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The
Technological Base to Clinical Practice:
Management
& Marketing
A
Primer
David
B. Adams, Ph.D., ABPP, F.A.Clin.P.
Dr. Adams is a Fellow of the American Psychological Association, Fellow
of the Academy of Psychosomatic Medicine, Fellow of the Academy of
Clinical Psychology, and Board Certified in Clinical Psychology, ABPP.
He is a Distinguished
Practitioner of the National Academy of Practice in Psychology. He serves on the editorial board of multiple scientific journals. Dr.
Adams is the author of greater than seventy articles and textbook
chapters on the interface between psychopathology and pathophysiology
including two chapters for "Soft Tissue Injury - Diagnosis and
Treatment" by Windsor and Lox (Eds), published by Hanley &
Belfus. Dr. Adams is the clinical director of Atlanta Medical
Psychology and consults to corporations regarding psychological
factors affecting physical conditions and violence in the workplace.
OVERVIEW:
Professions are defined by
their domain and their technology. The domain, whether dentistry,
medicine, surgery, podiatry, optometry or a host of other clinical
professions, includes those clinical areas for which the doctor is
held responsible. Technology enables, and demands, changes and
progress within a field, and technology arises to meet needs emerging
within that field and the society it serves.
In dentistry, as the
incidence and prevalence of carries ebbed due to improvements in
dental cleaning, fluoridation and dental education, dentists
bifurcated and moved either into cosmetic or oral surgical procedures.
Routine filling and extracting of teeth could not support a large
professional group. Similarly, nursing and medicine advanced as their
shared technologies progressed both in pharmacotherapies, diagnostic
studies and surgical procedures.
The new millennium finds
America having become a technologically based society. Ease of
communication, access to data, a wide range of personal entertainment
potential and access to technological advances in health care
characterize society as the twentieth century comes to a close. It has
been reported that this was once a society based upon oil supply, but
is now a society defined by silicon technology, fiber optics, and
issues such as bandwidth, multimedia, and ease of access.
The science and practice of
psychology involves the acquisition of information, complex analysis
of data, and precision in communication. The incorporation of computer
technology into clinical practice, which some would estimate as having
been possible to only a slight degree three decades ago, is a logical
direction of growth within the field. It is, however, clear that there
has been resistance to the computer learning process and avoidance of
responsibility for technological skill development, likely to the
detriment of the field and certainly to the public which it intends to
serve.
The psychology of
computer-avoidance can be as complex as the psychology of
computer-dependency. In the former, the doctor fears failure and the
learning curve necessary to acquire a rapidly expanding body of
knowledge. In the latter, the doctor finds the computer a substitute
for other, sometimes more effective, means of dealing with practice
and interpersonal demands. Obviously, neither is an ideal outcome and
both can be threats to the growth of a clinical practice.
HISTORY:
The incorporation of
computers into clinical practice became viable in the early 1980s. By
that time, the Internet was already ten years old, albeit primitive,
and society was still ten years from the development of the
world-wide-web. Twenty years ago, the technology existed to maintain
databases on patients, to write consultative reports, to edit journal
articles, to create billing systems, to analyze patient data and to
track patient progress with greater ease than those same tasks could
be managed by secretaries, billing staff and transcriptionists.
Arguably, by 1981, a solo practitioner with a computer could be more
effective in practice management and marketing than could the same
doctor with a diverse staff. Simply, computers began to enable the
storage, retrieval and dissemination of data, vigilant for errors and
creating potentially new means of addressing a growing mental health
marketplace.
RATIONALE:
Defining the role of
technology in practice ultimately is expressed in the concepts of
efficiency and accuracy. The concept of time and cost effectiveness
has always been a problem in human service delivery. For most doctors,
there is no income when a patient is not being seen, and as necessary
as progress notes and consultative reports may be, often this is
non-compensated time. Additionally, the paperwork required by insurers
and other sources of reimbursement for care is subsumed in the fee
paid to the doctor, although the time spent on completion of paperwork
can substantially impact the number of patients seen.
