1. A P4 based Computer System as the main server My Choice : Any assembled Desktop
2. Two P3 based terminals. My choice : The Desknote from Meganet ***
3. Ethernet Hub for LAN communication. My Choice the Dlink 4/8 port hub ***
4. Windows operating system 98 upwards for LAN setup. My choice : Windows ME.
5. Dental Office Management Software. My choice : BITEIN Dental Software
6. A Digital Camera. My choice : Nikon 5400
7. Image Cataloguing Software. My choice : Smart Pix Media Manager
8. Flash Pen Drive for back up ***

I shall now analyze all the above options one by one and explain the options in detail.

The Main Server

Any assembled desktop would do for the server. There is no particular brand that is recommended for this unit. The suggestion is to buy from a source who is available locally for service. The suggested configuration should be as follows

Processor	1.8 Ghz (Celeron., Intel, AMD or Transmeta will do)
Hard Disd	40 GB or above
RAM	256 MB
CD Writer	52 X minimum
Display	15-17" CRT or a 14-15" LCD active matrix monitor
Sound Card
Speakers	Standard Stereo Speakers
Modem	56 KBPS
Networking	10Base T Ethernet

Make sure that you buy a new system or upgrade your existing one to the above configuration. The system should carry a one year on site service warranty. It should be installed with the Windows 2000 or Window ME system. One may opt for the Windows XP system only if the processor is 2.2 Ghz upwards and the RAM is 512 MB or else XP will slow down the system considerably which is avoidable.

The Terminals

The terminals can be desktop based machines or they could be laptops with an Ethernet connection. The recommended configuration is

Processor	1.0 Ghz (Celeron., Intel, AMD or Transmeta will do)
Hard Disk	20 GB or above
RAM	256 MB
CD Reader	52 X minimum
Display	15-17" CR
Sound Card
Speakers	Standard Stereo Speakers
Modem	56 KBPS
Networking	10Base T Ethernet

The recommended machine for this is the Desknote from Meganet. The Desknotes come in three configurations and the Transmeta or the Celeron configurations, are both good choices as terminals. The Desknote is a cross between a desktop and a laptop with prices very close to the Desktop machines. If space is not a constraint a desktop would also suffice and on the other hand, if economics is not a consideration, a laptop with the above configuration will also function as well. The same operating system as the main server is recommended for the same. Recommended choice is Windows ME.

The Ethernet Hub

This is a very crucial component of the hardware setup. A two machine network can function without a hub by having an Ethernet cable run from one machine to another. Then the two machines can communicate with each other and either of the machines can function as a server. In case more than one terminal has to be setup, i.e. if more than two machines are to be hooked up, then a networking hub is required. The standard hub today is a 8 port hub even though a 4 port hub would work quite as well for the conventional dental office. There are a number of companies which market Ethernet hubs. Recommended choice : Dlink 8 port hub.

The Dental Software

The primary step in creating an electronic paperless office is to obtain and train in a comprehensive patient and office management software specifically designed for the dental office in India. It has to be emphasized at this point, that what is important is an all encompassing user friendly software which carries out the basic task of managing patient database, office administration and accounts rather than patient education, or graphic inputs etc. etc.

It is perfectly fine to have and use a patient education software but this is only as an add on, rather than the primary requisite. Ideally, patient education should be distinct from the essential patient record management and office administration software. The education software can be used as a separate program on the terminal at the receptionist desk or even in an operatory to explain procedures to patients.

As mentioned earlier, more important and crucial specifically to dental practices is accurate record keeping. A computer with the appropriate dental software can help only if a system of record keeping has been instituted in the dental office. Without basic record keeping methodologies it can become very difficult to maintain even basic entry level records accurately. In India, today a number of options are available for a dental software. Any one of the dental specific packages that have been created can be purchased or a package can be custom developed. It is not recommended to try to get a custom package developed, since it is bound to require extensive time and effort from the dentist and it would also be a very expensive affair. It would be far more prudent to purchase one of the established dental software packages created for the Indian environment.

The first of the dental software developed in India was "The Dentist" by yours truly. It was a DOS based software and carried out all the text based tasks one required in a dental office. Extensive record keeping was available in a very simplistic and easy to use. Since its DOS days the software has undergone continuous evolution and now is available as Windows based software with a complete Graphic User Interface. It is an off the shelf package which takes about a five minutes to install and will function effectively even with Windows 95 on a P1 based computer system with a even a 4 GB hard disk. The software is completely intuitive and has a very short learning curve. A separate Patient Education module is thrown in with the software. Other options are the CCPL software, the Densoft program and a couple of other packages created by independent vendors in Gujrat and Mumbai.

