Sean Holliday, Author at The Ortho Cosmos Page

The Orthodontic Time Lord

March 5, 2018 by Sean Holliday 2 Comments

How to be a Time Lord

Managing time is a key step in gaining productivity in what you do. No matter how hard you try, you have only twenty four hours in the day, and as such, time is a non-renewable resource. One of the most valuable things in life and business comes down to managing time, since time is unforgiving. Want to do more at work and grow your practice? You will need to make the most of your time to make that happen. Want to spend more time with your family while having a comfortable lifestyle? Managing your time and balancing it for both personal and professional goals becomes paramount.

To be able to control time versus letting time slip by, several different options are available for an orthodontist who desires to be a time lord. A time lord controls his or her time and takes advantage of tools and skills to maximize time for both work and play.

Measure

Tick tock, measure your clock. As a time lord, it is important to first understand where you consume your time. As I mentioned, it is a non-renewable resource, so it’s use should be understood before you even plan how to improve your time management. Have you ever taken stock of where you consume your time? Time sinks are around every corner. In an orthodontic practice, we are bombarded with many things. It seems all things need to be taken care of, and with additional distractions such as email and social media, time becomes a valuable commodity.

It is critical to understand and measure where you spend your time on a daily basis. Measure your time with tasks and digital workflow. Measure your time in procedures and consultations. All of these tasks that keep us occupied each day. Analyze the usage of time on these and review where your current priorities lie. The amount of time you spend on each task will make it clear. Are those priorities in alignment with the things you hold important and valuable both personally and professionally? In a business sense, your productivity per hour greatly depends on your expenditure of time in what gives you and your practice the greatest output.

Find a Fix

For every problem, there is a solution. Once you have determined where time is spent, find a way to fix the tasks that waste time and don’t contribute to your professional and personal goals. Many of us can easily save time by delegating tasks or outsourcing them. As orthodontists, our time in the office is best spent in clinical care and productive tasks that lead to the greatest returns. Time is a non-renewable resource, but money is renewable. There are many opportunities is delegating and outsourcing tasks so you can gain productivity in what you do best and where your passion lies. Invest wisely, and know your worth.

Automate

Automate to augment your time. Machine automation leverages technology to remove mundane tasks so we can focus on important tasks that only we can perform. The human factor is important to be maximized by using machines to enhance human abilities. This is where recent innovations is machine learning and AI engines can be used to maximize human potential. Productivity apps and software platforms that relieve you of menial tasks are powerful for a time lord.

Optimize

Build powerful routines. There are some tasks that cannot be delegated nor automated with AI engines. In those circumstances, it is important to optimize your skills to get things done in a shorter time frame. To gain productivity and save time, it is important to optimize what we do. Building routines gain time by decreasing mental loads to redistribute brain function into higher level tasks.

Clear

Clear your head to clear time. Creating headspace can be achieved by clearing your mind of tasks and ideas that clutter your mind. Mind dumps help to relieve mental overload by taking information into reminder apps, lists, and journals. Voice AI engines such as Siri and Alexa allow for dumping those ideas and mental assets into a holding jar much like a notepad or journal could hold those thoughts for you.

Focus

Slow down time by sharpening your focus. Prioritizing which areas need your focus comes down to filtering data. Our lives are bombarded by a superabundant source of information and choices galore. A time lord can take advantage of recommendation engines to personalize the experience and leverage filters to cultivate higher quality attention at scale. A recommendation engine is a filter for content. It is based on a software platform that learns pattern recognition and focuses human attention. These engines learn our personalized preferences and narrow the focus into a smaller number of suggestions based on our unique experience. Google’s decision engines are a prime example for pattern recognition, and other platforms include Facebook, Amazon, Netflix, Pandora, LinkedIn, Spotify and others. The future holds increased utility of recommendation engines in niche markets such as orthodontics. A time lord augments their focus by leveraging recommendation engines to narrow the abundant possibilities into a very personalized and custom experience.

In a world of abundance, the only scarcity is human attention.” Herbert Simon, Nobel prize winning social scientist.

Keep Improving

Rinse and repeat. Constant and never ending improvement is another tenet of a time lord. Time is a continuing cycle, and we should continue to gain control of time as habits are developed. Keep measuring, continue finding time sinks, and renew your commitment to finding solutions.

Goal Setting – Be Smart and Stretch

January 16, 2018 by Sean Holliday Leave a Comment

Goals

As we begin a new year, it becomes a time of resolutions and goals for ourselves and our practices. Goal setting is a powerful exercise in strategic planning and an effective method to boost the team efforts in productivity and growth. The challenge with goal setting is seeing those goals come to fruition. Just like the gyms are full on January 2nd with exercise enthusiasts set on the goal to improve their fitness, by February 1st, the number of committed individuals has dwindled dramatically. Such is the case in many areas of life, including business and orthodontic practice.

The effort to improve your practice’s productivity and growth relies on a series of goal setting strategies that look at both the short-term and long-term vision. The goals require more than just a meeting and a series of promises. Most experts advise the first step in goal setting is to have written goals. The second is sharing those goals so others hold you accountable to those goals. To keep ideas moving into action, it takes having a large ambition of what you want to achieve, and then follow through with a series of steps to make that big goal achievable. This is what turns that goal into a reality. The tools that I intend to review are concepts of setting SMART goals and incorporating them in a stretch goal that aims to reach your large ambition.