It is more time efficient
and more data faithful to insure that notes and reports are available
in a consistent file format and can be reprinted and/or edited as the
need demands. Handwritten notes, due to time constraints, are chiefly
brief, often undecipherable, and only exist in one locale. Software
based patient information can be more extensive, bring together
multiple sources of data, and coexist in several settings (e.g.
offices) concurrently. Software based information can be hand entered,
entered by transcription staff or via the increasing accuracy of voice
recognition technology. Equally as important, when it must be
recalled, reproduced and/or resubmitted, it is readily and reliably
available. Prevention against loss, corruption, or misplacement can be
offset by a variety of technological means.
There are no clinical
situations that involve the acquisition and storage of patient data
that are not enhanced by the consistent availability of computer
technology. There are no research or educational situations in which
computer access does not serve an adjunctive role in the breadth and
extent of the work to be performed. Yet there are clinicians, with
rudimentary or no computer skills, that fear, loathe and/or avoid
technology, while complaining of being encumbered by the non-clinical
tasks of practice management and marketing.
IMPLEMENTATION:
New to the community or
new to practice, a psychologist wishes to communicate to potential
referral sources the nature of the practice, specialty areas,
populations treated and style of practice. One means of accomplishing
this goal is to mail an announcement to individuals and organizations
within the community. A more effective means is to purchase (or
assemble) a large database of individuals, corporations,
agencies and organizations, to then create a series of letters which
can merge with that database, and to send personalized, professional
information about the practice to a larger group. Announcements are
often ignored while letters are most often read, and letters can be
individualized according to recipient. The database can continually be
refined. The same database can be utilized with other letters, and the
letters can either be hand signed or a graphic of the doctor’s
signature incorporated. This is the concept most often referred to as mail
merge.
Data indicate that brochures
and newsletters are among the least efficient means of communicating
about a clinical practice. However, the exception to this is when
those who receive the newsletter or brochure are also those who appear
in the mail merge list and have received an introductory letter. It is
often then the content of the brochure and the newsletter that are the
deciding factors, and a format for each must be created that
represents aesthetic appeal, professional presentation, and usable
information. This is the concept most often referred to as desktop
publishing.
Data utilized to track
income by referral source, income by time period, patients by
diagnosis, and other concerns in which there are x, y and sometimes z
axes, require calculations and rotation of data to determine other
means of examining and accounting for outcomes. This is valid not only
in patient care but in any ongoing teaching/research activity for the
doctor in practice. These data are managed and analyzed by spreadsheets.
The telephone yellow pages
have been supplanted by a more meaningful entity, the web site. There
are inherently superior qualities to website marketing. While the
website can be infinitely revised, can contain analysis tools to
determine where website visitors spend the most time, and can reach
virtually tens of millions of individuals, the website itself costs
markedly less than even the most elementary yellow page ad. Websites
can be readily developed, are often available at no cost, and the website
development tools can be readily purchased and learned. The
existence, however, of a website does not mean that visitors will seek
or visit the web site. Traffic
to a website is determined by its inherent domain name appeal
and the decision by internet search engines as to whether a
site is sufficiently unique as to warrant being listed.
The scientist-practitioner
and concurrent lecturer will require a means of graphically presenting
data and concepts. The creation of presentation graphics into
35mm slides, overhead transparencies, animated files and even
multi-media presentations is neither complex nor time consuming. The
tools are easily acquired and the skills readily learned. Ultimately,
it is the content that determines the response of the audience.
While all software tools can
be purchased separately, and many feel that this is the optimal means
of selecting software, there is also much to recommend an office
suite package in which these modules are integrated into one
package, assuring a degree of compatibility among programs. In the
integrated office suite, for example, a psychologist can create a
database of referral sources that receive a selective mail merge
letter and also receive a newsletter. The newsletter format is used to
create a design-consistent website and serve as a model for slides for
presentations.
