Practice Management – AAO Tech Blog

Fix or Replace That Digital X-Ray?

By Bryan Delano

The film X-ray era is fully behind us, and we are now entering the second and third generations of digital 2D panoramic/cephalometric technology. The first models of digital X-rays, available in the late 1990s, were film-to-digital upgrades. In the early 2000s, direct digital 2D options were introduced. Today, practices have the option of implementing either new or pre-owned digital X-ray technology at a fraction of the cost of just ten years ago.

As some digital panoramic models reach almost twenty years of age, and most first-generation cone beam units are over ten years of age, warranties have expired, repairs are more frequent, and the cost and availability of parts is challenging. Additionally, software drivers that control these units are not keeping up with modern computer operating systems, limiting available compatible options in the event of a PC failure. When faced with these obstacles, a practitioner has the option to either invest in a costly repair or purchase a replacement unit.

Just like any modern technology, repairing an X-ray unit can range from a ten-dollar simple fuse replacement, to tens of thousands of dollars when replacing a failed sensor. Please see the guidelines below when faced with X-ray component failures.

Digital sensor failure

Unfortunately, there are few, if any viable sensor repair resources, so the replacement of the actual sensor is often the only option with a digital sensor failure. Some X-ray models such as Sirona, Planmeca and Instrumentarium are formatted with cartridge-type sensors that can be moved between pan and ceph. A pan sensor can only be used to capture a panoramic image, but a cephalometric sensor can be used to take a pan OR a ceph. Switching the sensor between the pan and ceph is easy and can provide a long-term solution or can buy time to research other options. It’s never good to feel pressured to make an expensive purchase quickly, so this option can help extend the decision-making period. Purchasing a new sensor can range from $3,000 to $15,000, depending on the manufacturer, but there are other options to consider. For example, often you can find X-ray sensors on eBay that offer Buyers Protection. This allows a buyer to receive the sensor, test it thoroughly, and return it for a full refund if it is defective.

“We don’t know what is wrong”

Many dealer technicians rely on the X-ray manufacturer for support. When your tech arrives, they inevitably will immediately contact the manufacturer for help. The older generation machines are often misdiagnosed at this point, and the tech will suggest ordering or trying up to several parts, which can be very costly. Some of these parts may be needed and others will not. The challenge of only ordering one part at a time could result in delayed repair time with multiple shipments and on-site tech labor charges. When ordering several parts at a time, however, make sure to ask if the unused parts be returned for full credit or a refund with a re-stocking fee, or if they cannot be returned at all. Major replacement parts can cost anywhere from $3,000- $10,000 (not including service), even if the sensor is not involved. Warning: Buying parts other than sensors on eBay can be limited or difficult, and often dealer technicians will refuse to replace these parts due to liability issues.

“I’m sorry, this unit is discontinued, and parts are no longer available”

By law, X-ray manufacturers must make parts and support available for their equipment for around eight years after the machine was last sold. For example, if your machine was manufactured in 2007 and sales stopped in 2010, they are obligated until 2018 to provide replacement parts and support. That doesn’t mean if your machine is dated 2007, then you are already out of luck. If that model is currently still manufactured, then you have a long runway for parts availability. Many manufacturers are still providing parts and support beyond the eight required years, but the challenge for them is that these parts were not made by their own company, but by third-party suppliers. If those suppliers choose not to continue manufacturing the desired part past the eight-year requirement, then the X-ray manufacturer is left with only the parts that they have on their inventory shelves. This is a common issue with many X-ray manufacturers.

Replacing the unit

Replacing an X-ray unit is a costly proposition. Fortunately, digital panoramic unit pricing has come down significantly in recent years. In addition, many quality pre-owned X-ray options are also available. The challenge now becomes that your X-ray is down and you need a replacement in a short period of time. This time factor could limit your options and ability to negotiate the best price. Many X-ray manufacturers have ended exclusive distribution deals, so you can shop for the same X-ray model from several distributors for the best pricing. Depending on the repair status of your current unit, you may be able to receive some trade-in value based on the remaining parts. Perhaps this is the practice’s impetus to choose and upgrade from 2D to 3D. If you want to “buy” some time for additional research, you can also ask the new / used X-ray vendor to fix your unit with borrowed / loaned parts until the new X-ray is purchased.

So, when faced with the challenge of repairing or replacing your X-ray, ask yourself the following questions:

What are the costs of the repair? Do they exceed the costs of purchasing a new or pre-owned unit?
Can I get away with “patches” such as swapping a sensor between a pan/ceph unit or buying parts on eBay?
If my X-ray is over eight years old, are parts still available?
Can I allow enough time to research my options and compare pricing between vendors?
Is now a good time to consider upgrading from 2D to 3D?