SMART goals

Setting SMART goals are about having a clear set of objectives that are specific, measurable, achievable, realistic and based on a timeline. This technique was developed in the 1970’s by Edwin Locke and Gary Latham, university psychologists who looked for the best ways to set goals. By 2006, they had more than 400 studies on increasing productivity and a review on who were able to achieve faster and better results. The common thread being that specific, high goals raised performance more than easy or vague, abstract goals.

Specific
Measurable
Achievable
Realistic
Timeline

SMART goals are about getting things done better and faster. The challenge is that SMART goals can easily focus on the short-term. Short-term goals and short-term achievements can keep an organization from growing no matter how productive you become, productivity does not always lead to growth. Long-term goals are also important to grow as an individual and as an organization.

Stretch goals

Don’t sell yourself or your team short. Reaching new heights take a stretch goal. Dream big and stretch. These are the goals that truly change an organization. While SMART goals help us achieve tasks, tasks should lead to somewhere. This is where laying out a vision of what you want to achieve becomes important. And that vision should require reach.

Stretch goals are not right for every occasion, but often they are well utilized in thriving but complacent organizations. Complacency is often our problem as our practices grow past the survival stage in the early years of practice and I see many orthodontists frustrated as they plateau in the growth and change that drove them into this profession. Setting a stretch goal also motivates those who work for us to see a growing and vibrant team who is driven by continuing improvement. Stretch goals are jolting events that interrupt complacency.

If your practice is not where you want it to be, what’s your big goal? Setting a target that requires extra effort to achieve often becomes the driver to the most exciting change. Maybe it is to grow to a larger organization. Maybe you have a production goal or a goal in net income. Maybe it is a lifestyle goal where your practice is the engine to freedom and time with family. These big picture goals are the vision that can be supported by action steps. It has been said: Vision without action is but a dream.

In short, we need stretch and SMART goals. It doesn’t matter if you call them by those names. It’s not important if your proximal goals fulfill every SMART criterion. What matters is having a large ambition and a system for figuring out how to make it into a concrete and realistic plan. Then, as you check the little things off your to-do list, you’ll move ever closer to what really matters. You’ll keep your eyes on what’s both wise and SMART.” Charles Duhigg, author of Smarter Faster Better

Consider as you begin your 2018, where do you want to be by this time next year? What about in five, or ten years? Implementing a process for doing things better often starts with a goal. So be smart and stretch.

Orthodontics: More Art or Science?

November 27, 2017 by Sean Holliday Leave a Comment

Art vs. Science

When you consider the orthodontic specialty, do you consider it more art, or more science? An artistic process is often based on individual judgement and highly variable. It is necessary in a changeable environment and a unique service where all patients do not want the service performed in the same way. It is generally desired in a highly variable, high value business environment.

Low value, low variability business processes are best approached from a scientific process. This incorporates more systemization and standardization that lends itself to mass customization or mass production. These two processes leverage economy of scale. If a customer does not value a process significantly, turning that process into a standard system is the best course of action. This allows for more time and effort to be applied to the more artistic components of orthodontic practice.

Where does art add value for patients vs. where do scientific standards make sense to gain efficiency and predictability?

In an orthodontic practice, what aspects are an art? These are processes that are suited for an artistic approach that produce unique or tailored results. These include customer service, business development, smile design, and leadership training. Many other processes can be approached from an artistic standpoint in an orthodontic practice. Smaller practices tend to apply artistic systems to highly customize the experience, but as a practice grows, these systems become unsustainable. Taking an unbalanced approach with highly artistic processes in a practice is often not efficient nor effective when patients do not value the artistic value of certain processes within a practice.

In the converse, scientific processes can be standardized and mass produced in a predictable, reproducible manner. Creating a scientific process that systemizes certain aspects of orthodontic treatment greatly increases productivity and reduces variability. A consistent and effective bonding protocol is an example, where gaining almost 0% bond failure is highly desirable. Office systems to standardize the bonding process and reduce operator variability are highly desirable. This example shows how a technique sensitive process such as bonding should take advantage of the predictable and consistent standardization process to improve a practice’s performance. The risk as a practice grows and implements many standard systems, is that employees can switch to autopilot, and although that may benefit bonding technique, excessive systemization will discourage employee engagement in the areas that are best approached from an artistic standpoint.

As an orthodontic practice grows. It is important to develop effective systems that lead to success. This requires an effort in the practice to determine which category of management those systems are best suited. This balance of an artistic and scientific approach allows for business growth while maintaining systems for quality treatment and a positive patient experience. These include the industrial standardized process, mass customization and art systems.

Industrial Standardized Processes

These processes are best used for work that is done best by doing it exactly the same way each time. Incorporating the type of consistency of a standardized process pays off big time because it reduces time spent on work that’s best done without a lot of variation, and reduces waste so that resources can be applied in other parts of the practice that can benefit from more creativity.

Technology often aids in making the process more standard and reducing human error. Following best practices of mass production can benefit a practice develop production systems for better performance. Often touted as a great example of this process is the Toyota Production system. Production systems are very useful when implementing technology, but I caution that technology is the means and not the end. We should always consider that we interact with people and the effect with have with them.

Mass Customization

Mass customization applies to work that is done in large quantities but cannot be made exactly the same way every time. This is a large part of orthodontic treatment. Where appliances, such as aligners, brackets or retainers, can be made in exactly the same way almost with industrial standards, except for the fact that each patient’s dentition is different and requires a custom design. Tooth anatomy or dental arch form have some common threads amongst people, but each individual has a unique aspect that must be compensated for.