PRACTICE
MANAGEMENT SOFTWARE
Practice management software
began with Unix (operating system) based programming that tied
together dumb terminals with a PC in the doctor’s office and
in turn to a mini-computer at the hospital(s). This eventually led to
a MS-DOS (or PC-DOS) based program written in compiled basic for the
personal computer. Eventually this led to a proliferation of
doctors’ office management software systems as medicine in America
flourished, and ultimately led to the end of these programs (through
sell-offs and acquisitions) due to the movement of physicians into
group practices, often corporately owned.
During the same timeframe
emerged a group of smaller programs, many ported (rewritten)
for a variety of personal computer operating systems. These programs
often are priced significantly higher than more complete office
suite programs due to high development costs and low volume sales.
They continue to exist in abundance and often garner their market by
profession-specific titles; many, however, lack essential features
available in similarly priced programs from their competitors.
Comparing programs for specific practice needs becomes essential and
the recommendations of other doctors can often serve as little more
than a starting point.
Open item accounting,
ability to add, modify and delete procedure codes and diagnoses,
ability to design custom billing (e.g. each State has its own
workers’ compensation) forms and integrated
problem-oriented-medical-records as well as patient scheduling are
aspects which should be considered minimum core features.
While
the installed base (number of practices utilizing a billing
program) can be a helpful statistic, often this is a spuriously high
number based upon the low cost of the program. There are, however,
doctors’ office management programs that have 15-20 years of
developmental history, ported to a variety of disc operating systems
and regularly updated with excellent technical support.
The
critical decision is based upon the probable longevity of the product
and company. Once several thousand patients are added to a doctors’
office management system, it is a daunting task to then adopt a new
program should the company become insolvent.
A
Mini-Course in Technology
FACTIONS
Invariably,
and consistently, there is the question as to which machine, which
brand, and which operating system is the most viable for clinical
practice. The current answer is analogous to “which psychodiagnostic
tool is the most effective in clinical practice.” And as with the
latter question, the current answer remains: “it all depends.”
Scientists
of human behavior know from the animal analogues that there is an
inherent biologic need for humans to compete. In early evolution, this
was based upon survival and procreation needs, and later it became an
essential component of capitalistic enterprise. As a result, there is
rarely a concept over which opposing factions do not emerge and claim
the superiority of their product. It lies at the core of a
capitalistic system, but more importantly, it resides at the core of
human behavior. The assertion of the excellence of one computer over
another in clinical practice is no exception, and it is specious.
Proponents
of one microprocessor type or one disk operating system and
permutations thereof, are plentiful. For those first entering
practice, and thereby first incorporating computer technology into
daily clinical activities, this becomes a confusing and often
indecipherable dilemma.
CENTRAL
PROCESSING UNIT
Often
the arguments surround the concept of speed of the central
processor unit (CPU) measured in megahertz. Chip speed, however, is
but one factor in determining the overall speed of a computer. The
speed of drive access, speed of random access memory, speed of the
movement from the CPU to peripherals (such as video and audio
processing) and the speed with which a system can write to its screen
(monitor) combine to determine the true speed of the computer. Two
personal computers (PCs) with identical CPUs may have markedly and
measurably different speeds.
There
is currently very little difference in the chip that fuels the high
end MacIntosh machines and that which powers the PC Windows machines.
In
very brief there are two kinds of chips. The Motorola PC chip, used in
the MacIntosh machine, is a RISC chip. RISC stands for reduced
instruction set computer. The PC based machine running Windows,
Linux or BeOS uses a CISC chip. CISC stands for complex instruction
set computer. An instruction set is the basic set of commands a
chip understands.
The
RISC chip takes multiple computer instructions and simplifies them to
run more efficiently. CISC takes few instructions, but the
instructions are more complex. Other than that, the two chips are
fairly similar.