When possible, the best practice is start planning ahead for older X-ray equipment replacement. But, since you cannot always predict equipment failures, it never hurts to start researching your options today.

Sharing Cone-Beam CT Images Online

By Dr. Dan Grauer

When diagnosing and treatment planning interdisciplinary patients, have you ever sent your three-dimensional images to a colleague? Have any of your patients requested a copy of their records for a second opinion? Or maybe, a patient declines a radiograph because another orthodontist has recently taken a CBCT image of the patient? In all of these instances, you will need to communicate with the other office to initiate the transfer of CBCT images. The purpose of this blog is to describe different methods used to share patients’ CBCT records via online means.

Images acquired in your office are requested by a second orthodontist/dentist:

The first question that will need to be answered is whether the other office has the possibility of viewing and analyzing the images in three-dimensions. In a few instances, I have found myself trying to transfer a full three-dimensional file, when the second orthodontist just wanted a cephalogram and a panoramic radiograph. If this is the case, your software will probably allow you to create a synthetic cephalogram and panoramic radiograph that can be emailed through a HIPAA-compliant email account. If the second orthodontist requires a three-dimensional image, two case scenarios are possible:

Case scenario 1: Second orthodontist owns software to read and visualize CBCT images.

In this case, your software is able to export the CBCT Images in DICOM format (Digital Imaging and Communication in Medicine). DICOM files are large, and a file transfer application is needed. Once transferred, these can be imported into the software of the second orthodontist for visualization and analysis.

Case scenario 2: Second orthodontist does not own three-dimensional imaging software.

Under this case scenario, the second orthodontist would need both the CBCT images and a three-dimensional viewer. Three main options are available.

Option 1: If you own a CBCT machine, your software is generally able to create a file that includes both the image data and a basic viewer. The files created are large and can be transferred with a file transfer application.

Option 2: Anatomage offers the possibility of uploading your CBCT images to the cloud, and these can be accessed online through Anatomage’s application, which acts as a visualization tool. At this point the software is in Beta-version and can be accessed at www.anatomagcloud.com. You, as the generating office, will need to upload the images to the AnatomageCloud database and use this application to allow the second office to access the specific patient images. The access is granted with a link embedded in an email. After receiving authorization to access the images, the second office will be able to access the images online without the need of downloading them or installing any software.

Option 3: Dolphin Imaging software offers a complimentary viewer, https://www.dolphinusers.com/dolphin-imaging-viewer/. The receiving doctor can view 3D images by downloading and installing the Dolphin Imaging Viewer software. Files are transferred in DAZ file format. This file format is proprietary to Dolphin Imaging, and the files are created by the originating doctor through Dolphin Imaging 3D Software. This option 3 would work also in Case Scenario 1, when both doctors use Dolphin Imaging 3D software, but it is important to note that only the unprocessed images need to be transferred, such as the DICOM file; the viewer is part of the software downloaded by the receiving office.

Images acquired by other offices:

Images that you receive from other offices should be requested in DICOM format. This will permit you to be able to import these into your 3D software. If you obtain the file in a different format than DICOM (that often includes the viewer), the analysis and measurement possibilities are limited; this is because your 3D software most likely includes all the features that you may need while visualizing and measuring 3D Images. If both offices use Dolphin Imaging 3D Software, a proprietary format DAZ can be used to transfer and share images. The advantage of this approach is that all patient images, including both 3D and 2D images, are shared simultaneously.

In summary, with Cone Beam CT becoming more popular in practices, sharing 3D images with other treating doctors or practices requires some additional steps. The first step is to initiate the conversation with the second office to establish the best system to use to share images. The advantages of 3D images over traditional 2D images are beyond the scope of this blog, but once you become accustomed to a transfer and visualization system, the collaboration between doctors and patient care may improve.

Am I legally responsible if I receive a patient referral from another dentist and it is sent to me unsecured?

By: Charlie Frayer, JD, MS, HCISPP, CIPP, CIPM

DISCLAIMER: Protected Trust cannot and does not provide legal advice, and the following question(s) and response(s)—like everything else we publish—are not intended as legal advice or opinion. If you need legal assistance, you should contact an attorney licensed to practice law in your jurisdiction.

For the purpose of this answer, we assume that “sent” means “emailed.” Yes, it is possible that you could be responsible if something bad happens to the patient’s electronic protected health information (ePHI) contained in the email referral, but only if it happens after you receive it.