Recommended choice is "The Dentist" available from www.bitein.com

The Local Area Network Concept

The above solution will work very fine with a single terminal dental clinic. A single terminal suffices for a single chair practice and might even do the trick for a two chair moderately staffed dental office. If the volume of work is large the office might require an additional terminal or may require terminals at each operatory. Getting the hardware necessary for each terminal has already been described. If more than two computers are to be connected a hub will be required. The software required for primary networking i.e. to make the computers communicate with each other, is known as the networking software. The recommended operating system, Window ME or Windows 2000 or upwards already has the networking system built it. This networking system should be setup by the hardware engineer who is supplying the computer systems.

All the terminals will have a special twisted pair cable which will connect from the computer to the hub. The location of the hub is actually irrelevant in the dental office environment. The hub may be placed at any location as long as a cable is able to reach it from all the terminals. Once the basic hardware has been set up and all the terminals are able to communicate with each other via this hub, it has to be decided which computer will function as the main storage area for the dental office. This computer is the one which will maintain the active data at all times.

Before explaining the setup required for the LAN, the term peer to peer networking has to be defined. Peer to peer networking is a concept in which all the terminals on any LAN system can share any of their peripheral devices with any other terminal for eg. Imagine a four terminal network consisting of T1, T2, T3 and T4 computers. T1 has a hard disk and a CD while T2 has a hard disk and a printer with no CD drive and T3 & T4 have only hard disks without printers or a CD drive. The LAN can be easily set up to The LAN can be configured to have T1 sharing its hard disk and T2 sharing its printer and T3 and T4 just accessing the additional hard disk and printer. The Peer to Peer concept makes it possible for T1 to share a hard disk and access a printer from T2 which in turn is sharing a printer but accessing a hard disk from T1. Another important aspect is the manner of sharing the devices. The hard disk on T1 has to be first set for sharing. Then the other three terminals can be set up to automatically connect to the this hard disk when the terminals are started and the hard disk of T1 becomes available to T2, T3 and T4 just as if it were attached to the computer itself. Usually a hard disk is referred to as Drive "C" in a computer. The shared hard disk can be mapped on the terminal T2 to be available as Drive "D" in case it does not already have a drive "D". In case it has drive "D" as a local drive it can map the shared hard disk as Drive "E" or "F" and so on. As for the T3 station a similar process can be set up and it can refer to the same shared hard disk of T1 as drive "D" or "E" or "F" or as the case may be depending on its individual local configuration.

Now that this concept is out of the way, attention will be placed on the LAN setup required for a dental office. The setup as available at my dental office can be easily implemented or expanded of modified simplistically following the above mentioned guidelines. This is how the set up goes

Terminal One (T1): Desktop with a regular monitor, 20 GB hard disk, CD writer, printer scanner and Smart Media card reader. The hard disk and printer on this has been shared. This has the dental software installed on it and the software stores the data on a folder in the local drive "C". This hard disk is available on the LAN for other terminals to access.

Terminal Two (T2): This is a Transmeta based Desknote computer on the receptionists desk and has a local hard disk and CD drive but no printer has been installed. The shared hard disk of T1 has been mapped on this computer as Drive "D". Hence when drive "D" is accessed on this terminal it is actually reading the data of T1. The dental software has been installed on its local hard disk but has been set up to access data of Drive "D" which actually is sharing the same data as on T1. This terminal also can print out reports using the shared printer of T1.

Terminal Three (T3): This is again a Celeron based Desknote computer at the consulting table and has the same set up as T2. This terminal also accesses the shared hard drive of T1 and has the dental software installed on its local hard disk but has been set up to access the data on Drive "C" of T1.

The Ethernet Hub: The Ethernet Hub has been placed near the receptionist counter where T1, T2 and T3 connect to it via the twisted pair Ethernet cable.

The key elements required in this setup are to first create the LAN protocols which will allow T1, T2 and T3 to talk to each other and then to map the hard disks as suggested. This will have to be done by the hardware vendor or a LAN specialist. Once this protocols, sharing and mapping is done the dental software should be individually installed on all the three terminals. On T1 it will by default access its own databases which will be created on the local hard disk. Hence T1 will be immediately up and running.