Another
factor to take into consideration when comparing speed is the ability
to process multiple instructions in the same cycle, or pipelining. The
pipeline is divided into segments and can execute simultaneously with
other segments. The Motorola (MacIntosh) chip uses Altivec
instructions, and the Intel (PC) chip uses SSE instructions. This
multiple processing can dramatically increase speed.
In the abstract, the Altivec instructions are faster, but in
the real world, chip speed does not make such a huge difference. The
operating system of a given computer is more relevant than the
hardware because the engine, for practical purposes, is essentially
the same in both MacIntosh and PC computers.
Returning to the concept of
analogies, if one were permitted only one psychodiagnostic instrument,
many would agree upon the one that would produce the most useful data.
However, not all would agree; it would not be a unanimous decision.
This is similar to being allowed to order only one blood panel; most
physicians would agree that one panel provides useful data in the
majority of cases seen. However, individual physicians may feel that
an alternate panel or profile tells them a great deal more about a
patient. Clinical agreement is not synonymous with clinical unanimity.
BIOS, RANDOM
ACCCESS MEMORY, AND CACHES
The computer’s basic
input output system (BIOS) consists of read only memory (ROM) in which
is stored the basic instruction sets to the computer. It tells the
computer what hard drives are installed, what ports are available, and
other basic data. Many manufacturers allow the BIOS (a chip) to be
upgraded by downloading a file from their site and flashing the
BIOS. Be aware that should the BIOS be inaccurately flashed, the
computer will simply fail to start; a daunting realization once
experienced. It is not an irretrievable dilemma but may necessitate a
service call in which the BIOS chip is replaced.
Information stored upon and
retrieved from a hard drive is slower than that which is stored in the
more volatile random access memory (RAM). A program, once opened, or
loaded into RAM, is all but instantaneously available. A program that
must be loaded from the hard drive can require an appreciable period
of time based upon CPU speed, hard drive access speed, and other
factors. While many operating systems will operate with 32MB of RAM,
increases in installed RAM results in improvement in performance,
reaching asymptotic levels at approximately 128MB of RAM. For those
who have their billing, word processor, diagnostic, database, and
graphics programs open concurrently 256MB of RAM may be a good
investment.
Cache memory is that
utilized by the CPU itself to rapidly load and unload information to
the processor. The thinner (measured in microns) the microprocessor
is, (e.g. .18 versus .25), the faster the processor. The larger the
available onboard cache is, the more efficient the processor.
Technological advances have permitted thinner processors to be
manufactured and larger caches to be attached to the processor.
While a 1GHz CPU with 8MB
cache and 512MB RAM would be an impressively fast computer, as would a
computer motherboard supporting dual processors, its speed would be
realized only in intense graphics and video design applications and
may be undetectable in a clinical office setting.
PERIPHERALS,
INTERFACES AND BUS SPEEDS
Peripherals are devices
attached to the computer either through their external ports (serial,
parallel, USB, IEEE, Ethernet, etc) or internally. The internal
interface exists in five forms: the ubiquitous PCI slot with which
most modern peripherals are compatible, ISA slots used in older
computers, AGP slots for video cards, IDE slots for the more common
hard drives and removable drives, and SCSI slots. The latter SCSI
slots/cards drive the fastest and most robust hard drives. They
provide faster access speed and often greater reliability but are less
frequently found on standard computers from major manufacturers since
they contribute to cost, and, eventually, their technology trickles
down to IDE drives which take advantage of drive technology yet
continue to decrease in price.
AGP is an evolving video
standard and permits greater video speed (writing to the monitor) and
manipulation of color and three-dimensional effects. The speed of any
peripheral and its ability to communicate with the CPU is determined
by BUS speed (a gateway between CPU and peripherals). The standard of
several years ago was 66MHz bus speed; 100MHz, 133 MHz, 200MHz and
greater bus speeds rapidly followed. Optimizing bus speed, drive
speed, cache, available RAM, and improved software design which can
optimally utilize this technology all contribute to the speed of the
computer.