Our business relies on a biologic process. That innately prevents several parts of what we do from being exact. This is a great challenge in the clinical research we rely on to make treatment decisions. So many variables can affect the outcomes we would like to predict every time, that some customization to individual response becomes a reality in providing treatment. Orthodontic appliance manufacturers often play in this space. Bracket design, custom labial or lingual appliances, and aligner systems leverage incredible systems in mass customization. The growth of the 3D printing market offers most practices an added entry point into mass customization systems.

Art Systems

Orthodontics relies on working with people. That in itself adds so much variability that customer service interactions are more an art than a science. The challenge in orthodontic treatment is the high variability in physiologic response and the high dependance on patient compliance. Patient compliance, therefore, incorporates a high tendency for artistic systems since human behavior is not always predictable. These are areas of practice that have a high degree of variability and require custom approaches to leverage our humanity in making a connection.

How can art be trained? While the science of orthodontics can be taught by the literature and scientific body of evidence gathered over the decades, the art of orthodontics is more of a challenge. That is where master clinicians and KOL’s come in to lecture, teach, mentor and share their artistic talent on how they manage all the situations that are beyond the standards. Nurturing an artistic culture can be done by apprenticeship from a master clinician and another method comes from storytelling. With new technology, forums, study clubs, blogs, journals, webinars, live lectures, etc. more can be inspired to build on the art of orthodontics.

How do you measure success in an art system?

The simple, internally focused metrics for a scientific process, designed to make sure everyone executes it the same exact way, will not work for art. An artistic process has to rely on external measures of success. Artists need continual exposure to customer feedback, which prevents them from constructing their own idiosyncratic notion of quality.” Hall & Johnson

The artistic approach is a humanistic approach. The journey is what matters in orthodontic treatment when it comes to the patient experience and their desire to recommend it to others. The artist should be careful to avoid false patient experience assumptions and be careful of habituation by adapting to changing shifts in culture.

Orthodontics is both art and science. The art is more human, while science is more machine. As I have suggested before, our future is not so much human vs. machine, but human enhanced by machine. Like many areas of life, a good balance of both acts helps to design a model that gains in efficiency AND experience. We should design specific standard processes that are rather rigidly used all the way up to the final “artistic” act. This allows for efficiency to free up time for the artistic aspect. In the common case of service the efficient standards would aid in the actual interaction with the patient. By making the system as consistent as possible in the early stages, we’re able to minimize any unnecessary variability and bring us to the moment of more complex interactions in great shape.

Seven Strategies for Success in a Digital World

October 16, 2017 by Sean Holliday Leave a Comment

A Unique Value Proposition

The digital world is flexing it’s influence across the marketplace and professions can see the potential effect. When products and services become ubiquitous, there is a challenge in remaining relevant. Corporations, economy of scale and technology buy-in change the culture in orthodontics. There is a general fear that this will commoditize our specialty and bring down the opportunities to a generation that is feeling the increasing costs of education and capital investments in building a business.

A large body of knowledge is being gathered and used strategically with the power of data. Our knowledge database once controlled by the few who put in the time and effort to educate themselves and train as professionals and specialists, to a cloud-based, digital knowledge data set available to many.

In the industrial age, production became exact and cheap. In the digital age, a process can become exact and basically free. This is what has affected so many industries and professions. The correlation into the orthodontic specialty depends on the premise that orthodontic treatment can become exact, which is rarely the case. Although treatment data can augment and facilitate treatment modalities, a repeatable and scalable process is much tougher when you treat a broad range of malocclusions. Assuming a subset of orthodontic cases can be treated repeatedly and exactly, the interesting part is that as things become cheap and virtually free, there is a greater interest in what is unique. Hence the role of a unique value proposition.

Better than Free

I recently read a book by Kevin Kelly, called The Inevitable. In this book, Kelly reviewed technological forces shaping our future. One of those forces, is how in the digital age, whatever can be copied, can be copied for free. “When copies are superabundant, they become worthless. Instead, stuff that can’t be copied becomes scarce and valuable…what can’t be copied? Trust, for instance. Trust cannot be reproduced in bulk. You can’t purchase trust wholesale. You can’t download trust and store it in a database or warehouse….” Trust becomes branding and it leads to authenticity. Authenticity is one of these factors that cannot be copied or faked. The other strategies I found relevant include immediacy, personalization, interpretation, embodiment, patronage and discoverability.

A unique service cannot be cloned, copied, mass produced… it’s better than free. And if you can compete with free, you can compete with anything.

Immediacy

The digital age requests for companies to move away from saving time and efficiency for the business, but to save their consumers’ time. Provide a service within reasonable time and faster becomes better. This unique value proposition is not easy and we all can feel the pressures in delivering results that are faster. Saving treatment time with efficient treatment options and implementing same day starts are two examples of delivering immediacy. Faster is realtime and realtime doesn’t come cheap and certainly not free.

Personalization

Personalization leads to a custom offering. Another concept that is important to consider is avoiding entering a market with a generic service. Not providing a unique patient experience and memorable journey, becomes easily copied and therefore fraught with risk. Taking on the challenging treatment, custom treatment plans, providing unique results, and offering unique experiences with personalized service, become very valuable sources of personalize care.

Interpretation

Software = free, instruction manual = $5,000. This is where the expert advice from interpretation helps in gaining success. Professional training and expertise has a unique value and will become key to the new digital future. In health care, we have this distinct advantage. The dynamic is changing for many, where simple treatment methods are becoming easily reproduced. Another change is coming from the value of those who can best travel the new digital world. In many ways, we are not racing against the machines. Instead of human vs. machine, our value will be heightened when we can work with the machines. The real need for an expert becomes valuable and better than free.