Now is the tricky part. The concept data sharing has to be understood to implement this aspect properly. The purpose of a multi terminal LAN is to be able to carry out data entry simultaneously from multiple points and physical locations while at the same time also be able to access the data, get reports etc. etc. This means that that actual data has to be stored only in a single location and be accessed by different terminals. (Please not that this is not even remotely similar to the shared keyboard and dual monitor systems that were prevalent a few years ago). In the above described scenario, the data is on Drive "C" of T1. The software is separately executing on T1, T2 and T3 but has to be set in such a way on T2 and T3 that it will access the data on T1 rather than on a local drive.

This is a very simple setting. The dental software has a provision to set up the data drive. By default it is drive "C". This can be changed to the mapped drive name. On T2 the shared hard disk has been mapped as drive "D". Hence on T2 the dental software data source should be set up as "D". That's it !!!! The same applies to T3. Once this concept is understood, the setup is a piece of cake. The actual functioning is totally transparent. Data backups has to be only made from T1.

Information Updation and Retrieval

Once a methodology has been adopted and the mechanism put into action the data available from a computerized system will start paying rich dividends. This path, is nevertheless fraught with a lot of ups and downs. It will not necessarily be smooth sailing all the way through. The following is one of the recommended patterns of data management in a dental office. The points are listed in a sequential manner and the ones mentioned in the beginning should be implemented first and then latter afterwards.

Step One: Read the complete manual on the software. Make your receptionist, office manager and all others who will be working on the computer.

Step Two: Start creating a proper record for each patient who takes treatment in the dental office. This is known as patient registration. Implement the patient registration with all details of each patient as each new record is created. In case a computer system is being put into an existing office with paper records, start updating the back log but at the same time register all new patients directly. Do not wait till the entire back log has been updated on the system.

Step Three: Start keying in the work done entry for each visit of each patient. This entry should be a detailed entry. Start only with the basic information of work done.

Step Four: One month down the line start checking if all the data has been correctly entered on a daily basis. This is called an authentication system. A sheet of paper listing all the necessary procedures for data entry should be drawn up and multiple copies made. This sheet should be ticked for all items everyday to confirm proper record keeping. An example of this is presented as an appendix

Step Five: Once a regular data entry schedule has been established and set, start making very detailed entries in each field on the Patient master and Work done input screens. Start checking the various reports and analysis data which is generated from the program.

Step Six : Start generating all the bills from the software and also print all prescriptions from the dental software.

Step Seven: The next step is to incorporate complete accounts management into the software. This will require updating the bank books, cash voucher entries, expense payments etc. etc. It is recommended to take advise from the associated C.A. to start maintaining financial accounts.

Step Eight: Start considering including digital photographs in the scheme of things. Consider acquiring an RVG system and not just store the pictures and radiographs, but also classify them for searches.

Step Nine: Make regular back ups of all the data that has been stored digitally.

The Digital Camera

As the above mentioned concepts are implemented and put into action, the dental office will become almost dependant on the software system for day to day functioning. At this point it is a good idea to incorporate digital photography into your practice. Digital cameras are a class apart from Intra oral cameras and it is important that these two are understood to be different. This article does not delve into the intricacies of digital cameras and the technology. If interested, a entire concept and an evaluation of available digital cameras has been presented in a two part article which has appeared in the Journal of the Indian Academy of Aesthetic & Cosmetic Dentistry. The rest of the concept in this section assumes the availability of the suggested Olympus 4000/4040 or the Nikon 4500/5400 or the Canon G2/G3 or the Fuji camera.

Making photographs with any of the above mentioned digital cameras is not too difficult. Taking the proper angles, the appropriate frames and photographs is also a part of learning photography. The focus here is how to manage and maintain the digital photographs made with a digital camera. Any digital camera will capture each photograph as a digital file and store it on a removable media within the camera. This media will be either a smart media card or a flash card or a similar device. The number of files on the media card will determine the number of photographs taken.. This removable media has a certain capacity which is dependant on the size of each file, which in turn depends on the resolution at which the picture is being taken.

The digital cameras suitable for dental photography will have a minimum resolution of 640 x 480 and theses size images make very good pictures on a digital presentation and even as hardcopy postcard size prints. If a greater resolution is desired the next level of setting can be used i.e. 1024 x 768. As the resolution setting of the digital pictures is increased, the image size increases considerably and manipulating the image takes the little extra time which can be annoying. The size difference is not so critical if a few images are being managed, but when the number runs into thousands then it starts affecting the performance of the systems. The maximum recommended image resolution is 1024 x 768. A still higher resolution may be set very occasionally if a picture is being made specifically for being enlarged or put on a brochure or print media..