DISC
OPERATING SYSTEMS
While there are
advocates who prefer the MacIntosh for its ease of use, its stability,
and its superiority in tasks of desktop publishing and graphics (e.g.
website) design, there are those who prefer the choices inherent in
purchasing a PC from one of a seemingly incalculable number of PC
builders. Since the PC basic input output system (BIOS) is open-code
(widely available), one can virtually build a PC. By contrast, the
MacIntosh is not an openly available system, and only Apple can
legally build a MacIntosh. Similarly, the MacIntosh disc operating
system is an evolutionary model and has no true competitors. Some
would argue that lack of competition builds complacency. Others would
say that it has permitted an assured stability.
By
contrast, the choice of the disc operating system for the PC (personal
computer) is growing. While there is one dominant player that tightly
holds the source code to its operating system, there are now several
open-source (publicly and freely available) operating systems. Several
of the new open-source operating systems are inordinately stable. They
support multiple-processors (two CPUs working concurrently within the
same computer), multi-threading, and permit individuals and small
companies to design their own programs. Several major software
manufacturers and several PC computer makers are now offering these
open source operating systems as optional installations on their
computers.
And,
despite MacIntosh’s arguably superior stability, advantages in
graphics design, website development and in some applications, speed,
the majority of the desktop and laptop computers are PC rather than
MacIntosh. The culpability lies not with the technology but with
Apple’s self-limiting decision to not permit their Basic Input
Output System (BIOS) to be open source. MacIntosh machines are,
therefore, produced only by Apple. By contrast, the number of PC
manufacturers would be difficult to estimate since any individual with
a list of parts can assemble one for reasonable cost and with minimal
skill.
The
goals in selecting a PC operating system would (in order) be:
stability, ease of use, availability of software programs for the
platform, and technical support.
Many of the open source operating systems can be freely
downloaded, ordered for little more of the cost of the CD-ROM and
shipping, and even freely exchanged with others. The downside is that
until recently, these open source products were difficult to install
and configure.
In
passing, it should be noted that a PC could be configured to have
multiple operating systems residing at once on its hard drive. When
the computer boots (starts), a menu appears and the user chooses which
operating system to employ. This has permitted many new users to have
the stability of the most widely used operating system but also to
begin to learn the open source programs in preparation for changes
that may occur in the future. There are aftermarket products that
permit this multi-boot option, and one of these products is often
included with the open source operating system.
PORTS
Legacy-free computers,
those designed for forward technology without a goal of using older
peripherals (printers, scanners, external modems, etc) come equipped
with only universal serial bus (USB), advanced second generation
universal serial bus (USB2) or IEEE-1394 (“Firewire”) ports. The
advantage of USB and Firewire lies in speed, and most of the
peripheral devices (printers, scanners, networking, digital cameras,
musical instrument digital interface, etc) are numerous from which to
choose.
USB and Firewire devices
require that you install their software and then simply plug in the
unit. There is no configuration of hardware settings (often called
interrupts or IRQ) and no need to have sufficient internal capacity
(spare slots) for the devices. Firewire is a “faster” port and
allows more rapid data interchange. Networking with Firewire or even
USB is very simply accomplished in minutes.
The older ports appearing on
most computers include parallel (also called LPT) ports for
communicating with printers, scanners and other devices. There are
also serial ports for attaching external modems and similar serial
devices to computers. Finally, many computers have Ethernet ports for
network and/or cable modem installation.
By contrast, the advantage
of USB and Firewire devices is that they most often can be equally
used on MacIntosh computers as well as the PC, and software for each
“platform” (MacIntosh vs. PC) is often included on the same CD-ROM
that accompanies the device. The CD-ROM senses upon which computer an
installation is being attempted and defaults to the software which is
compatible with that platform.
