Home Forums Discussions General Discussion Starting New Practice - need your blessings

Well, I'm sure Mr. Ballmer or an associate can tell u a zillion reasons why it must say "Pentium Inside."

Short answer, yes. Long answer, depends. The older Pentium-based Celeron processors had very little cache and were outdone by most processors, i.e. Pentiums, AMDs and its counterpart, AMD's Duron.

Intel now makes a Conroe-based core architecture which is very cheap and better than the older Celerons and is single core.

Bottom line. If you already have a Celeron processor, then it's most likely fine for office computing. If you are going out to purchase one, then get either Intel Pentium or AMD. You can debate Pentium vs AMD forever, but we all benefit from their processor wars.


Actually, that is not true. Business-N is very available in the U.S. and is on many of the DVD disks. Business-N is pretty much Business without the media player and movie maker. Due to the European lawsuit with Microsoft, the media player was not allowed to come with the OS. Europeans still buy them without the "N."

I see very little reason to purchase the Business-N since it costs the same. But, if for whatever reason you came across a copy with a CD Key, I wouldn't advise throwing it away. You can install it and simply download Windows Media.

Bert said, "...I woke Adam up...so I should get some credit.."
PKA then said, "Chill."
Bert then replied, "I was just kidding."
I never knew such a statement would get so much play. Of course, this thread has taken on a life of its own.

I did call Adam and asked him to comment. He was sleepy. I just figured saying, "I called Adam when he was getting ready for bed and asked him to comment," just didn't sound as good as "I woke Adam up."

Now before anyone else comments on the above silliness, I am just having fun, kidding, you know joking around.

Happy New Year to everyone.
Just saw on TV.. NZ and Ozzie have already celebrated the ball-drop.

A bit side question- What are the benefits of making a S-Corp? More specifically, about vehicle, about hiring my wife so that she can be an employee rather than an independent contractor.
I know that 1) we can pass a small part of profit as non-wage income and save by not paying employment taxes on this non-wage income. 2) some general liability protection

Thanks for all your thoughts. My brother in law (who lives a long way from me) has alot of experience with networks. He likes the idea of the redundancy one would expect from a server set up with an NAS. Here is what he said:

Basically,
1) you set up the NAS (get the RND4425 $877 from Amazon and set it up with RAID5 and an online spare... resulting in 500GB of redundant shared network space for the software and anything else)
2) you set up the first client (allow it to install to c:\...)
3) you move the data from the first client to the NAS (new drive letter)
4) you reconfigure or reinstall the software on that first client to point to the NAS share (using new drive letter)
5) you install the software on the other clients and point to the NAS (using new drive letter)


How does this sound oh omniscient ones?

Bill,

Here is my two cents worth. First, with computing, it doesn't matter how far away he lives. If he lives more than 200 miles away, he may as well be 1,000 miles away. He can still remote in. In some ways, I would go with what he is saying, because as it has been said many times on here, you would have someone to help who knows your setup.

That being said, I would highly recommend going with a server and a server OS such as SBS 2003 or 2008. The NAS you are certainly would server your needs, has redundancy and can do backups, etc. I didn't see where it could do shadow copies or another type of used files snapshots.

There are other NAS such as NetAPPs which cost ridiculous amounts of money with more functionality which you don't need. I would think of this NAS as a great addition of backup space if you needed it. Certainly 500GBs would be plenty larger enough and, as you say, other things could be put there. AC's database would take would take years to file that much hard drive space.

While on the topic of AC, yes, you would either install it on a server, install on server and move the database to a shared drive or best, install it on a workstation and copy and paste it to the server. I haven't done this with SQL, and I am nowhere near a SQL expert, but with the AC databases, you would ONLY need to put the six databases in a folder on the server and share it out.

I am not sure about all the drive letters. Maybe with the NAS, there is something do with that, but say you are using a server or a dedicated workstation for your databases or even a non-dedicated one for that matter. When you go around installing AC to all of the workstations, they will install by default to the C: drive under Program Files. You can, of course, change that and install it anywhere you wish or to any drive you wish. Generally, there is no reason to install it anywhere other than C:\Program Files\Amazing Charts. When you move the database to what you are going to use as a server, you can put it anywhere. Again, there is no need to do anything with the drive letter or change it, etc. Most centralized servers would be set up in the following way:

C:\ for the OS
D:\ data
E:\ this is just my preference, but ANYTHING I install to the
network such as AC or print drivers, Office, etc. I copy
to a drive I call E:\Installs. I even copy all CDs there.

