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I entered my first patient into Amazing Charts yesterday and I can definitely see the advantages.
Currently, I am using Dragon to dictate into patient folders that I keep in My Documents.
I think that a hybrid EMR would work best for me and I would love to have your opinion on whether it is, in your opinion, feasible.
At this point, my ideal situation would be:

1) My desktop server networked with my receptionist/office manager's laptop (her computer is connected to our all in one laser printer/scanner/fax).
2) When a patient arrives for an appointment, my receptionist would print off a summary sheet that includes the patient's ongoing problems and current medications and ask the patient to check over for accuracy. This sheet then becomes the front of the patient's paper chart for the visit. She then attaches our paper progress note that will include the patient's name, today's date, space for chief complaint, space for vital signs and PE notes, space for diagnosis, lab orders and plan.
3) I will carry a laptop, but, preferably a tablet, PC with me in to see each patient, but use it only for reference for past visits, health maintenance etc.
4) I will, as time allows, go to my office and complete the Amazing Charts documentation using my paper progress sheet as a guide. The summary sheet, with any notes I have written for the patient, will go with the patient. The paper progress sheet will go into the patient's paper folder for an undetermined time.

Since I am in a solo practice, this plan would allow replacement physicians to sit in for me when I am on vacation, CME trips etc. I would not schedule full physical exams during those times and I would have the option to scan in the paper progress sheets from his/her patient visits and he/she would not have to train on my EMR and Dragon.
I am unsure on how to network my tablet PC with my server; should it be wireless (would encryption make this safe in a University building?) or should I simply take my backup CD from each day and load it into my tablet each morning?
I still want to attempt to do all of this without my patient computers connected to the Internet. I will have an Internet connection with my personal laptop and printer.
I am having a bit of a problem with my trial and error on Amazing Charts (I lost one daily encounter because I could not understand which action saved it). Is there a primer, either written or electronic, that would guide me through?
The primary question that I have is whether this plan, or which part of this plan, is feasible.
Best,
Jim
Jim Blaine, MD
Springfield, MO

Jim,
Welcome to the Club! Have you gone on the basic AC webiste yet? John gives a nice rough over-view of how to set up a basic P2P network which with only 2 computers in the office is all you really need. It you want easy rock solid connections, then wires are always more reliable than wireless. But that being said many of us are using wireless with good results. I have tried a few and my Netgrear MaxRange wireless router with the seven internal antenas is doing really well here and we have 2 other networks near by and we use a 2.4 phone system to boot. But yes make sure you "lock down" your network good and tight no matter what you do. In Wireless use nothing less than WPA encription, use static IP's if you can and most importantly, use MAC addresses. Then only those specific cards, wired or wireless are allowed on your network. All others are not welcome and can not get in.

As I've said in other posts I first paid two different gurus to set us up with two different routers. I got fed up with being dependent on these guys and have less than stellar results. I bought Wireless Networks for Dummies and quickly learned how to lock up my system tighter and set it up better than these supposed experts. You are obviously an intelligent guy, your a doc for goodness sake, take some time over the weekend when all is quiet and you don't need your system to work. The first few times you struggle with it you may get a little frustrated, but do it once or twice and it starts to make sense.

There are many good posts here about basic set up and networks, brouse around. I'm sure you'll do just fine. Good luck in the next few days....

Paul

Jim,

Hi. Welcome to AC. I will try to help. I hope you don't mind if I throw in a few opinions on your ideas.

First, it sounds like Amazing Charts will be perfect for you. Solo practice. Not many computers. Very nice.

I think the summary sheet is a good idea. The only issue is I find the summary sheet to get a little convoluted as the problem list is more of a list of diagnoses. But, see what you think.

If you could get the courage to do it, I would try to get rid of the paper charts. I know it's like a lifeline, but they are costly, and then you find you have data in two different places.

The biggest issue I have, and the one I hope I can persuade you to change is the paper progress note. The whole idea of an electronic medical record is so you can document electronically. AC is, by far, the fastest EMR on the market in terms of documentation. Why not document right in the room, save the note, and be done with it? I am not sure how many patients you see in a day. If ten, then write it all down and go to your office later and do your note. But, if you see 20 to 30 patients, you will find yourself charting long after your last patient has gone for the day. Then you will find yourself trying to remember those tiny details. You can do all of your charting in the room. If you discipline yourself, you can make sure you finish your notes before you leave the room. I make it a rule to even type my consult note before leaving the room. Out of the room = done with the patient encounter including documentation. Now, even though you may forget a detail or two by documenting later, you probably can write a more thorough note, but I think that is offset by the amount of time you waste doing that.

