program “modules” they want on a month-to-month basis. The company provides a monthly software license for the modules, delivers the software electronically, and provides Internet and/or phone support.

WHAT NEEDS TO BE INCLUDED IN PAPER OR ELECTRONIC RECORDS?

Regardless of whether an office is using a paper chart or a computerized format, certain elements need to be part of any patient’s dental chart (Table).
According to the ADA, it is not necessary to keep financial information, including benefits, claims, or payment vouchers, as a part of a patient’s treatment record. While many of the items noted in the Table can be easily accessed using a paper chart, digitized records must be able to provide access to all of these as well. If you are using computerized records, your software provider should be able to help.
And if your office is still using a paper record, you are in good company. The majority of medical offices, hospitals, and dental offices still use paper. Paper charts have the advantage of being inexpensive, familiar, easy to use, easy to retrieve, and difficult to alter without discovery. Despite these facts, as time goes on, more and more practices will become computerized. The world is becoming more automated, not less. Privacy issues will always be of concern, and, no matter how records are kept, electronically or by paper, the key elements of an accurate record are not likely to change in the near future.

Ms. Tekavec is the author of the Dental Insurance Coding Handbook, as well as the designer of a dental chart that has been endorsed by the Colorado Dental Association and others. She is also the author of a series of patient brochures explaining various dental procedures. Ms. Tekavec practices as a dental hygienist and is the president of Stepping Stones to Success. She has appeared at all major US dental meetings and is a presenter for the ADA Seminar Series. She can be reached at (800) 548-2164 or via her Web site at steppingstonestosuccess.com.

From the famous ancient library of Alexandria in Egypt, to the futuristic “singing discs” in H.G. Wells’ The Time Machine, the world of records has been important to the human race. Without records we would have no way of knowing where we came from. Without records it would be impossible to learn from the past and create for the future. Records have always formed the framework for civilization.
Similarly, records in healthcare have always been the backbone of patient treatment as well as the core of risk management. The state boards of dental examiners stipulate accurate record keeping for dentists who face licensing problems. Malpractice insurance carriers consistently advise their doctor-clients that detailed records can halt a malpractice lawsuit. When well-kept and detailed records are presented at the outset of a possible malpractice case, the plaintiff’s attorney(s) may decide that the case is not winnable, and the dentist can be saved from going to court. Records are also essential for documentation and support when dealing with third-party payers. Utilization review and the newer concept of “pay for performance,” or P4P (“Utilization Review and P4P: What Dentists Need to Know”—Dentistry Today, November 2007), hinge on data collection and dispersal.

Illustration by Cheryl Gloss

In this environment of medical and dental record-keeping requisites, we find ourselves poised between two worlds. On the one hand is the familiar world of paper charts and forms. On the other hand is the wide-open world of electronics. While many disciplines have already embraced electronic data recording, health systems have been slower. The reasons are varied, but include a wide range of available but incompatible software systems, expense, unfamiliarity, and a lack of trained individuals to work with the systems. (Hospitals and physician’s offices report a shortage of clinicians with a background or training in general information technology. Dental practices are no different.)
While a lack of trained clinicians can be an issue for each individual office, incompatible software systems create an “across-the-board” problem. A software program may work fine within the confines of a particular office or hospital, but information may not be structured to flow to another hospital, office, or third-party payer that is not utilizing the same system. As an example, although e-filing for dental insurance claims is commonplace, a clearing house often is still necessary as an intermediary between payers and providers.
With this and other concerns in mind, during 2005, the AHIMA (American Health Information Management Association) and AMIA (American Medical Informatics Association) provided a focus panel to examine common issues concerning electronic records. Besides compatibility, they discovered that a major challenge for the medical, dental, insurance, and government industries is deciding on a standard definition for what constitutes an electronic medical record. Some systems are a compilation of scanned reports and text, while others contain clinical data and details. Proprietary vendor systems make matters worse. Addressing this same issue, the ADA has recently created a Standards Committee on Dental Informatics, which has published a series of Dental Informatics Specifications and Technical Reports that are viewable at ADA.org. One of the purposes of this committee is to address continuity and standardization issues. Without continuity and standardization, the medical and dental community will not be able to catch up to the rest of the world in the areas of information, documentation, and data support.