That way, I can easily access any installations over the network, and I know right where they are in alphabetical order. I also don't have to back the E:\ drive up a lot, although I do back it up after a few new executable files.

Again, while your C:\ drive should be backed up on a regular basis, the D:\ drive is the only drive you need to make SURE is backed up all the time. You can always reinstall your OS from the CDs, but you can NOT replace your data. So, it's nice to know that ALL your data is in one place.

So, with this setup, your databases would, of course, reside on the D:\ drive. This is just the most common setup (with the exception of the install drive), but you could set it up anyway you wanted. No reason you couldn't call the data drive J:\ but it just makes more sense to go with C and D, etc. Not sure how Windows would handle the default shares such as C$ and D$ if the letters were changed around and Computer Management - Disk Management would be different.

I am guessing you are most likely on a workgroup currently since you do not have a domain controller. By using a server, you could use it in your workgroup as a "super client." You don't have to use it as a domain controller right away. BUT, you would have the option of using Active Director and connecting all your computers to it in a domain fashion without changing anything in your network setup. SBS 2003 and 2008 come with Exchange Server already, and you can add Exchange to Windows 2000 or 2003. It is much cheaper to go with SBS than purchasing Exchange separately.

Some NASs (I think) can work with Exchange, but the Netgear one cannot. I think the ability to use a server as a file server and other things would sway me in that direction. IMHO, SBS 2003 is the greatest little server for a small business. You will find no better deal. It already comes with Exchange and the company web (Sharepoint) is something you won't be able to live without once you start using it. Sharepoint is just the neatest thing ever, and your users will love it. The premium version has its own firewall (ISA), which is 500 times more robust than Windows Firewall and even better than many hardware solutions. Another nice thing about SBS is the wizards. It makes very easy to set up, although probably not a great idea to set it up yourself for the first time.

When you purchase a server, you can decide a model with a case which allows you to add as much RAM as you want depending on if you are using 32 bit or 64 bit, which most including myself would still be 32 bit.

So that's my opinion.

Here is a picture of our standard workstation.
Linksys SPA942
Shuttle Box with CPU
22 inch KDS Monitor

I agree with your approach with the RND4425.

Setting up the NAS you must decide about permissions and user set up so there are a few more setup details but you have the gist.

Bert's comment about NAS not running exchange raises a valid concern - if you want to run other services than simply a file share (exchange is just one of many possibilities), then you should buy a dedicated server instead as it will have more capabilities. The increased setup is a consideration though for many solo, non-tech practices. A simple NAS out of box can be very easy to setup and administer in comparison.

PKA,
My business is an S-corp.
This helps separate my personal from business incomes.
I have an ex-wife (who doesn't?) and it's very pertinent for me to keep the two separate. You could easily form a LLC, many docs do that. But the income from an LLC is counted as personal income.

About vehicle: I'm not sure if you are asking about a literal "vehicle" or using the S-corp "as a vehicle [toward some specific purpose]" We lease a business car for my business use, and personal use as well. The full cost of lease is tax deductible whereby a purchase can only deduct the depreciated value per year.

If you want to hire your wife, then hire her. My wife worked for me and it worked out great. She was the office manager and office R.N. She worked for pennies on the dollar too compared to what the hospitals pay for R.N.'s.

How do I find a suitable Tech help to set up server?
****************
As to the corp., I will be starting practice while my wife takes a job as independent contractor hospitalist. My idea is that corp will contract with the hospital and then hire my wife to work as hospitalist.
With this arrangement, she will get to get benefits (malpractice, health insurance for whole family, etc) on corp's expense. This way, we will pay for expenses pre-tax rather than paying them after tax and getting some of it back in tax refund.

what do you think?

I have done some search on various types, s-corp is the only one that I am focusing on now.

