Digital Dentistry Data
Unlocking the Power of Open Architecture
Martin Jablow, DMD
Closed systems with proprietary image formats may have been an advantage early in the computerization of dental records, but they are often a hindrance to efficiency in 2019, locking practices into their imaging ecosystems. Dental office data and cloud-based services built on an open standard would be an advantage to the industry as a whole. Clinicians should be able to use their data with the best software that is available to them, and open systems allow dental offices to access their own data on any system. Interoperability is key to the future of dental software and hardware.
The sharing of dental records and radiographs has always been a challenge. Prior to the advent of digital technologies, collecting, organizing, and sharing patient radiographs was a labor-intensive task. Although digital patient records have made it easier to share clinical data, the lack of file standards (with the exception of those for cone-beam computed tomography [CBCT]) has impeded collaboration among clinicians. In addition, this lack of a standard file structure and format for clinical imaging has slowed the development of software products that would be beneficial to all of dentistry.
Open systems have been shown to encourage a more competitive market and drive innovation. They put pressure on products to compete by developing features, which greatly increases the available options. Furthermore, an open system approach obliges software vendors to provide exceptional customer service because dental practices have the ability to more easily switch systems.
For example, look at the reminder/web reputation software market. The ability to interface the various practice management software databases has resulted in the addition of more companies to the space as well as lower costs and better feature sets. However, the 2-dimensional imaging market is still mostly represented by established companies that innovate slowly and restrict access in many cases.
Recently, I was faced with the task of merging two dental practices. Even though both offices were using the same practice management software, merging the databases was far from a simple task. It required countless hours of planning, and even then, we were not able to integrate all of the information that was necessary to be up and running on day one. This frustrating experience required many hours to rectify and continued to create issues 6 months later. Imagine how many additional problems we would have encountered if the two offices were utilizing completely different practice management software systems.
The Medical Standard
The exchange of radiographs between dental practices is another critical issue. Many offices are not adept at properly sharing 2D radiographs. Sometimes, they only provide a JPEG image of the radiograph or a less-than-diagnostic-quality copy printed from a standard laser printer, which then needs to be scanned into the other office's imaging software. At this point in the development of dental technology, the industry should be able to use a standard format to transfer information seamlessly within a secure environment.
Digital Imaging and Communications in Medicine (DICOM) is the open radiography standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. When dental offices use the DICOM format, any radiograph file can be viewed or enhanced in any other practice using whatever software they choose. Converting the file to a JPEG is no longer necessary; instead, practices can just securely send the file via an email system that is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security rules. The file can then be incorporated into the patient's digital imaging chart, where all of the data can be read at full resolution and the ability to enhance the image is retained.
Although some imaging software programs include optional DICOM support, the fact that so few dental offices are actually using these programs can make it appear that the benefits are not worth the associated cost. This is slowly changing because more offices are moving to solutions that utilize the DICOM image format, such as CBCT. Practices that are currently looking to purchase or upgrade their imaging software should consider adopting the DICOM format.
Hardware may also be locked into a closed system. Plugging a 2D sensor into a universal serial bus (USB) port should prompt the imaging software to recognize it and load the appropriate drivers, simplifying the process and reducing information technology (IT) costs. However, this does not always occur, as closed systems continue to promote their own products for easy integration. Work-arounds, such as using TWAIN interfaces and drivers, can facilitate successful integration but with increased complexity and a less user-friendly workflow. When considering imaging software, practices should plan for the future integration of new hardware. The best imaging sensor today may not be the most viable in a few years.
Digital impression and CAD/CAM systems were initially developed as closed systems, which allowed for the technologies to mature and made it easier for dentists to provide in-office restorations. However, the marketplace has called for the ability to integrate these data with other software and hardware systems outside of the closed environment. Over time, many manufacturers of these closed systems responded by generating open file structures. The ability to produce stereolithography (STL) or polygon (PLY) files provides dentists with the freedom to choose any laboratory or milling machine. This does not prevent practices from continuing to work within a closed system; it simply allows them more options to move to another manufacturer. It should be noted that this ability is not always absolute because corporate policies that restrict file sharing with certain entities can limit these options.
In addition, practices that use a portal to transfer files to the laboratory are, in a sense, still part of a closed system. Portals can make transferring files an easy task, but if a laboratory does not pay the fees to participate, the practice may have to transfer the files directly to them.