VIDEO:
A
video system for the computer consists simply of a video card and a
monitor and the software necessary for the computer to recognize and
optimally utilize the monitor and the card. There are studies that
indicate that a movement from 15 inch to 17-inch video monitors
results in statistically significant (and large) increases in
productivity. A liquid crystal display (LCD) flat panel monitor has
many advantages including clarity of image, rapid management of
graphics and very little desk space usage. Its downside is a
significant differential in price between that and the traditional
cathode ray tube monitors that are essentially high-resolution
television sets.
Resolution
is produced in dots (pixels), and the smaller the pixel size, the
greater the apparent clarity of image (and consequent decrease in
visual demand). A screen writes in rapidly scanned lines. The faster
the rate with which the screen refreshes, the less apparent is
flicker, and again, there is less visual fatigue.
The
visual image is the result of the combined effects of the CPU, the
video monitor, and the video card. The latter can vary in degree of
color resolution, speed of writing to screen, and availability of
options such as input of video devices (VCRs, camcorders, cable
TV, etc) and output to other devices (TVs, VCRs, etc).
The
importance of color rendition may be comparatively minor to a
clinician. Sixteen, twenty-four and thirty-two bit color refers to the
number of bits of color information assigned to each screen pixel. A
16-bit color video card is capable of 65,536 different colors. Both
24- and 36- bit color yield 16.7 million colors. The 8-bit difference
between 24- and 36-bit is the result of an 8-bit alpha channel that
permits 256 levels of transparency. The importance of this is critical
to video gamers, graphic designers, and those manipulating video
animation. Unquestionably, the early video quality of computers,
limited to 256 or even 16 colors, is impractical in current internet
access or designing of visually compelling marketing documents for a
clinical practice.
The
difference is salient only to those clinicians who are working not
only within their own clinical area but those who are also working in
hobbyist interest areas, extra-vocational pursuits, or studies of
sensation and perception. The clinician working with word processing,
database management, and internet activities (even internet design)
will have limited, if any, need for the higher levels of visual
information. Succinctly, an 8MB, 16-bit color video card is a more
cost effective purchase than a 32+MB, 36-bit, over clocked (forced to
drive faster; often creating heat and reliability concerns) video
card. When the less
powerful card attempts to run the higher demands of video games or
graphics programs, it results to dithering effects and does not
recreate smooth transitions between colors. Again, in word processing
and database management, this is likely irrelevant and not a
cost-effective concern.
When
an individual purchases a brand name computer, the manufacturer has
often predetermined which video components are installed. There may be
options at the time of purchase, but most often the default decision
is suitably matched and cost-contained. Additionally, it is a
common practice for manufacturers to integrate the video as a chip on
the motherboard (MOBO) which houses the CPU and the RAM. Rather
than dedicate part of additional RAM for video, the video chip
accesses the system’s RAM for video memory. This practice reduces
cost of manufacturing and cost of adding computer systems to the
practice.
AUDIO
Audio
resolution, certainly for encoding audio data in voice recognition
software, and increasingly as individuals collect music files (MP3),
may also be an issue if the doctor uses clinical biofeedback (audio)
and the sound has clinical application. However, short of this, audio
is not a critical issue in the clinical setting. It can be managed
either through integration of audio as a chip on the MOBO or by a
range of audio expansion cards with impressive capacity for audio
fidelity, developed when the potential for the computer as a home
multi-media entertainment center was realized several years ago.
INPUT
DEVICES
Clearly the “mouse”
in combination with the keyboard has become the de facto standard of
data input. While increased CPU power and speed of RAM will permit
more accurate and responsive voice recognition, the latter would have
to exceed 99% accuracy to be truly time effective in clinical
practice. Remember that 90% accuracy in voice recognition software
would require that the doctor (or staff) correct one of every ten
words dictated into the computer. The editing, thereby, becomes more
cumbersome than the hand entry the voice dictation was to supplant.