PKA,

For IT help, go to the following site:

http://www.microsoft.com/smallbusiness/hub.mspx

At the top right, you will see a place to enter your zip code to find a Microsoft Small Business Specialist. There are many IT classifications for Microsoft. Microsoft does NOT give these out easily. Depending on the size of your city, you will get a number of places. Here in Bangor, we get three. I have worked with all three, and I can tell you while they are all good, some are better than others and some work for companies. You may always be better off with somene with their own business.

When you find these places, depending on how many, visit each. Show them what you are looking for. You can have an idea of what you want, but as has not been done on here, write done specifically what you want, e.g. I want a network with seven computers that can run billing and EMR software. I would like it to be expandable up to 15 computers.

All of these MSBS should be able to come out and give a FREE estimate and consult. Some don't, but ask them to apply that to the overall charge. Ask each to provide you with at least three businesses they have set up. Make sure you ask the businesses.

Just as servers offer different types of warranties such as being available to come out 7 days a week, 24 hours a day; or 5 days a week next day, etc. make SURE you know what their support is. Can you be OK with downtime of 24 hours or do you need someone to be able to come out with four hours. Do you want a contract whereby you can get support for no cost for a year or do you want to pay for each time. Pay as you go is probably best, but in the first year, maybe a contract.

Finally, (and this is hard), you are better off using someone who will show you what he or she is doing so you can troubleshoot yourself, but most won't as it is job security.

As to your corporation question, I am not very helpful there, but it sounds as though you are putting the cart before the horse. Not everyone would agree, and I know there are physicians out there that do it all, but you may need a CPA and a cheap lawyer (oxymoron). If you go with a CPA, then he or she can tell you the benefits of each.

Rather than having a thread which is solely devoted to your start up including help with financial questions, vehicles and computers, you are probably better off having separate threads for the network stuff versus the financial stuff. Just a thought.

thanks Bert
you have all the answers

Usually, lol. I just keep thinking of what one of the experts on Experts-Exchange tells me. Most of the problems in networking stem from the network and OS not being set up properly the first time.

Networking is a lot like Scabies. I know, weird. But, John Stokes, I believe it was, stated a long time ago that Scabies was the easiest and most difficult diagnosis to make in dermatology. I think he is right. Networking is the same. It is simple at times, but it can be overwhelming at times. Another favorite expert of mine always tells me something his computer science professor told him: "99% of the time, the problem is DNS related." You can Google it.

No matter what you do, if you take my advice on the following you will be happy. If you are going to purchase a server with an OS, go with Small Business Server 2003 or 2008. You will absolutely love it. Of course, to get the full benefit, it will have to be set up correctly. And, you will need RAID, etc.

Exchange Server (which comes with SBS and can cost nearly what another OS cost on its own) will be beneficial and something you will enjoy down the road. But, Sharepoint will be something that ONLY SBS offers, and you will absolutely love it and, even better, your staff will love it.

I forgot to tell you one thing. You should tell the IT person what your needs are but also give him or her a budget. That will help tremendously.

I look forward to hearing your progress as your progress through the steps of building a network.

Another thing:

Things like Exchange Server, which is basically like having your own email service on your server which has many advantages, can sit there dormantly at first if you don't want to set it up. You can always use POP3 from each computer to your ISP and use Outlook or Outlook Express for email. Your IT person could then set up Exchange when you want to get more technical.

Adam and I both set up our network ourselves with a lot of help with some experts on the Internet and some books. We made many mistakes, some of which kept us up all night as we had to have everything working by 7 AM. But, it is a great learning experience. Whether you do it yourself, and I wouldn't recommend it or not, you may want to purchase a book on it. But, one resource I would highly recommend is the Train Signal courses. They are DVDs by Microsoft Specialists, and they are VERY good. The one on SBS 2003 is invaluable, and if I have to reinstall SBS 2003, I still use it for help. It isn't that costly, and it would be a good idea to sit through the DVD before any IT person installs anything.

I am not truly understanding the reason for the complicated relationship you describe. You wife will work for the hospital and you will lease her services from the hospital? I am not certain if I understand this properly.

Is the hospital providing her benefits? Is that the reason for doing this?

