JADA Continuing Education
Designing your office for technology
MICHAEL UNTHANK, D.D.S.
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ABSTRACT
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Background. To practice efficiently, dentists need to consider the successful integration of technologies, which can benefit their practice of dentistry. The physical environment of the office must be developed to accommodate not only the appropriate placement of computer hardware and high-tech dental devices, but their interconnectivity, as well.
Conclusion. Dentists need to make appropriate decisions regarding the types of technology they choose to integrate into their offices, and they need to understand how the technology will be installed and integrated. An office designed to optimize the use of technology will produce ongoing benefits for dentists, their staff members and their patients throughout the lives of their practices.
Practice Implications. A dentist’s practice must be planned to accommodate networks of systems hidden below floors, above ceilings and within walls, as well as to support and connect diverse technology items throughout the office.
Technology in the dental practice can have an immediate and positive impact when it is integrated successfully. To appropriately incorporate technology, dentists need to give attention not only to the positioning of the various hardware components and dental devices but, just as importantly, their interconnectivity. Dentists need to plan their offices so that the wires and cables that tie together the various technology components can be distributed easily throughout the facilities.
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INFRASTRUCTURE AND ACCESS
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With various technologies requiring integration throughout the dental office, access for purposes of wiring and systems distribution is of paramount importance. While wireless technology eventually will replace wired data communications within the office, potential interference from other devices that use radio frequencies continues to plague the currently evolving wireless standard. Industry standard category 5e or 6 Ethernet cable should be used to ensure secure data transmissions between the office terminals and the network server.
An office designed to optimize the use of technology will produce ongoing benefits.
In addition to office network cabling, other office systems such as telephones; background sound; cable or satellite television wiring; electrical conduit; plumbing supply and medical gas piping; and heating, ventilating and air conditioning ductwork require distribution throughout the office. Horizontal and vertical "raceways"—spaces dedicated to providing access from one point to another—are necessary to accommodate the installation and maintenance of these systems. In architectural terminology, this grouping of raceways is referred to as "interstitial space," as it is similar to the space between cells in the body. In the case of the dental office, however, it is between structures of the building. Such spaces may occur below the floor, above the ceiling or within the walls. These spaces routinely are incorporated in the shell of commercial office suites.
The only systems that must be delivered from below the floor are plumbing waste lines, which are gravity-driven, and anything that connects to the patient chair, as the chair is an "island" in the treatment room or bay. The dental vacuum system can be distributed above the ceiling, though, owing to gravity, a check valve failure could prove to be messy.
If a horizontal space is not available below the floor of an office suite (as in a single-story, slab-on-grade building) to accommodate office network cabling and other office systems, a horizontal space must be planned above the ceiling and below the attic, as opposed to in the attic. This is a clean and conditioned space that is unencumbered by insulation and always is at room temperature (Figure 1
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Once horizontal access is established, vertical access for any low-voltage wiring to a wall location is ensured via plastic pipe in the wall’s stud spaces. As mentioned previously, special consideration must be given to the patient chair. An access raceway must be provided below the floor to avoid potential interferences on the floor surface caused by wiring or cabling required for any chair-mounted technology, pneumatic tubing (if using any other than for a chair-mounted delivery unit) or foot controls for nonchair-mounted devices (Figure 2). A plastic pipe of adequate diameter that extends under the floor from the appropriate nearby wall or delivery unit to the chair base can serve this purpose. Electrical service for the patient chair is run separately in conventional electrical conduit below the floor.
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BUSINESS AREA DESIGN
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The business areas consist of the reception, financial arrangement and consultation workstation areas. Business area computer workstations generally are used for longer continuous periods than are workstations located in the treatment areas. Ergonomics—the interaction of the human body with the built environment—merits substantial consideration when configuring the business area workstations.1 Flexibility of body positioning at the workstation requires variability in the location of the technology components. Tailoring the keyboard and mouse placement for each user can be achieved by having an articulating arm, which can be adjusted for height, extension and tilt (Figure 3). This articulation allows the keyboard to tilt down and away from the user, resulting in a more relaxed wrist position. Gel-filled wrist rests provide additional comfort and support.
Flat-panel monitors have an advantage over older, substantially larger and heavier cathode ray tube, or CRT, monitors because they are easier to place and position at the appropriate viewing focal length of 24 to 27 inches. As most business area desks or work counters are approximately 30 inches in depth from front to back, CRT monitors, which are much deeper than a flat-panel monitor, often cannot be placed far enough away from the person using it to achieve this focal length. The thinner depth of flat-panel monitors compared with CRT monitors also creates more available work surface. Positive patient perception is an added benefit of flat panels. Regardless of the high-tech dental devices you may have in the treatment area, flat-panel monitors at the front desk can convey a high-tech image to your patients.