Authenticity

Truth and security lead to authenticity. As stated earlier, you cannot copy and easily build trust. Trust comes from years of reputation. It provides safety and safeguards to consumers. Take as an example free software. Easily accessible and copied a tremendous number of times, but the dark net of piracy is fraught with viruses and damaging software that adds risk. In this example, trust brings peace of mind. Risk to any aspect of our lives adds value to those who can build on the trust that comes from a favorable reputation. Your branding becomes key at this stage where it is invaluable in generating a unique value proposition to lower cost solutions. After all, you can only sell what is true.

Embodiment

The concept of embodiment pivots on the body’s experience that goes beyond the digital realm. In this strategy, you are making the digital into a special experience. A great example of this is the fact that people pay hundreds if not thousands of dollars to attend events in person that can be streamed for free. So many musicians and bands earn most of their living these days from concert performances and not from music sales. In orthodontics, it is so critical to maintain a great patient experience. The journey in the process becomes far more important than the destination.

Patronage

Patronage is a strategy based on building a fan base. There are some unique factors that have to be in play when you want to leverage patronage. People have to care about supporting a real person. A corporation or nebulous provider cannot leverage this factor. Fans want to pay creators and artists because it allows them to connect with people they admire. This is challenging and not easily copied, since it means the provider must be at the center of the patient experience. This provider must also have an appeal and charisma that goes beyond the service we provide. Finding connection is key to this strategy.

Discoverability

The strategy of discoverability is predicated on the fact you have to be discovered. You must be able to be found. Being found is valuable since you don’t want to be the best kept secret out there. Discoverability often relates to the story you are weaving online. Being visible through online search engines and review sites are two examples. This strategy is dependent on many other efforts to develop word of mouth and online relevance.

The next time you start relating to the demise of Kodak or the music industry’s pressures from digital music sales, take into account that many others have succeeded after disruption by finding ways to offer services that are better than free. Kelly states, “success no longer derives from mastering distribution.” We can no longer count on copy protection, technical tricks, hoarding or scarcity. Knowledge and technology are democratizing, so developing skills and services that cannot be easily replicated becomes paramount. Most of those succeeding in this new reality are using the seven strategies of immediacy, personalization, interpretation, authenticity, embodiment, patronage and discoverability.

What’s SWOT?

October 13, 2017 by Sean Holliday Leave a Comment

Business Strategy

The SWOT analysis is a business development tool used is strategic planning. Developing your business strategy and strategic thinking in orthodontics are important methods to improve your business metrics and outcomes. Patient care is a key component in the clinical care we provide, and developing a business strategy is extremely important for the business we support.

S – Strengths
W – Weaknesses
O – Opportunities
T – Threats

The SWOT analysis is encouraged when an initial or a continuous business plan is being developed. This plan is a critical component in setting practice growth in motion and staying on a continuous path of improvement. The key to a strategic plan is to take account of where you are now, where you want to go, and what you will do to get there.

Strengths

The key in identifying your strengths, is placing focus on the positive things you are doing. By acknowledging them, you can work to nurture and expand them. These should come both from your perspective, as well as the perspective of your patient base. Some areas to consider include: Knowledge and reputation, tangible assets, competitive advantage, company culture, quality service, patient experience, and innovative ability

Weaknesses

Recognizing weaknesses stems from the concept of self-awareness. You should be well aware of what you are good at, but be honest and caring in the fact that we all have weaknesses. That gives us the opportunity to improve those weaknesses, and perhaps turn them into strengths. Plugging holes in your organization or your systems allows you to gain tremendous improvement and reduce stress. Take a look at: Your vulnerabilities, market weaknesses, what needs improvement, poor timescales, falling behind competition, are there limited resources, outdated technologies, issues with reliability of data, or poor planning.

Opportunities

Almost any challenge presents you with an opportunity. When focused on strategic thinking, opportunities abound. Take a look at your strengths and weaknesses for inspiration to many opportunities for your practice. Some of these include: Changes in the market, emerging technology, competitor vulnerability, global influences, changes in social patterns, and rapid growth rate.

Threats

Threats are obstacles you face. They are not necessarily bad situations. Especially when you set high standards for your team and don’t compromise on those standards. We should work with threats or work beyond them to make the changes we desire. It is important to acknowledge threats to mitigate any potential damage they could instigate. Some potential threats out there involve: Political or legislative issues, emerging competitors, a shift in consumer behavior, bad debt or cash flow issues, competition for talent, and poor management strategies

When utilizing the SWOT analysis, involve your team in the exercise. It is important to prepare and ensure you are using accurate data and metrics of where your practice is. The analysis should be detailed and not based on guesswork. Accurate and relevant data in orthodontics is an asset. There are data sources out there from advisory groups, consultants, as well as comparison data from third parties that can help your decision making.

Plans without action are but a dream. Remember that once you have setup your strategic plan and reviewed the SWOT analysis with your team, it takes action to make it happen. Set a list of goals and action items from your SWOT exercise. Setting reach goals and manageable goals will help with your success.

The Layers of Technology

October 6, 2017 by Sean Holliday Leave a Comment

There is a fun line in the movie Shrek: Ogres are like onions because they have layers. This reminds us not to take things at face value. Consider that scary piece of technology also has layers of opportunity. When I talk to many doctors about implementing pieces of technology in their practice, there is a common theme where leveraging that capital investment falls short as a value add.