Under HIPAA, a health care provider is called a “covered entity”. The HIPAA Privacy Rule defines “treatment” to include, “…the referral of a patient for health care from one health care provider to another.” The Privacy Rule also states that, “A covered entity is permitted to use or disclose protected health information…[f]or treatment…”. Therefore, under the scenario you describe, neither the referring dentist nor you are violating HIPAA by merely sending (disclosing) or receiving a patient’s ePHI as part of a referral. Given this good news, the core question now becomes, “Does a covered entity violate HIPAA by sending (or receiving) ePHI in an “unsecured” manner?” Again, the answer is mostly good news, but BE VERY CAREFUL AND READ THE REST OF THIS RESPONSE!!!

First, we have to know what makes ePHI “unsecured” vs. “secured”. Then, we need to know whether HIPAA requires ePHI to be secured (seems like a silly question, but you’ll probably be surprised). And, lastly, if HIPAA does not require ePHI to be secured, then what risks do you have if you face by choosing to leave it unsecured?

Unsecured vs. Secured ePHI
The HIPAA Breach Notification Rule states that, “Unsecured protected health information means protected health information that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of a technology or methodology specified by the Secretary [of HHS] in the guidance issued…”. The HHS guidance emphasizes the use of encryption to make ePHI secure. So, technical details aside, the simple answer is that “unsecured” means unencrypted, and “secured” means encrypted.

HIPAA: Encryption Is NOT Required…What?!?
That’s the title of one of our blog posts from Feb.-Mar. 2016—republished by AAO, which we highly recommend that you read immediately (here or here). Although you would be crazy to not use encryption when emailing ePHI—because the risks are enormous, it is true that HIPAA does not literally require encryption (again, read our blog post here or here right now). Rather, what the federal government decided to do was strongly encourage the use of encryption by making it a get-out-of-jail-free card (apologies to Parker Bros.). Under the HIPAA Breach Notification Rule, you must notify certain persons and/or entities whenever you have a breach (e.g., a loss or theft) of unsecured (unencrypted) ePHI. For example, depending on the breach details, HIPAA requires notifying not only the affected patients, but also the federal government (HHS) and prominent members of the media. But—and here’s the GREAT NEWS—if you have a breach of secured (encrypted) ePHI, you do not have to notify anyone. Why? Because the loss or theft of encrypted ePHI—which cannot be read without the key(s)—is not considered a breach at all. So, encryption=no breach=no notifications=no problems for you.

Risks of NOT Encrypting ePHI Emails
If you’ve already read the above-mentioned blog post—and, if you haven’t, stop now and do so immediately (here or here), then you already know the frightening list of risks you face for not using encryption. In summary, in the event of a breach of ePHI:

No Encryption = Notification(s)

Notification(s) = Investigations, Fines, Lawsuits, PR Disaster, and Lost Business

Investigations, Fines, Lawsuits, PR Disaster, and Lost Business = Wasted $,$$$,$$$.

Our Recommendations

Never email ePHI without using Protected Trust Healthcare Email Encryption.

Require all of your fellow covered entities (e.g., health care providers and insurers), other business associates, and patients to use Protected Trust Healthcare Email Encryption.

IMPORTANT REMINDER: As a Protected Trust client, all of these third-party persons and entities can communicate securely with you, free of charge, and forever. No catch!

To comply with HIPAA, make sure everyone in your office has their own Protected Trust Healthcare Email Encryption account (shared accounts are not permitted by HIPAA).

Improve your Communication through Screen Sharing

By Dr. Doug Depew
Acworth, GA

We all know how frustrating it can be to present your proposed treatment to one parent, while the other one is not present, hoping the first one will be able to make a decision by themselves. Typically however, that is not the case. More often we end up depending on Mom to carry home the dizzying array of information to discuss with Dad. And since she cannot regurgitate all you spent your time explaining, all Dad hears from her is the treatment fee, without hearing an explanation for the fee and all the wonderful things about you and your practice. In order to increase our success, screen sharing allows us to have one parent sitting in the room with you and the other virtually participating in the discussion.

Screen sharing software allows users to share their computer desktop with another individual through their Internet connections. When screen sharing, the other party will see what is displayed on your entire screen in real time. It’s the next best thing to meeting with someone one-on-one. Many of us have been on the receiving end of screen sharing with some of our support companies, study clubs, or for educational experiences. How about being the person to initiate it and use it to our advantage in discussing treatment?