These pictures, have to be stored on the computer system once the removable media of the camera fills up. This should follow a certain method and a system. One very good method to adopt is to create a unique folder for storing all the digital photographs. This folder can be named as "Digital Photographs" or "Digital Pictures" or any such name. A small tip, if your main server hard disk has been divided into Drive C and Drive D, create this folder on Drive "D" and leave the space on Drive "C" for program installations. Once hooked onto making digital pictures, they rapidly multiply and soon start chewing a lot of real estate on the hard disk.

More on the the "Digital Photographs" folder. Storing all the pictures in a single folder makes maintenance of the files and accessing them very amenable and simplistic. Under this folder a sub folder has to be created for each patient using the name of the patient. A consistent protocol for patient names should be followed. The most logical protocol is to use the family name followed by the first name. At times if a duplicate crops up, the initial of the middle name or the entire middle name can be used as part of the folder. An example is "Kakar Ajay". This would be the folder for storing all photographs made for Ajay Kakar. Another subfolder "Pillai Laxmi" would have all photographs of Laxmi Pillai. Each digital photograph will also have a name. This name is auto generated based on the date by the digital camera and keeps on sequentially increasing (the camera should be set for this auto name generation). There is no upper limit as to the number of sub folders that can be created nor is there any limit on the number of digital photograph files that can be stored in any particular sub folder.

In realistic terms, if the number of sub folders are more then 400 the performance becomes a bit sluggish and locating a specific folder of a patient can take a bit of time. When the number of patients start crossing 500 it is a good time to split the main folder into two sub folders. The first subfolder would contain all patients with names from A-N and the balance from O-Z. The same principal can be applied when each of these subfolders have more then 500 subfolders each. This kind of scenario can be applied as the database keeps on growing.

Dental practices in India after a tenure of over 20 years would generally have an active database of about 6000 patients and this is very much manageable with the above suggested schematic. Each patient sub folder will store all digital photographs for that particular patient. This kind of storage schematic makes digital file management and storage a very simple task. Viewing these pictures and analyzing and maybe modifying them is a task that should be done with a good image management software which has been discussed in the next section.

Image Management Software

Digital photographs, once taken, should be easily retrievable and available as and when wanted. This requires storing and maintaining the files in a convenient and reliable fashion. There are two options available for digital image management. You could very well use the basic dental software and its image cataloguing features. On the other hand, a far more powerful and sophisticated image management software is available which is very well suited for a dental office. Recommended Software : Smart Pix Media Manager

Irrespective of the system used, the photographic data should be stored with a protocol in mind. This has been discussed at length in the previous section. Storing the data in the above mentioned manner will make the digital files available for display from the BITEIN Dental software and will also be available for extensive cataloguing from the Smart Pix Media Manager. Details of how the files can be displayed and printed from the regular software can be obtained by using the software itself or else by reading the manual for the same.,

The recommended Smart Pix Media Manager can be obtained by downloading the software at a very nominal charge from www.xequte.com This software not allows direct viewing of the digital files arranged by patient but will also allow classification and categorization of each file by a number of keywords. There is no limit on the keywords that can be created and also no limit on the number of keywords that can be assigned to any file. If a comprehensive keyword allocation is done for all the digital images, sorting of the image via this database of keywords can be done to obtain absolutely fascinating results. This is an invaluable tool when the number of files grow very large in number.

Smart Pix can almost instantly sort picture files by any single keyword or a group of keywords for eg. in case all pictures of caries have to be seen, the keyword can be selected and instead of showing pictures of a particular patient, the software will display all photographs which have been assigned the keyword "Caries". Multiple keywords can be allotted any photograph. Hence the display can be further narrowed by selecting "Caries" and "Maxillary". This would display only photographs with both the keywords assigned. Selections can also be done by for any one of multiple keywords. The permutations and combinations are multifold.

In addition to the above, Smart Pix can also carry out limited image editing and modifications. The editor is very nifty and simple to use with almost a non existent learning curve. This editing far more surpasses all requirements a dentist would have to edit or modify any digital image.

A small mention about the much flaunted direct image management of dental pictures for patient motivation. A number of software programs are marketed along with intra oral cameras which are supposed to have features to allow the dentist to carry out mock treatment on the computer and project a post op situation to the patient. These options should be viewed with some caution. Any mock modification on a digital photograph to demonstrate possible outcomes of treatment requires a lot of effort, expertise and time. There is no automatic method of effecting changes on a digital image of any particular dental procedure. Diastema closures, Crown lengthening, tooth whitening can be demonstrated with image manipulation but the end results are not easy to arrive at and may not always be exactly correct and are not generally possible in all views. In fact, all the image manipulation options of such software packages are available in a far more powerful and extensive set in any conventional general purpose image editing software.