Take into consideration that the digital space offers many opportunities outside of the analog world we are used to. The layers I refer to are best explained when you think about the use of a smart phone or smart watch. If your intention with a smartphone is simply to make better phone calls, you are missing the big picture. A smart watch is also a piece of technology that is not intended to just tell time. If I wanted a timepiece, then there are probably much more elegant devices out there that do the job. The smart watch integrates apps and layers of functions that measure my heart rate, remind me to take a break to breathe, measures the number of steps I have taken, tracks my golf swing, sends me messages, links to my calls, integrates with my car, sends me reminders, and with a voice command serves as my personal assistant.

Beyond phones and watches, many of us are integrating pieces of technology in our practices. They become a means and not an end. These tools are often used as an alternative to an analog process, where the layers of benefit are often missed:

Intraoral Scanning

If your focus on scanning is to replace alginate or PVS impressions, then you are missing several of the benefits this technology offers. The impression is a basic benefit. We often take a digital process and integrate it to replace an analog one without implementing the added layers this equipment delivers. Most intraoral scanners offer several different add ons that build value for both practitioner and patient. The Trios scanner, for example, offers full color images in 3D, where this could replace intraoral photography. The outcome simulator Trios will be offering as well as the iOSim iTero has integrated into their device suddenly offers a layer of benefit to the patient on boarding process and treatment presentation. The digital and visual treatment presentation tool now delivers a new workflow in planning treatment, progress tracking, retention and post-tx monitoring.

CBCT

I have heard that once you go 3D, you will never go back to 2D. That is clearly a benefit in a diagnostic tool. I see many doctors taking a CBCT and reconstructing 2D images to get back to our comfort zone. In that case, I can see the argument that a pan and ceph have lower doses, lower costs and similar benefits for the average patient. It’s like using that smartwatch simply to tell time. The benefits of 3D imaging expand the layers of benefits to view cases differently and open up the transverse plane, better perception of asymmetries, fewer artifacts, volumetric measurements, and a better representation of the actual patient we are treating.

Aligner Therapy

Let’s tackle the obsession with aligners vs. braces, are they comparable in outcomes? As orthodontists begin to actually learn how to use this technology, and the technology improves in predictability, we start seeing the destination of both appliance systems becoming more similar and equal for some of us. If we leave it at that, then we have also missed the added layers of benefits aligner therapy systems offer to patient experience, practice efficiency, and practice growth. If you are offering aligners as an alternative to braces, then you are leaving a lot on the table and similarly using a smartwatch to tell time. Clear aligners are less about the clear part, and more about the journey. A braces practice and an aligner practice cannot operate with the same systems. The scheduling, clinical flow, CAD workflow, treatment presentation and marketing efforts are not the same. Trying to fit the round peg of aligner therapy into the square hole of brackets and wires continues to frustrate many who wonder why they can’t see beyond the high lab fee. If you are working to implement aligner therapy in your practice, don’t forget about those layers beyond the exterior.

Fixed Appliance Therapy

Let’s not forget that brackets and wires are still the most common tool used in the orthodontics today. Treatment becomes less about moving teeth, than on the layers added to the treatment experience. Orthodontists are more than just tooth movers, and we must consider how the choice of fixed appliances can save time, save office visits, change perceptions and enhance the motivation to achieve the desirable result. There are many layers of opportunity in the development of fixed appliance technology.

3D Printing

The integration of 3D printing still makes many rant that it is a useless digital toy that is an expensive alternative to plaster. Again, the analogy applies. If your limitation in using additive manufacturing for printing models is to replace plaster models keeps proving my point about missing the layers of benefits. Additive manufacturing will continue to disrupt the orthodontic lab industry in ways we have only started to imagine. The availability of free/cheaper software solutions, faster turn around and full control of the CAD/CAM process within the average orthodontic practice have more layers of benefits than I can put into this post. As stated above, taking this tool and making it fit into the analog process and traditional scheduling and orthodontic methodologies misses most of the benefits that add layers of value. Manufacturing in-house changes the game, period.

These are but a few of the technologies out there that I see don’t get their due acknowledgement. We keep comparing them to the traditional methodologies, where their potential to improve our specialty are not fully realized. The benefit of time is that it is a constant, and the inevitable progress will continue to move forward whether we embrace it or not. Across industries and professions, technological innovations will continue to add to the layers of benefits being offered and change the landscape.

Productivity vs. Efficiency in Orthodontics

September 20, 2017 by Sean Holliday Leave a Comment

We all want to be more efficient, and certainly more productive with our time. In orthodontic practice, like any other business, efficiency and productivity can seem as very similar terms. But innately, they are a different mindset.

Efficiency is about doing the same with less.

Efficiency is a great goal when it comes to treatment time and other metrics. We want to achieve the expected results with less time and less resources to minimize the cost of treatment and/or improve treatment profitability. I would caution that concentrating on efficiency in staff utility can limit practice growth.

Some practices work to improve labor efficiency by finding ways to reduce the number of labor hours required to produce the same level of output. This translates into savings because the company spends less on wages and other labor-related costs. Efficiency, then, is about decreasing in an effort to improve profitability.

Productivity is about doing more with the same.

For a practice, it is directly tied to performance. With higher productivity, an orthodontic team can produce more with the same amount of relative work. In contrast to efficiency, productivity is about expanding the output in order to deliver greater growth from the same workforce.

When it comes to practice productivity, implementing better techniques and systems are best suited for doing more with the same amount of resources. The biggest difference from efficiency being that you are driven to grow and leverage increased production to reduce the costs of business and leverage that growth to improve other metrics. This further reinforces the concept of the top line vs. bottom line in orthodontics.