The mouse, the keyboard, and
the video resolution contribute to significant improvement not only in
productivity but also to decreases in repetitive use injury. An
ergonomic mouse and/or keyboard result in decidedly less daily
fatigue.
STORAGE
CAPACITY
While hard drives are
available with a variety of interfaces (to computer) and consequent
differences in price and size, in the typical practice, it is
difficult to utilize all the space that is afforded with even a modest
computer. If the hard drive is cleaned (erased) of unneeded files, and
if permanently archived reports, notes, articles are stored upon
replaceable media, ever-increasing hard drive size is not needed.
Twenty, thirty, and fifty gigabyte hard drives with 10,000 rpm
rotational speeds can be very useful in the creation and editing of
video programming. In the office setting, they are rarely needed.
Other removable media exists that enables transport of data between
offices or home and office and can vary in size, price and
portability.
CD-ROM
(DVD and CD-RW)
Most software comes
loaded on compact data discs (CD-ROM). This is more reliable, less
expensive, and less cumbersome than furnishing programs on diskettes.
Virtually hundreds of diskettes worth of information can be stored on
a single CD-ROM. Even more data can be stored on the increasingly
popular DVD (digital versatile disc). When the DVD was initially
released, there was immediately a series of patient education medical
and dental titles available for playback in the clinician’s office.
Two hours worth of video and audio data readily fit on a DVD in
contrast to the 74-minute maximum audio content of a CD-ROM. In
clinical practice, the speed of loading software from a CD-ROM is more
central to a doctor’s daily activities than are the multi-media
capacity of a DVD unless, as noted, the latter is utilized for patient
education.
CD-RW (recordable and re-writable)
CD-ROMs have become standard equipment in many mid-priced computer
systems. This permits the backup of significant data onto a CD-ROM
that can then be carried between office and home, and it permits the
copying of CD-ROMs for archival purposes. A CD-R (or CD-RW) copy of
owned software is effective insurance against a missing or damaged
original CD.
Recordable DVD has even
greater potential due to storage size, and in many practices, a DVD
would be capable of holding the complete contents of a doctor’s
computer.
PRINTERS
AND SCANNERS
Dot-matrix printers still
exist and are used by many practices to print mailing labels and to
print forms that require duplicate and triplicate copies.
Unquestionably, this market has yielded to the laser printer with its
markedly faster speed, impressive print quality, graphics capacity,
and color. Laser printers are one-third the price of several years
ago, and ink-jet printers (the slowest means of color printing) are
remarkably inexpensive.
Similarly, scanners are
available for one-tenth the price of several years ago. As with laser
printers, the costs have plummeted while the quality (measured in dots
per inch) has increased from 150 dpi to 1200+dpi (a computer
monitor’s resolution is closer to 72 dpi), enabling the scanning of
articles and graphics into storage and retrieval at very low costs to
the clinical practice.
CONNECTING
TO THE INTERNET
Internet connection has
traditionally been through “dialup.” A modem (standing for
“modulation-demodulation”) internal or external to the computer
connects the computer to the Internet via standard telephone lines.
The connections can range from no cost to $25 per month for unlimited
use. Access is slow, connections not always assured, and line drops
(disconnections) not uncommon. There are increasing numbers of
companies offering free Internet access and free E-mail services and
associated free web hosting. In exchange, the user permits (sometimes
massive) advertising to bombard them when online. It is not ideal, but
it is cost contained.
Dial up Internet connections
require a dedicated telephone line. Otherwise, while “online” in a
one-line office, the doctor is inaccessible; there are call waiting
modems which will permit a brief interruption of the internet service
to inform a caller that a call will be returned upon disconnection
from the internet.
Cable modem service is not
available in all locales. Where it is available, it can offer 50-100
times the access speed, and the cost is typically less than that of a
dedicated telephone line and a dial-up Internet service provider.