Some screen sharing programs are totally web-based, while others may require you to download a small program. Some programs even allow you to sketch or make annotations the remote person can see. Some vendors offer screen-sharing technology either for free or they may have a cost associated with it (per-use, monthly, or annual fee for access). Any cost is usually pretty small and worth it due to some of the extra features such as the ability to record your sessions, and the high quality images and video content you can share. In either situation, you may share patient photos, digital models, patient education videos, and images of similar cases. Although the “no cost” programs may be adequate for many doctors’ needs, there may be some limitations such as:

You can only share with one other person at a time
Unable to record the sessions
Slow and jumpy video on the remote end
No ability to annotate or mark-up the screen

So how do you go about making this happen for new patients? Well, ideally we would love to have both parents attend the initial consultation appointment. Even though we might suggest such on the initial phone call, for whatever reason, it hardly ever happens. The non-attending parent is left with the main deciding factor being the fee.

Through careful scripting during the new patient phone call, confirmation phone call, and upon arriving for their initial appointment, it may be possible to have both parents actively involved in the initial consultation. With some preparation, the second parent can be at work, in front of a computer, and be ready for a call at the appointed time. Screen sharing works best if you are on the phone with the person while sharing your screen. Once the oral exam is finished, simply have Mom call Dad from her cell phone, put him on speaker, and then have him log in to your chosen screen sharing web site by giving him the necessary access code.

In doing so, you are often able to help the parents make a decision at the time of the exam, when they otherwise would not have been able to. In the case a parent is not available at the time of the exam, you can either record that portion of the appointment and make it available to them, or make an appointment to screen share at a separate time. Screen sharing potentially can save both time and money. A second appointment is not needed, there is no need to travel, and it is much more effective explaining things using visuals than to do it verbally.

Screen sharing is also quite helpful in collaborating with our colleagues such as a patient’s general dentist or other specialists. Whether it is reviewing your treatment rationale for a patient’s dentist or navigating around different views of a cone beam CT in real-time, this technology makes it much easier to explain concepts and make joint decisions.

Screen sharing can help enhance communication by sharing information that simply cannot be done just over the phone. And if a picture is worth a thousand words, a video is certainly worth a million words. Screen sharing is a cost effective and convenient way to share our findings with a parent or colleague.

As with all things technological, the number of providers is constantly changing. A simple Google search will show several you can evaluate, many with free trials. Some of the more popular that seem to have staying power are:

Join.me
Beamyourscreen.com
GotoMeeting.com
Mikogo.com

Tossing the Fax Machine and Embracing Modern Faxing

By Matthew Larson, DDS, MS

In the modern world, hearing the dial up noise of a fax machine represents a technological step back in time. However, the widespread use of faxing will likely continue for the following reasons:

Universal Acceptance: Faxing is almost universally accepted by insurance companies and dental offices, while some do not accept emails. These fax numbers are also typically easier to locate in business directories.
Security: Due to the point-to-point nature of fax protocol, attempts to intercept data will typically cause the transmission to fail. Therefore, faxing is generally considered secure and meets HIPAA requirements for electronic transfer of data.
Legally Binding: The receiving machine must properly acknowledge that a fax was successful. This means that the message can legally be considered received, which is different than most other forms of electronic communication, such as email.

These benefits mean that the capability to fax is still important in the modern orthodontic office, but it does not necessarily mean a fax machine is needed. Fax machines function well, but requires a modest initial cost ($45 to $200+) and the ongoing expense of an additional phone line (~$20/month). Although it is possible to avoid an additional line by attaching a switch to an existing voice line or using a dual ring, these methods are not as consistent as a dedicated line. This option is straightforward, but are there better modern options?

Yes! Moving from traditional faxing to IP faxing (also known as internet faxing or FoIP – Fax over Internet Protocol) offers numerous benefits and less cost! It allows an orthodontic office to remove the extra phone line, get rid of a fax machine, and still utilize all the previously mentioned benefits of faxing. The switch to IP faxing has occurred slowly because previous IP faxing protocols did not interact well with traditional fax lines. However, modern protocols (T.37 for store-and-forwarding or internet faxing, and T.38 for real-time faxing) have greatly improved reliability. Options for moving to IP faxing include purchasing software for a computer or a VoIP server, buying a FoIP/VoIP server, buying an IP fax machine, or using a 3^rd party online provider. All these options have certain advantages, but purchasing any equipment or software for the office will incur higher up-front costs and may need ongoing service.