Consider a productivity mindset that is fostered by avoiding bottlenecks in your practice that prevent team members from getting things done. This includes simplifying office systems so an orthodontic team can deliver great care to patients without complex and bureaucratic steps. Every business is fraught with organizational obstacles that prevent growth. Orthodontic practices are no different.

Productivity mindset is also nurtured in organizations that inspire their team’s talent to achieve their best potential. Inspired employees can produce more than 2 times what a satisfied employee does. This comes from a practice culture that promotes inspirational leadership. This leadership style promotes a positive office culture that leads to greater productivity.

In today’s economic climate, developing a productivity mindset is important to nurture growth. Efficiencies are certainly important in treatment, but think about implementing steps to gain productivity with your orthodontic team.

Are All Aligner Systems Equal?

September 19, 2017 by Sean Holliday Leave a Comment

Aligners are aligners are aligners…right?

With the advent of digital technology, clear aligner therapy has become a large growing segment of orthodontic treatment. In the modern-day orthodontic practice, clear aligner therapy has opened the door to the treatment of many patients who would never have sought out orthodontics. This treatment modality continues to grow at a significant pace, and with that growth, have come more options for doctors delivering care.

For patients, a clear appliance is an appealing treatment method. There is no doubt that the popularity of this esthetic appliance is a preferred choice amongst patients [1,2,3]. Most of us continue to see patients ask for clear aligners and the Invisalign appliance by name. The marketing efforts of Align Technology, Inc. and the innovation of mass production 3D printing have leveraged this treatment technique into a powerful message. The growth of the adult market in orthodontics is largely driven by the improvement of clear aligner treatment. This change in modality continues to drive adults into orthodontic treatment and has started to change the expectations of adolescents. There are many communities where children look forward to the alternative to braces.

For doctors, the primary concern that is expressed is the quality of outcome. As this method becomes more common, there is a call for data, proof, and literature that shows clear aligner therapy can keep pace with the outcomes orthodontists expect from fixed appliance treatment. Most outcome studies are linked to the development of the Invisalign product as they are the market leader [4,5,6,7,8]. Their technology advancements keep moving the needle of progress forward and grow the applicability of aligners. This growth in treating various malocclusions also leads to more analysis of the clinical outcomes that are being delivered. It begs the question of whether other entrants into the clear aligner market can deliver a comparable product.

Amongst the top reasons doctors are concerned about the clear aligner appliance, is also the cost factor. Lab fees become an added feature that we all have to consider. There is certainly a desire amongst orthodontists for competition in the clear aligner space to bring down the laboratory costs for doctors. We should also consider the cost of the appliance goes beyond the lab cost, but also in the time economics. The significance of doctor time, staff time and the additive nature of the manufacturing process all play a role in the decision making. As we consider the impact aligner therapy has in each of our offices, the CAD workflow has several areas of cost and ROI. Each aligner option has its own workflow, and the digital workflow is a foreign concept for many doctors. The freedom in having technicians prepare cases delegates a lot of duty from the doctor to a third party. Most of us realize that this delegation is not a replacement for doctor time since our involvement in the design of the appliance is critical to improve outcomes. It appears to me that many “lower cost options” and do it yourself options come with significantly more doctor time involved. This is changing through software development, but it becomes a risk. When deciding amongst aligner systems, the investment in time is a key feature to keep in mind.

Kleenex and Aligners — Is Invisalign® the Kleenex® of clear aligner systems?

When reviewing all the options available for patients, it is important to consider aligner therapy goes beyond the plastic. The development of the plastic used in the appliance is an important focus, but have you thought about all the factors that matter in choosing an aligner system? Many are available these days, and more are coming.

The main factors I would highlight in the decision of clear aligner systems are:

Material Science

There are a variety of plastics currently available for aligners. Invisalign began using the EX30 material back in the late nineties. They evolved their materials into the multilayer plastic: Smart track back in 2013. The latest Smart track plastic is proprietary and only available through the Invisalign product. Other aligner systems allow the use of plastics that are not under patent protection. These are similar to Align Technology’s EX30 material, and include Zendura, Essix plastics, Invisacryl, and others. With the varying types of plastics, the forces transmitted onto the teeth becomes an important factor. The modulus of elasticity, force degradation, temperature effect, thickness, fit and adaptability all become key metrics [9,10,11].

Software

The key to a digital system is the software that creates the CAD data. The interface of any software becomes an important decision maker with all of these options. Just like any other software you use, browser, email, word processor, and operating system all vary by the user experience. Software support, ease of use, learning curve, portability, replicability and system requirements all matter. For example, a CAD software that only runs on high-end hardware is a totally different beast from a CAD software that is cloud based and can be viewed on any device, including a smartphone. Unless you run a digital lab, orthodontists have to scale the portability of CAD data into at least every operatory in the office. Some clear aligner systems require installation and use of a native software platform that is not cloud based and very demanding on its hardware requirements.

The integration of this software is also important, so the ecosystem that it inhabits is another key feature. For example, how seamless is the link between the digital impression capture into the CAD software design. As more digital scanners become available, they will all have export features that provide image data. Just like switching between a Apple ecosystem to a Windows platform present many challenges, using various software platforms can affect compatibility and efficiency. The iTero ecosystem is an example of the software integration that Align Technology has worked hard to integrate. This ecosystem obviously links scans to aligner case submissions to improve digital workflow, but also links the clincheck process to outcome simulation and progress tracking of clinical cases.