The Data Factor
Although digital impression and CAD/CAM systems have made the leap to an open architecture in a shorter period, digital radiography and practice management software systems still languish in their proprietary file formats, locking dental practices into both hardware and software choices.
One reason for this delay in transitioning to open systems is the complexity of demographic and patient data. Data is extremely important to technology manufacturers because user demographics and clinical data can be used to advance innovations across the industry. Companies are building huge data sets for future use, and this has the potential for both positive results and negative consequences. These data sets can help drive innovation, such as with the implementation of artificial intelligence. They can also be de-identified and sold for various research projects. In many cases, dental practices are helping companies build data sets while remaining unaware of how the data will be used, both directly and indirectly.
A Turning Point in Integration
A cloud-based program is a software application running on a remote data center server that is accessed via the internet. In this manner, the application is available to any smart device or computer for users to log in to access their data and applications. A large part of the population is already using the cloud on a daily basis to receive email, make purchases, or stream entertainment, accessing all of the data via remote servers.
So, how can the cloud positively impact a dental practice? Cloud-based practice management and imaging technologies provide powerful computation in remote data centers that far surpasses that of the less powerful computers in the office. Multiple staff members can access the information both simultaneously and from different locations, making it valuable for practices with multiple locations. The information is available anytime from anywhere in the world.
In terms of security, cloud-based systems offer inherent off-site backup and the latest in security protocols. Because the data is stored in a state-of-the-art data center, it is always backed up and can be easily retrieved in instances when a computer fails. This is why many offices use the cloud or another off-site location for storage as part of their data protection policies. Cloud technologies can provide HIPAA compliance, alleviate security concerns along with data management and monitoring activities, and further reduce IT costs.
New cloud-based practice management companies are entering the market that offer integration with some of the new cloud-based imaging software systems developed by third-party manufacturers. This arrangement allows for easier access to management and clinical information and drives workflow efficiencies in diagnosis and treatment planning that facilitate better outcomes. The fact that there are cloud-based imaging companies utilizing the DICOM standard further encourages flexibility and freedom in the market. Again, DICOM allows practitioners to share clinical data with any DICOM-compatible system, which makes collaborative dentistry more efficient.
An integrated open-architecture approach using the cloud should be the core of all technology for connecting dental applications and data sources. Data regarding practice management, diagnostics, and scans should all coordinate seamlessly. Implicit in this proposal is that the cloud remains open and vendor neutral. Dentists should not be beholden to any company for the ability to access and use their data in the manner that they see fit.
No business can afford to be locked into a vendor for digital integration, which is why an open cloud is so vital. Practices should be able to use any hardware, sensor, CBCT machine, or mobile device data; store it where they want; and access it with all of the current tools at their disposal. This is a critical paradigm as we continue down the path of merging data sets (eg, CBCT DICOM files with intraoral scanning STL and PLY files). The future of this integration is inexorably tied to the future of dentistry.
The Goal of Integration
What does all of this ultimately mean? Through the use of open formats and standards, the dental office should be able to integrate hardware and software much more efficiently, and better data integration will drive enhanced dental diagnostics and treatment planning.
In an ideal example in which a new patient is transferring patient and clinical data from another provider, industry-standard file formats and open-architecture systems would allow a simple import into the new practice's management and imaging software systems. After a quick import of the patient's dental and medical history, the practitioner would be able to determine when previous restorations were placed and review the chart notes associated with the procedures without the need for IT staff to be involved.
Intraoral and extraoral photographs, 2D and 3D radiographs, and caries detection images could be imported into the imaging software and then accessed over time to ascertain advancing pathoses. With this level of interoperability, the complete patient history can efficiently be made available to any clinician involved in the treatment. No more wondering what procedures were performed, what type of implant was placed, or what shade was selected for the crown or denture teeth. All of the information from the lifetime of the patient can be made available to the current dental practitioner almost immediately.
As dental software systems continue to evolve, the ability to transform and manipulate patient data will evolve with them. More and more dental companies will start utilizing open-architecture designs in their practice management and imaging software products, and this transformation will benefit the entire dental community. New products that are developed will compete based on their value rather than their place in proprietary systems, which will bring cost savings and better products to the dental marketplace.
In today's digital dental office and, more specifically, in this era of cloud computing, it's all about driving technology-enabled change to create a more efficient working environment. Integrated platforms are becoming more valuable, and open architecture is key.