I will clarify Bert's comment: HE made many mistakes, and I subsequently learned from his errors which minimized my own. However I did mess up my own fair share of things.

I love Sharepoint. You will too. It's your Intranet home page, upon which you can post all of your office documents and tools. The staff love it, because everything is right there in front of them. No more searching in file cabinets for papers.

I only had to set up my RAID 10 about 5 times to get it right.
Bert, you must be up to 25 times by now?

can I meet new CMS requirement about e-Rx while using AC? If yes, how?

good question PKA.
My answer is no.
But if anyone would be able to prove that answer incorrect, please let us know !

so what will all the AC users plan to do when medicare comes and says "Do e-Rx the way we tell you or you will not be paid" ????
It WILL happen and it will happen within Obama admin.

I will go back to hand writing or making pharmacies call me for refills. I will not pay for the software to do the government's work.

Leslie

I am not sure if I am reading an anti-regulation animus here or not. Is there a provider out there who believes that the use of e-prescriptions is a bad thing for medicine? I believe that the multiplicity of e-prescription vendors is a bigger issue. What is the "standard format?" Who controls the format? Is it in the public interest?

Now with regards to "it will happen withing the Obama Administration" Check that! It has already HAPPENED IN THE BUSH Administration.

Medicare Offers Incentives for e-prescribing.


There is an old Liberian saying: "you cannot travel far if you want to hold on to the canoe and keep your feet on the shore."

I'm not sure I understand how one can embrace electronic heath records while at the same time rejecting e-prescribing, because it is government mandated.

George, it is as simple as that. First, at this point, e-Prescribing does not sync with AC. Second, many of us have paid for quite a bit of intrastructure for faxing, and it has taken months for the pharmacies to adopt it fully.

The government should not be able to force yet another unfunded mandate upon us. You have to love the algorithm they have come up with.

Those of us who have embraced electronic records should not have to take up another electronic system simply because we can. We are allowed to pick and choose what works for us and our patients.

The other thing is when e-Prescribing is able to allow us to write a script as fast as AC, then I will think about it. But, that is how captialism is supposed to work and/or business is supposed to work. If you build a better mousetrap, then someone will buy it. You shouldn't be able to build a lousy mousetrap and then have the Medicare push the mousetrap down your throats.

And, I know about mousetraps, after all I am Mighty Mouse.

Bert, when you say

You are saying that a missing feature in AC is that it has no support for e-prescribing. Most e-prescription vendors have a STANDARD CERTIFICATION process for each EHR vendor to go thru to achieve technical compliance. You can see an explanation of SureScripts' at:

http://www.surescripts.com/TechCompany/certify.aspx

Now, we have broached this topic before, but at some point Jon will have to make a decision to either expand his development team or to allow 3rd parties to expand the functionality of the product.

It will not be possible, for any EHR Vendor to survive, without adequate development resources to keep up with the rapid changes in the technology landscape.

It does not strike me as an unfunded mandate is MY EHR does not support e-prescribing and other's out there do.

Hello, I am new to AC, I am starting a new practice. I see most of the users are primary care practioners. I was wondering if there are any speciality practioners ( pain management or neurologists or physiatrist or orthopaedics specialists) are using AC? I will appreciate if anyone can respond and share or give some tips in creating templates.
Thanks
TSSM

George,

When a company comes up with an e-Prescribing solution that is very fast and not a ten-step drill down process, I will look at it. It's just not worth the time and effort to use them.

TSSM,

A way to start would be to go to the User List at the top of the boards. Many list their specialty on the right most column.