Scale

Clear aligner treatment can be used as a small subset of an orthodontic practice, or can command a significant amount of production in an orthodontic practice. The term “share of chair” has become more common in describing the percentage of utilization of aligners vs. fixed braces in the orthodontic business. Many clear aligner systems have the advantage of a lower cost per case compared to the market leader, Invisalign. With lower costs and a potential commoditization of aligners in the orthodontic marketplace, why would anyone consider using a more expensive system over a cheaper alternative? My perspective is scalability. Having tested many different aligner systems, scaling both the design and manufacturing of CAD/CAM designed aligners has many factors that Align Technology has mastered and that become a challenge for the average orthodontic practice.

Since clear aligner systems cost more than fixed appliances, the advantages when using clear aligners come from time economics. A digital system has the potential to reduce staff and gain productivity. The challenges I have experienced is in the digital workflow and the clincheck dilemma. This means that digital workflow requires digital efficiencies and care in the doctor time needed. The best clear aligner systems should protect the time economics of taking lab workflow into the practice. Delegating more of the workflow into an experienced company can save time. Taking on more of the workflow in-house will add challenges in developing a scalable model that does not trade laboratory savings with a significant increase in staff time and worse yet, doctor time.

Outcomes

When it comes to a comparison of clear aligner treatment data, the market leader continues to be the Invisalign system. Since more than four million patients have been treated using this clear aligner system, the power of data in orthodontics becomes much more evident. Simple cases can be treated with CAD methods and aligner manufacturing that was available two decades ago. Invisalign did it back then, and the large surge in clear aligner options will do so as well. The change in upcoming treatment quality and outcome studies will likely be affected by the data driven treatment design. The addition of data-driven staging and optimization are the current examples of how the Invisalign product has evolved from a rudimentary appliance, to a competitor to fixed appliances. As aligner systems are released to the market, the data-driven decisions in the design of the appliance will be a critical component for doctors who are concerned about the outcomes they deliver from plastic. Everything from attachment design, staging, to force systems, make a difference. Experience in the design of appliances and manufacturing play critical roles in the use of different clear aligner systems. Are you a practice that treats only simple cases? Have you developed a skill in treating more complex cases? The applicability and predictability of the aligner system you choose to use makes a difference in the choice of current appliances.

Branding/Marketing

Consumer acquisition has also become an important factor in the clear aligner market. Since Invisalign has become a household name, they have leveraged the name recognition to get millions of people asking for the product by name. So far, Align technology is the marketing leader in this arena and continues to drive prospective patients into its doctor locator website and more recently into its concierge service. These marketing efforts are clearly meant to keep the large investment in branding within the Invisalign brand. That is part of the cost of using their product, and a value add promoted by Align Technology, Inc. This comes from the fact customer acquisition continues to be a concern for most orthodontists, and new patient flow is the life blood of an orthodontic practice.

References:

1. Miller, et al. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. AJODO. 2007 March;131(3):302

2. Rosvall, et al. Attractiveness, acceptability, and value of orthodontic appliances. AJODO. 2009;135:276.e1-276.e12

3. Abbate, et al. Periodontal health in teenagers treated with removable aligners and fixed orthodontic appliances. J Orofac Orthop. 2015 May;76(3):240-50

4. Djeu, G., C. Shelton, and A. Maganzini, Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop, 2005. 128(3): p. 292-8

5. Kuncio, D., et al., Invisalign and traditional orthodontic treatment postretention outcomes compared using the American Board of Orthodontics objective grading system. Angle Orthod, 2007. 77(5): p. 864-9

6. Gu, J., et al., Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. American Journal of Orthodontics and Dentofacial Orthopedics. 151(2): p. 259-266

7. Zheng, M., et al., Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis. Orthodontics & Craniofacial Research

8. Kravitz, et al. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. AJODO 2009 Jan;135(1):27-35

9. Kohda N, Iijima M, Muguruma T, Brantley WA, Ahluwalia KS, Mizoguchi I. Effects of mechanical properties of thermoplastic materials on the initial force of thermoplastic appliances. Angle Orthod. 2013;83:476–483

10. Fang D, Zhang N, Chen H, Bai Y. Dynamic stress relaxation of orthodontic thermoplastic materials in a simulated oral environment. Dent Mater J. 2013;32:946–951

11. Hahn W, Dathe H, Fialka-Fricke J, Fricke-Zech S, Zapf A, Kubein-Meesenburg D, et al. Influence of thermoplastic appliance thickness on the magnitude of force delivered to a maxillary central incisor during tipping. Am J Orthod Dentofacial Orthop. 2009;136:12.e1–12.e7

The Middle Seat

September 13, 2017 by Sean Holliday 3 Comments

Do you ever wonder why there are still middle seats on most flights? In a recent trip, I remembered the frustration boarding an overbooked flight and getting seated on the middle seat on the plane. The fact that most planes are a large sardine can stuffing as many people as possible takes away all the joys of travel. The airline business is the prime example of what can go wrong in a business culture. The service erodes, and with new travel bargain websites, the race to the bottom is in full effect. It wasn’t always this way. Many newer, nimble, airline companies are realizing that great service does not have to add incredible expense. By purchasing long, skinny planes, some airlines are getting rid of the least popular seat: the middle seat. There is a way to improve the flight experience outside of purchasing first class tickets. Soon, domestic flights continuing to force customers into the middle seat will perform what is equal to economic suicide.

Consider that the middle seat is a service or product a business offers that people don’t want, but are coerced to accept anyway. On a plane ride, all seats arrive at the same destination, but the experience sure varies. Seat selections often leave the middle rows to the last minute bookings or stand by passengers. Despite paying a similar fare, it’s a long frustration that many endure in order to make their destination.