PRIVACY, RECORDS, AND HEALTH RECORDS BANKS

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) began the push for digitized records, although the advantages of a computerized health record were readily seen prior to that. Hurricane Katrina put record keeping in the spotlight. Displaced persons with little knowledge of their own medical histories, plus medical and dental offices that were destroyed in the aftermath of the storm, highlighted the problems associated with a lack of electronic records. Fragmented record keeping made caring for these patients even more difficult. If electronic records had been the norm, it would have allowed hospital and other healthcare workers to pull up patient histories, allergies, drug dosages and other concerns instantly…possibly preventing many problems and averting potential medical emergencies.
Despite the advantages, electronic records’ privacy and safety issues continue to be a major concern to both providers and patients. In fact, two thirds of consumers contacted during a survey sponsored by the California HealthCare Foundation in 2005 said that computer security problems made them worry about the privacy of electronic health records. More than 50% worried that a lack of control and privacy might enable their employers to access and use their medical information to limit their job opportunities. It does not help that every day there is more news about “lost” (or misappropriated) credit and other computerized database information. Privacy is a definite and ongoing concern.
Despite this general apprehension, one of the goals of HIPAA is to set up a national digitized system whereby providers and patients can have access to a database of health information by utilizing identifier numbers. Patients and providers would each have their own identifier numbers, allowing access to their own records or those of their patients. The records themselves will exist on the Internet or contained within some type of health records bank.
A recently published article (“Are Health Records Banks the Answer?”— Health Data Management, January 2008) provides an extremely detailed and interesting description of a possible system for warehousing confidential health information. The article quotes William Yasnoff, MD, one of the architects of the national health information infrastructure and the keynote speaker at the 2007 Clinical Automation Summit. He recommends health records banks, rather than the Internet, as the best solution for a “sustainable business model for paying for electronic health records systems and exchanging electronic patient data.” As a former senior advisor to the US Department of Health and Human Services, he envisions the creation of local trusts that would build and operate health records banks as central storage locations for medical records information. Expenses would be covered by patients, who would pay collection and maintenance fees.
Health records banks would operate this way: The health records bank would charge fees to individual patients to collect their medical records from physicians, hospitals, dentists, pharmacies, and others, while maintaining them confidentially. No one could access the information unless the patient gave the go-ahead. Dr. Yasnoff believes that a per-patient charge of $5 per month could build and maintain such a bank. The bank would use one portion of that money to maintain the service. Another portion would be used to pay physicians, dentists, pharmacies, and others a certain amount per encounter for the work of submitting the information that they have on file for that patient. He believes that these payments could also fund physician (and dentist?) costs for implementation of an electronic health record system and give providers a remotely hosted electronic record. His theory is that consumers would trust a health records bank more readily than the Internet because individuals already trust their financial and banking institutions. In addition, having patients, rather than providers, pay for maintaining their records would increase provider acceptance.
Others who might also benefit from this plan include software and hardware companies, information technology experts, insurance carriers, computer sales, the government, venture capitalists, and a new entity: the health records bank executive.
Next month we will take a look at additional issues surrounding electronic records, privacy, national provider identifier numbers, and record-keeping essentials, whether paper or digital. We will also talk about how the actor, George Clooney, and HIPAA privacy rules recently came into conflict during a hospital stay.

Ms. Tekavec is the author of the Dental Insurance Coding Handbook, as well as the designer of a dental chart that has been endorsed by the Colorado Dental Association and others. She is also the author of a series of patient brochures explaining various dental procedures. Ms. Tekavec practices as a dental hygienist and is the president of Stepping Stones to Success. She has appeared at all major US dental meetings and is a presenter for the ADA Seminar Series. She can be reached at (800) 548-2164 or via her Web site, steppingstonestosuccess.com.