George,

I quite clearly remember in 1988 when Managed Care was being forced down our throats that physicians were told they had to jump on the bandwagon or lose their funding. This freightened many, many private practices into selling out to hospitals or to larger groups in an effort to "enhance" their bargaining capabilities with these entities. Solo practitioners were told they were "doomed to fail". That bandwagon unfortunately led many of my cohorts down a disasterous slope. I, however, am still plodding along, doing as well (or maybe a little better) than I did 20 years ago and constantly have other physicians ask me how they too can get back into a small practice. I embrace the technologies only if they can prove they save me time or improve my care or the outcomes of my patients. The same way I must pick and choose what tests will benefit a patient and which will not provide any additional useful information or impact the treatment recommendation, I must pick and choose those technologies that are truely helpful. Just because I have the ability to do so does not warrant my ordering an MRI on every patient in my practice. Not only would this mentality among physicians quickly bankrupt our health care system but this mentality is what has contributed to the fall of Wall Street and the housing markets. Oh look!! An empty field...lets build 100 houses on it and we'll get rich! In the end, what works is what works....what serves the users the best...not what has the most technology, bells, whistles, or fancy crap that is useless.
If this Recession/Depression does nothing for us, I hope it will reset our priorities a little. Growth is not always good, just ask the thousands of business that over-extended themselves and now are failing or the cities that have poured billions of dollars into "growth projects" which are now standing idle and unfinished. Or ask the repair industries like cobblers, watch repair stores, and auto mechanics...their businesses are up substantially now. Small and simple and inexpensive are still inherently desirable and we may find more and more businesses looking hard at how to regain this type of mentality.
I agree with Bert ( ). The day e-prescribing improves my ability to care for my patients is the day I will evaluate it. I will turn a deaf ear if it is mandated. It has nothing to do with money. It has to do with principle. I believe those of us who have chosen to maintain simplicity tend to have a bit more of this than those big, greedy (but technologically superior)capitalists you disdain.

Leslie

George,
I forgot to add this in my last post. There is an old Hoosier saying "it is more better to noodle for catfish by the crick shore than git et by sharks out thar in the ocean".

Leslie

quote from surescript site


NewCrop provides a complete electronic prescribing system for the individual medical office as well as ........

The following vendors use certified software from NewCrop for two-way electronic connectivity with pharmacies:

Amazing Charts
BH Solutions
CareData
DataTel Solutions
MDTablet
MedLink
OfficeAlly
PracticeIT

so we have 2 way connectivity in AC if we have newcorp/surescript connection ?? Right?

That is a question for Amazing Charts

Leslie
your points are well taken and appreciated. I was not around in 1988. What do you think next few years will bring for us? There are lots of talks about govt taking over healthcare and socialization of medicine.

{quote=PKA]There are lots of talks about govt taking over healthcare and socialization of medicine.[/quote]
Good question. But, I always love the assumption that the government hasn't already begun the take over. It would like the VA, Medicaid, Medicare are the beginning. And, if you come to my city, you can see the local FQHC not just providing healthcare for those who couldn't get it elsewhere but growing out of control buying up one practice after another.

my biggest fear is the 'baby medicare' plan that they are planning to offer to those who are unable to get insurance otherwise. In all likelihood it will be cheaper than currently available commercial plans and soon it will acquire an ever bigger market share. BCBS etc will collapse (I like that) BUT it also means govt. controlling more of our patients and that means they can impose regulations rather easily than in the past.

PKA,

If I could predict what the next few years would bring in the health care system I would be famous and get to go on the Oprah show. IMO, as long as people have a sense of "Entitlement" and maintain the notion that government is there to take care of them then we are doomed. When people opt for a "change" wherein those that work hard and succeed must give up their aquisitions to those who made bad choices but still feel they deserve to have the same, the end of our culture as we know it is near. The only way I see our private health care system can survive is to remove the responsibility from employers and put it back in the hands of the consumers. When consumers are empowered, things happen. When choices are possible, voices are heard. I remember how nice it used to be when there were 3-4 different small banks in my home town. You could call them on the phone with a problem and they worked hard to keep you happy and thereby keep your business. Now, after conglomerating, there are fewer choices and these huge entities do not really care about me or my pittance of a savings account. If health care continues to follow this route (it is already happening with UHC buying out all the small plans and it could only get worse if it were put into the hands of the government) poor service, poor care and poor reimbursement will result.
Personally, I would like to believe that in the near future the same things that happened to Wall Street and the housing industry will happen to the private insurance market...it will bloat itself until it collapses and then the doors will reopen for small, service-oriented companies. But, for them to survive, we must put the power back into the hands of the individuals. They will then make good choices.
I do not envy you younger physicians. However, if I were younger I would look hard at alternative ways to make a living. Right now I am too old to change but too young to retire...stuck on the hamster wheel just trying to grind out another 8-10 years.