Now think of what the middle seat means in orthodontics. Think about the areas of your practice that would be considered the middle seat. Beware of habituation, because most of us have not critically looked at the middle seats we have in our offices: The undesirable appointment times, the appliances patients would prefer to avoid, impressions that gag, separators that hurt, broken brackets, unavailable emergency visits, long wait times, inflexible financial arrangements, extended treatment or inefficiencies that add appointments to treatment. The list can get pretty long if we take the time and courage to critique our process.

Orthodontic treatment isn’t just about the outcome, or “destination,” it’s mostly about about the experience. Whether your service is “first-class” or you serve those who typically ride in coach, think about those middle seats that will not be tolerated in this new economy, and this educated consumer.

Augmented Reality in Orthodontics

September 5, 2017 by Sean Holliday Leave a Comment

The Digital Twin

It seems that virtual reality (VR), and augmented reality (AR) are hot these days. With the launch of Pokemon Go and the AR tools from Apple, these new technological advancements are growing in utility and reaching customers for mass consumption. Besides offering a novelty item for gamers and hobbyists, have you considered the possibility these could be used in the business community and even the orthodontic specialty?

Augmented Reality

Augmented reality is a view of a real-world environment that is digitally enhanced or augmented by digitally created video, images or sounds. Most AR is done on a real-time basis to enhance a real-world experience with digital data. Augmented reality is intended to enhance a person’s current perception of reality. Virtual reality, on the other hand, replaces the real world with a simulated one.

AR was developed in the early 1990’s. The first functional AR system started with the Virtual Fixtures system developed at the U.S. Air Force’s Armstrong Labs in 1992. At the core of an AR system comes a display that integrates the real-world visualization and the computer generated data. Display options include eyeglasses, HUD (heads-up display), contact lenses, tablets, virtual retinal display, eye tap, spatial projectors, and headsets.

In the evolution of digital interaction, we have come from the personal computer to tablet computing, and the next innovation in interface with technology is AR.

Wearable AR Devices

Smartglasses – Google glass was introduced in 2013 by Google X. Due to privacy and safety concerns, the project stalled after criticism and legislative action. This technology has since been relaunched as a business solution, the Google Glass Enterprise Edition. Several partners have integrated these glasses with built in heads up displays. Even in the hospital setting, the goal is working smarter, improving communication and saving doctor time. Other industries have also embraced the technology to improve work efficiency and reduce errors during complex procedures. Glass promotes staying hands-on, working smarter and more collaboration by being able to access instant expertise.

Smart Phone AR

Pokemon Go – became one of the most profitable mobile apps in 2016. This very popular game created a movement in traveling around town to integrate real locations revealing fantasy characters and avatars. This new concept has proven that the interface is interactive and has mass appeal. Once you get proof of concept, the next step is taking it from gaming to business applications.
AR Applications for iPhone and Android – Earlier this year, Apple announced to it’s app developers what is calls the AR kit. This new software development for iOS will open doors for software developers to create AR applications that use the camera and device features of the Apple ecosystem to further enhance the experience and interaction of the Apple culture followers. The games and applications that were demonstrated revealed how games and further interaction between the digital and real world will overlap more in our lives. One example of this new use in in the Ikea Place app, where furniture from the Ikea catalog can be placed into your room using AR. This way you can try before you buy. Try before you buy smiles…the future is at our doorstep.
Bridge from Structure – Structure has developed a camera that integrates with tablets and smartphones to further enhance the built in camera. It does this by adding a 3D scanning device. Rooms and objects can be digitized to take the real world and bring it into the virtual world. The Bridge device unites them into a VR and AR world without the need for complex design systems. The headset and camera combo allow users to create their own AR experience they call a mixed reality.
Creo – I was impressed to see a recent webinar from PTC, the developers of Creo, where augmented interactions between the physical world and the digital world were presented. An image was shown of a motorcycle, and augmented reality would blend with the real image to add digital tools and metrics to further diagnose the status of the motor bike or any other CAD design. This software can enhance the digital design and integrate a digital twin into the process. Although this company is not in the orthodontic field, imagine our new orthodontic reality is growing in the digital space. CAD design is already here for us. Augmented CAD design can move into our treatment planning and treatment monitoring process.

All of these AR functions got me thinking, we are not far off from having a patient interactive, augmented reality solution for orthodontics. Imagine an application where special glasses, a tablet, smartphone, or an intraoral scanner could augment CAD treatment design, 3D diagnostic tools, progress tracking, compliance indicators, tooth movements rates, space closure, and treatment simulations over real images. These could take systems like clincheck, outcome simulators, progress tracking, 3D imaging and treatment monitoring to the next level.

Orthodontic Apps Nearing Augmented Reality

Current systems are using a separate interaction interface, where the patient or doctor see the treatment from a third person perspective. Imagine getting an augmented reality view where progress or proposed results are visible in realtime and overlaid the actual patient. A true blend of the digital and real-world is a natural evolution of at least three of the current available technologies:

Dental monitoring1 — Dental Monitoring App

Align_iTeroElementProgresstracking — iTero Progress Tracking

Align_iTeroElementTimeLapse_1 — iTero Timelapse

As AR and VR grow. Let’s not forget that technology continues to penetrate our specialty and will drive future growth in treatment modalities and patient education. Imagine how AI and AR can further enhance the quality and experience of patient care. New innovations and change can be scary, but for many of us, these are exciting times.