Digital Radiographs

Digital radiography is the next successive move towards digital management of dental information. An RVG is a great utility and enhancement in the dental office. A RVG sensor not only reduces the radiation exposures but also bring a consistency in the quality of radiographs being made. The problems of lower resolutions and interpolation of the previous generation digital radiography sensors have more or less been resolved with the modern day sensor. When selecting an RVG system, the resolution should be confirmed and the true lines per mm should be confirmed. The second issue is managing the digital radiographs. All RVG systems will come with bundled software to display and interpret the radiographs. As mentioned earlier, most of the options on any of the RVG software are generally available on any general purpose image management software and will invariably be far more powerful.

The digital radiographs can be catalogued and restored via the specific RVG software or optionally managed in the same manner as the digital photographs are managed. All the radiographs can be easily stored in a folder called "Digital Radiographs" and a separate folder created for each patient. A replica of the imaging system can be thus created. The Smart Pix Media manager can do as good a job as any other software.

Data Backups

The overwhelming advantages of storing data electronically also comes with similar high risk management issues. The chances of losing all electronic data in a couple of strokes is very high. This same huge amount of data, which can be manipulated, modified and retrieved with such great ease can also be totally wiped out with a little bit of carelessness or due to inherent hardware damages to a computer or software viruses.

To combat these problems, data backups of all necessary data is a must and should be a part and parcel of computer usage. There are a number of backup systems and methods available. Choosing any single reliable system is good enough for the dental office. Any back system requires a media on which a copy of the electronic data has to be made. The size of the data to be backed up determines the media on which the back up should be made. Available back up media with current technology are Zip Drives, Compact Discs, Secondary Hard Disks and Flash Drives. Floppy disks have not been included in this list, as they are no longer a reliable means for data backups and should be desisted from. A dental office will need to back up three levels of data.

Level One is the basic patient records, administrative records, accounts etc. etc. This level of data only refers to basic text data without any images. This data even after being maintained for a large number of years is generally not extremely large. Even if the data files grow in size, they can be easily compressed with routinely available software. After compression the size becomes extremely small and can be backed up. In case compressed data has to be restored it is a very simple task to do so. Level One data can generally be backed up on a Zip disk which routinely is available in a 100 MB data size at least. A flash drive is another media on which data can be backed up almost instantaneously.

Level Two is the basic text data plus digital photographs. Digital photographs occupy a large amount of data even in the lowest resolution.. If a resolution of 1024 x 768 has been set, the data size grows substantially. If digital files are being stored, then a CD is a good media to maintain backups. A single CD can store upto 7000 to 8000 digital images and all the text data of over 15 years of information.

Lever Three data is the basic textual dental data, the digital images and radiographs and other information like E-mails, Word processed documents, presentation files and any other data generated from the web. If entire Level three data has to be maintained then the backup would have to be made on multiple CD's or multiple media like a Flash Drive for the text data and a CD for the images and another CD for the rest of the data. Optionally all the data can be copied on a parallel hard disk which is being maintained as a back up media, on one of the terminals if a LAN system is available.

Backup Protocols: There is a schematic known as the Mon-Wed-Fri protocol. Always keep three sets of back up media - This means that if you a making a back up on a rewritable CD, please have three to four CD's and use then one by one in turn. It would be a good idea to mark the CD's as Mon,Tue,Wed. The CD's can be repeated on Thu, Fri and Sat. CD 1 should be used on Mon and Thur. CD 2 on Tue and Fri. CD 3 on Wed and Sat. A fourth CD would serve just as a weekly back up CD.

It is possible at times to corrupt the data in the records and not realize that it has been corrupted for a couple of days. In such a scenario, it might so happen that the corrupted data is being backed up. Hence the original as well as the backed up data would be of no use. By following the protocol suggested, there is a built in safety factor of the previous day data being safe and even one day prior to that. As additional precaution a weekly back up CD is always available. Please note that instead of a CD, a zip drive or a pen drive could be as easily used.

I have created the above described solution not just as an article appearing in a dental journal or a website, but rather from personal experience. The scenario solution can be seen for real life at my own private practice. It has now been in function for over 10 years and records are available from 1989 onwards for every visit to the office by every patient since then. The system also has over 6000 catalogued digital photographs.