Personally, I feel that most orthodontic offices should consider internet faxing using an online provider. This keeps startup costs low and requires no additional equipment (assuming you already have a computer and internet access). There are a large number of companies to choose between, so I would suggest looking into HIPAA-complaint companies with positive reviews that offer a good price for the volume of faxes sent by your office. Some providers even allow a small amount of online faxing for free (e.g. eFax, faxzero), but some of these accounts may be disabled after 30 days of inactivity. Our office currently maintains a plan for $3.49/month and $0.05 per minute of faxing (Faxage), and our monthly bill has never exceeded $6.00 – much less than the cost of a phone line. For a slightly higher base fee ($6.59/month), some companies offer integration with Dropbox, Outlook, and Google Drive (e.g. Ring Central). Overall, these online services typically offer the following advantages:

An online portal where all incoming and outgoing faxes are stored.
Faxing using traditional email with an attachment. (NOTE: this is sent securely from the online service, but will have the limitations of email while being emailed to the service). A receipt is emailed back when the fax is successfully sent.
The ability to directly save the file to the computer and upload into practice management software without printing, keeping the practice paperless!
Higher quality images than traditional faxes with the ability to print on any desired printer at your office.
The ability to use multiple workstations to send and receive faxes.

There are two potential downsides to consider when switching to IP faxing. First, it is very easy to create a fax number, but it may take more work to maintain a current number. Second, these services typically provide T.37 store-and-forwarding faxing – meaning they hold the fax in a queue and it may take 1-2 hours to send. If these concerns are not issues for your practice, consider looking into IP faxing to inexpensively and conveniently handle your faxing needs.

But I Thought I Was Backing Up My Stuff!

Author: Steve McEvoy, Technology Consultant

For 3 years Michelle had worried about the office backup. Each day she would bring in the oldest off-site tape from home in a special case. She would swap it for the one that backed up last night, and then carefully label it with the date and place it back in the case and carry home that night. She slept well knowing her backup was done.

I was hired to take over the network maintenance, and the first thing I did was ask about the backup. She explained her process to me and I was impressed. Standing at the server I asked “What software do you use?” A quizzical look appeared on her face, and I knew there was trouble. Two minutes of checking revealed that there was NO backup software, and EVERY tape she ever changed, labeled and took home were completely blank. She turned grey.

I have seen this story repeat many times in all sorts of variations. The result is still the same, a Practice without a backup of their precious data.

If you stop and think about it, do you have a nagging feeling about your backup? Are you 100% certain it’s working? Are you certain it contains ALL your Practices data?
Let me jump to my recommendation now: Proceed on the assumption you have NO backup until proven otherwise.

Be sure All your Data is on the Backup
You probably have most of your data in one place – usually the ‘Server’. Backup the Server and you have everything right? Not usually. Often your Practice Management database has special backup needs. Users have terrible habits of saving documents to their Desktops or My Documents folders. 2D and 3D CBCT X-ray system save their data to the PC you use to run the machine unless you adjusted it otherwise. Applications like Invisalign, OrthoCAD and Geodigm save their downloaded data to the local PC by default.

How are you supposed to know where the data is? You aren’t expected to, but you should press your IT person to find out and know for sure. Your job it to tell your person what programs you use, and ask them to specifically determine what needs to be backed up for each and how. It might take them an hour or two to figure it all out, but that will be time well spent. Push your IT person to really, really think about your data and make sure it’s all backed up.

Verify your Backup is working by doing a Routine Restore
So once you think you have it all backed up, you can’t trust the backups are working reliably. Too many times I have gone to use a backup only to find it’s corrupt or incomplete. The cure to this is to periodically test your backup by going through the process of actually restoring a few critical pieces of data each month. This tests the software, backup media, and that someone knows the steps for recovery. I’m not talking about using the ‘Verify’ function most backup software has built in, I am suggesting doing an actual restore of your data to an alternate location. I don’t usually restore all the data, but a few of the most important pieces (maybe your Practice Management database and Quickbooks data file).

Ask your IT person to do this on a routine schedule, and then show you the restored data to prove to you the system is working. It won’t take long and is well worth the trouble to know it’s working.

Monitor the Backup on a Daily Basis
Even with doing a test restore Monthly, what if the backup malfunctions the day after? You could be surprised with losing 29 days of data should a disaster strike.
Most modern backup software programs have the ability to email you a status update each day. They will tell you if they worked, were incomplete or failed. Regardless of what they tell you, it’s good information to have.

I recommend that you assign the duty of checking this email to one of your responsible staff members and make it clear that it is a VERY important job responsibility and must be reviewed each day. It will take 15 seconds on most days when things are working, and on days when it doesn’t they should be given the authority to contact the IT person to remedy the situation. Usually this is the person also tasked with carrying out the off-site backup (you have an off-site backup right?).

Conclusion
You should be worried about your backup. Without one, your Practice is at risk. Imagine what it would be like to lose all your data. Could you ever completely recover?
Assume you don’t have one and call your IT person now. I bet they find something that needs improved.