Leslie

This calls for the ultimate I agree with Leslie. VERY well written.

The two worst things to happen to American culture: Entitlement and video games.

In order for consumers to be "empowered" they have to have money. Nearly 2 million Americans have lost their jobs, millions are facing home foreclosure.

What choices are there? The choice of private insurance? When Bill McGuire, the former CEO of United, takes a compensation of 1.6 Billion dollars, yet his company denies benefits and finds every possible way to reject claims, who exactly does this choice benefit?

With regards to people feeling "entitled," the people benefiting THE MOST from this entitlement are the rich. There is NO EMPIRICAL data which demonstrates that the money spent on social programs is more than the money spent on farm subsidies to wealthy farmers AND the Bankers on Wall Street. But it is easy to target social programs because the beneficiaries are poor and do not have the same lobbying power.

If you want to see the sense of entitlement close up look no further than all of the successful failures on Wall Street, who even though their firms are bankrupt and receiving government bailouts, still feel they are ENTITLED TO their multi-million dollar bonuses. Where I grew up a BONUS was a REWARD for doing BETTER THAN EXPECTED, not a reward for failure.

Take a look at the following:

What does it say about a country, that can find 700 billion to fight an unnecessary war, and then say the citizens who are living in a severe recession have a sense of entitlement when it comes to something as basic as health care.

I guess I believe healthcare is a right, not a privilege, and as a result it falls under the "commons" and should not be left to profit makers.

Finally, the sooner doctors RECOGNIZE that the insurance companies ARE NOT, REPEAT ARE NOT on the same side as they, the sooner they will begin to see some progress in shaping the healthcare debate. The insurance companies are already lining up at the trough and saying that reducing physician re-imbursement is one way to reduce healthcare costs...no matter that their executives, like Mr. McGuire, are draining the system of 1,600,000,000.00 in compensation.

George,

I think what is happening with CEOs and the bailout is not entitlement. I do not think the Wall Street has any expectation of the government to give them something for nothing. It was up to Congress to decide if they got the money or not. Entitlement at the Wall Street level or CEO level would be if the brokers and other major financial people didn't go to work and still got paid these millions of dollars.

I do not want to guess what reimbursements your wife gets, but here not everyone sees Medicaid and Medicare. I do, and most Medicaid patients are doing the best they can, but there are some who do not. It is very difficult to be reimbursed 1/3 of what the supposedly terrible 3rd party payers are paying and still watch as those on government insurance go to the ER with an ear infection.

Why do my privately insured patients not go to the ER? Because their copay at my office is $20 while at the ER is more than $100. That is incentive for the patient to take responsibility and wait until the next day to see the doctor. Do you know how many times I see a patient and there are actually three, "because I was bringing patient A in, so I may as well bring in patients B and C.

Yes, the insurance companies are a problem, but when we fight back, the DOJ strikes us down. And, what happened on Wall Street is an entirely different thing than the overwhelming amount of welfare in this country. We are moving each day closer to be a socialist country. That is fine if that is what we want in this country.

If I lost my job today, my friends and family would take me in until I got back on my feet. Then I would go back out and earn my way. That is what we should be doing with social programs.

I apologize for my very simple minded approach to the problem. I am sure I am way off base.

I have already been told by my Amish friends that if I lose my job I have a place to practice with them. They will even set me up with a good buggy horse (I already have the buggy) and my husband and I can get in on the next hog killing social. They will even teach me how to render the lard. I almost look forward to my business here going belly up!

Leslie

And, you can bring your TV and VCR and show the movie "The Witness" with Harrison Ford and Kelly McGillis.

That reminds me. Harrison has gone on to many more movies. Whatever happened to Kelly McGillis?

I went to local grocery store today and took a gallon milk and as I was walking out, store clerk stopped me and demanded payment. I told him that Food is my right. I begged to him. I yelled at him. I told him that without food, I will die. I asked him what kind of brutal society is this where a Madoff scams 50B and a poor person can not even get milk?
He told me- yeah, food is your right, but dont expect others to pay for it. His associates came out with baseball bats.
So much for my entitlementiasis.
:-)
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Now, a real question.
Can I run AC on Apple laptops?