For convenience, the business area is a logical location to place the network server and associated hardware—patch panel, switch, router and so forth. For accessibility purposes, these items may be "rack-mounted" along with any electronic components used for distribution of other systems within the office. For example, the sources for background sound, video and patient education systems and television can be placed in a "technology closet" to facilitate your access to their wiring connections (Figure 4). Having a temperature-controlled and relatively dust-free environment for the technology components is important, as dust not only interferes with moving parts but also creates an insulation layer that leads to buildup in electronic components. This technology closet should be of adequate size to allow for access to the various hardware components and their connections.
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Figure 4. A "technology closet" houses the network server and associated hardware, the sources for background sound and video, patient education systems and television, while allowing easy access to their wiring connections.
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In situations in which the computer monitor needs to be shared by more than one person at a time (such as in the financial arrangement area or the case presentation room), the work surface should be configured to reflect this use. The architectural axiom "form follows function" suggests that a conventional round table located in the middle of the case presentation room may not be the most appropriate solution. So that multiple people can view the monitor simultaneously, a "peninsula-type" conference table is advantageous (Figure 5). It allows the relevant office team members, the patient and anyone accompanying the patient to gather around the curved end of the table in a "conversational arrangement" and to view the monitor easily. This type of table also accommodates the wiring connections between the central processing unit, or CPU; monitor; keyboard; mouse; and any adjacent printers better than a round table placed as an island in the middle of a case presentation room.
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Figure 5. A peninsula-type conference table allows the monitor to be viewed by all participants and accommodates the wiring connections between the central processing unit, monitor, keyboard, mouse and any adjacent printers.
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ESTABLISHING THE TREATMENT SPACE FRAMEWORK
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The integration of technology in the treatment space first requires an understanding of the appropriate positioning of the dental personnel.2 A right-handed dentist most often is positioned in the 10 to 11 o’clock position (the top of the patient’s head being at the 12 o’clock position relative to the oral cavity). To allow for an unobstructed view of the patient’s oral cavity, the assistant should be seated with his or her eye level approximately 6 inches higher than the dentist’s. The assistant’s thighs should be parallel to the patient’s adjacent upper arm, and the assistant’s hips should be approximately adjacent to the patient’s shoulder. This allows the assistant to see over the dentist’s indirect-vision hand or cheek-retracting hand, while maintaining proper posture. When the assistant is in this position, the primary area for instrument delivery to the dentist’s finger rest is from a surface located directly in front of and slightly overlapping the assistant’s knees. This surface also is the most convenient location for the assistant’s three-way syringes and high- and low-volume evacuation tips.
Cabinetry in the general area behind the patient is convenient for delivering ancillary pieces of equipment for treatment use. It also is a good area to place a headlamp light source, as the wiring can be delivered directly to the back of the headlamp on the dentist’s head. An intraoral video docking station can be accessed conveniently from this area, as well as any devices that require compressed air, water or suction. These utilities already are present in this location to serve the assistant’s three-way syringes and evacuation tips. If the dentist chooses to use flexible rear delivery, his or her handpieces, three-way syringes, intraoral cameras and so forth are delivered from this area as well (Figure 6).
Cabinetry at the head-of-the-room end (on either the assistant’s or the dentist’s side of the treatment room) is convenient for delivery of devices or equipment used in the oral cavity (Figure 7). Electrical outlets can be provided in these cabinets.
The lanes of circulation along the side of the patient’s chair allow access for mobile dental technology, such as a laser or chairside porcelain restoration design device, which may be too costly to have in each treatment room (Figure 8).
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Figure 8. Unencumbered circulation space allows access for mobile technology. Photo courtesy of Dentrix Dental Systems, a Henry Schein Company (American Fork, Utah).
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PRIMARY CLINICAL WORKSTATIONS
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As I described previously, when the assistant is positioned properly, he or she faces the patient’s oral cavity and the area behind the patient. A clinical workstation monitor positioned behind the patient is in the assistant’s direct line of sight. If this monitor is attached to a flexible arm, which allows the monitor to move up and down, swivel and extend toward the head of the patient chair, it also serves the dentist and the dental hygienist (Figure 9). The location of this clinical workstation is convenient for viewing digital radiographs, entering treatment notes and dictating "voice recognition" periodontal charting, as well as referring to additional private information that should be shielded from view by people outside the treatment room.