Aside from speed there is a central advantage to cable modems; the
user is always connected. There is no access time. As with cable
television, when the computer is turned on, the Internet access is
present. Aside from availability, there is a rather vexing problem
with cable modems: the user shares bandwidth (access speed) with as
many as 1500 neighbors. There are times of the day or evening when
cable modem speed is only 2-4 times faster than dialup.
ADSL (asynchronous digital
subscriber line) requires that the office be located near the
telephone company’s switching station. If the standard telephone
lines in the office are modern and/or can be replaced, ADSL offers the
advantages of cable modem speed without the disadvantage of a shared,
and thus slowed, signal. The speed remains constant. However, as the
distance from the switching station increases, the bandwidth
decreases, and in theory, the ADSL line could become no faster than
standard dial-up access.
Internet access, in whatever
form, has become mandatory. Most computers come with a modem and many
manufacturers offer price incentives in exchange for use of the
Internet service packaged with the computer. Many higher end computers
come with a network interface card (NIC) which permits connection to
cable modem.
Digital satellite Internet
access is more problematic. Download (receiving from the Internet) of
information may be quite rapid and not influenced by shared access by
neighboring offices. By contrast, uploading (sending information to
the Internet) is often managed by conventional telephone lines and a
standard modem. The end result is a compromise. The advantage is that
even in the most rural practice, where cable and ADSL are improbable,
digital satellite access can be installed.
NETWORKING
There was a time period in
which the networking of personal computers was complex and required
skill, patience and debugging problems. Currently, two computers can
be connected to each other and share resources (drives, printers,
etc), including Internet service, for less than the price of three
months of Internet service. This requires no more than a NIC (network
interface card) in each machine and connecting them by an Ethernet
crossover cable. Buying two name-brand computers and NICs, the entire
networking mission can be accomplished for less than the price of a
single computer only one year ago.
MAKING
INFORMED DECISIONS
Applications running
today, on current computers, will run 10 years from now on the same
computer. The concern held by many is that there will be new software
that makes demands for which the current computers are unsuitable. The
obsolescence of computers in the 1990s was a phenomenon worthy of
observing.
The
current conceptual model, however, will likely persist: technology of
today will cost one-third the current price within 18 months. The
fastest computer of today has a half-life of about three months before
being superceded by something measurably faster.
This,
however, need not be a concern, since in most office applications, a
300MHz processor, 64-128MB RAM, 8.4+ GB hard drive, CD-ROM and 17 inch
monitor by any manufacturer offering 24/7 technical support will meet
the needs of most offices for the foreseeable future. The concept is
often referred to as legacy in which the individual computer
must be capable of running applications from the past and use
peripherals from the past. Legacy is a mixed blessing in that it
assures some degree of compatibility, but it also slows the process of
eliminating design concepts that were shown, over time, to be flawed.
SOURCES OF
INFORMATION
Fifteen years ago, the
monthly computer magazines permitted access to current technology. Ten
years ago, the weekly trade magazines provided the needed currency of
information. Within the past several years, daily television programs
and entire channels, provided the most current information. Within the
past year, the most current information was available at the website
of the manufacturer. And most recently, the most current information
may be available in chat rooms, newsgroups, and list services of end
users, programmers and information technology professionals.
The most parsimonious
approach to equipping the clinical practice with a computer is to
discuss the doctor and office needs with an informed individual,
reseller or manufacturer. A viable, reliable, and productive system
for office practice is readily and inexpensively installed and
implemented. The learning curve is brief.
There is a concept that is
worth considering. It is frequently asked as to whether a computer
saves valuable time and thereby permits more patient contact. The
corollary question is whether marketing with a computer requires less
time due to its efficient use of data.
The answer is ambiguous.
While the quality and consistency of data into and from the office is
markedly and impressively increased by integration of computers into
clinical practice, the computer gives rise to numerous and endless new
concepts of marketing and documenting care. Many find that while a
computer removes the drudgery of old tasks, it also creates an
imperative for new and creative concepts. In short, workload does not
necessarily lessen, but it may become more effective and efficient.
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