The central processing unit’s, or CPU’s, powering clinical workstations can be located in the same general area as the monitors or more remotely. All CPUs, as well as servers, need to be ventilated adequately to prevent overheating and failure. For flexible placement of data input devices, an infrared or radio frequency wireless mouse and keyboard can be used along with receivers remotely located from the CPU.
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PATIENT VIEWING MONITORS
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The critical factor in the location of the patient’s monitor is the patient’s viewing angle. Monitors attached to the patient chair generally are too low for patients to see when they are reclined, as are monitors on the wall at the foot of the chair. Treatment room side wall locations either are blocked by the assistant or are too far to the dentist’s side of the room, which encourages the patient to turn his or her head to a less-than-ideal treatment position.
When determining the optimum placement for the patient’s monitor, consider the patient’s orientation and any obstacles interfering with his or her view. Obviously, the patient generally faces the foot-of-the-chair area when seated upright. What is not so obvious is that when the patient is reclined, owing to the natural angle of declination of the eyes, he or she generally is looking at or through a region directly over his or her midcalf area, which is approximately 7 feet above the floor. This area is suited ideally for placement of a monitor to be viewed by the patient when in any treatment position.
During treatment when the dentist and the assistant are positioned as described previously, the assistant partially blocks or constricts the patient’s viewing area, as do oral cavity lights and, occasionally, the dentist’s head. As a result, the only view available to the patient in any chair position is approximately 2 feet to the dentist’s side of the long axis of the patient chair and 7 feet above the floor. Placing the patient’s monitor in this position not only allows it to be used for patient education when the patient is seated upright, but also for entertainment during treatment (Figure 10).
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Figure 10. The patient monitor is viewable from any patient position. Image of Dentrix reproduced with permission of Dentrix Dental Systems, a Henry Schein Company (American Fork, Utah).
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Multimedia monitors are well-suited for use by the patient in the treatment setting. They allow for various input sources through industry-standard video jacks, S-video and computer monitor cables and, in the case of a multimedia monitor with a built-in television tuner, cable or satellite television. A remote control is provided with these monitors to switch between input sources such as digital radiography via the computer monitor cable, patient education videos, office-provided movies or television programming. This is a technology that becomes a marketing tool and a positive office experience about which patients may tell others.
Video goggles have the advantage of always providing a video image in the patient’s direct view. Their use, however, can interfere with assessing the patient’s comfort status by monitoring his or her brow. If the dentist or staff members bump the video goggles, the image provided by the video goggles will be jostled significantly, which can be disruptive to the patient. With all technology, it is wise to try before you buy.
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TREATMENT SUPPORTIVE TECHNOLOGY ALCOVE
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Depending on the technologies used in the office, it may be advantageous to have a "technology alcove" near the treatment area. This area may consist of a stand-up counter-type workstation for scheduling an appointment for a patient (if the dentist needs to vacate a treatment room quickly so it can be readied for a waiting patient) or for simply accessing patient information. If it is near the digital panoramic radiographic or cephalometric machine, this alcove could provide the computer terminal necessary to ensure that the radiographs are entered in the correct "paperless" patient record. This alcove could be used as the image management workstation for digital photography, imaging and any radiographic tracings. It also can be a convenient location for printers to be used in conjunction with treatment, as opposed to a more remote location such as the front desk or the business area.
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CONCLUSION
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It has been said that "change is inevitable; suffering is optional." It is hard to imagine change more rapid than that in the field of technology. A facility designed to optimize the use of technology will allow the office team to avoid suffering that can result from using outdated systems.
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FOOTNOTES
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Dr. Unthank is a registered professional architect and the owner, Unthank Design Group, 5930 VanDervoort Drive, Lincoln, Neb. 68516, e-mail "mike{at}unthank.com". Address reprint requests to Dr. Unthank.
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REFERENCES
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- Ergoweb: resource center. Available at: "www.ergoweb.com/resources/index.cfm". Accessed July 8, 2004.
- Unthank M. Design for treatment. JADA 1999;130:1583–5.[Abstract/Free Full Text]
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C. M. LEVATO
Putting technology in place successfully
J Am Dent Assoc,
October 1, 2004;
135(suppl_1):
30S - 37S.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INFRASTRUCTURE AND ACCESS