I understand your idea about your visiting doctors. But, I have medical students documenting and saving notes on day 1. AC has no learning curve. It's flat. You can figure it out in one day. If you scan in the paper notes of the locum tenens, now you have progress notes everywhere instead of in Past Encounters.


If would have to be wireless unless you used wired RJ45 Ethernet jacks and then plugged a patch cable into the laptop each time you entered the room. I would suggest using a good Wireless router with WAP or higher and using MAC addresses as suggested by Paul. I think DHCP is just fine and just as secure. With wireless, it's a good idea to limit the DHCP scope on the router to the same number of computers that are on the wireless network. I am not sure what you mean by the Backup CD, but I would say no. I would use the wireless router to connect to the "server" and access your data. Also, your reference to the backup CD infers you would have one daily backup. Make sure you have at LEAST two weeks of data backed up on CD-Rs or DVD-Rs and not CD-RWs. And, take home the Friday CDs.

http://blogs.techrepublic.com.com/window-on-windows/?p=189


Why do you not want to connect your patient computers to the Internet? The Internet is where all the information is. Just from my perspective, but I would estimate I use the Internet at least 20 to 30 times a day. Too many good sites such as Lexi-Comp, eMedicine, UpToDate, etc. to have to wait to look it up. If you have a good firewall configured correctly and use software firewalls such as Zone Alarm (free), security shouldn't be much of an issue. Just as with medicine, it's a risk/benefit issue; and my thought is the benefits far exceed the risks.

In the program itself, the help contents are very extensive. You can read through them. It shouldn't take long for you to feel comfortable saving a note. You can continue to print them out (paper again) or print to PDF and save in a folder for awhile for security until you feel comfortable just with the electronic chart. It's nice with an MA because he/she can take all the subjective data and forward the chart to you. So, at first you can open the chart from there and choose not to delete it from your inbox, so you will always be able to go back and at least still have the HPI, ROS, Vital signs, etc.

Well, there you go, I knew I would take a completely opposite approach. Hope it helps. Feel free to email or PM or post back with any questions. Welcome to AC.

Cheers!

Jim,

Break the paper habit! Currently I have a desktop and printer in each exam room. Refurbished computers and ebay laser printers and 17 in. CRTs can outfit an exam room for under $550. Yes, the ebay printer is sometimes quickly recycled, but when you find one that works, it's good for years. I see 20 to 25 patients a day and all but 5 notes are finished in the room before the patient leaves, that includes all lab orders, imaging orders, and prescriptions. It helps to type fast, but Dragon Naturally speaking was working fine with AC last time I tried it. I just like typing better. Wireless laptop would work well too, but you may have to go through a few routers until you find one that works well. I recommend Buffalo.

Thanks Paul, Bert and Kevin,
I plan to take your collective advice and attempt to go paperless. The College IT department is going to set up a wireless network for me. I will have a new laptop in my two exam rooms and at the receptionist/office manager desk. My desktop server will be in my office. I will continue to attempt to integrate Dragon v9. I have already learned the hard way (signed my charts before I checked them closely for Dragon errors) and I now forward them to myself to proof read during a quiet time. I love the advanced search feature! Hopefully, we will be able to connect our LabCorp computer to the AC and have direct entry for the lab.
I would sure like to have an AC meeting to attend to pick up more pearls, but I am very appreciative for the advice I have recieved here.
Best,
Jim

Jim,
Glad we could help. AC meetings are something some of us have been knocking around here. Where are you in this here big country? Some of us East Coast and New England guys keep trying to have a get together. Anyway, break a leg...
Paul

Jim,

You're most welcome. Let us know how it goes.

Paul,
I am in Springfield MO. Apparently, I am the only one in the area who is currently using AC.
I have a new clinic that cares for the full time employees and their dependents at a local college (Ozarks Technical College).
I am paid on a per employee per month basis via a contract with the college and so there is no patient billing.
Our clinic has been open for three weeks and I have a hundred patient on AC so far (I am responsible for 455 employees plus their dependents).
I attempted to burn a backup CD on Friday, but, although the CD opens with all patient data on the server desktop, it opens without my patients' info on my home computer.
Have you had any problems with backups?
Thanks,
Jim

Jim,
What an interesting business model. What do you do about consumables that can get very expensive? Like vaccines and other less expensive but still they add up things, like gowns, speculums, ECG leads and all the like? Are those factored in to your per patient price structure or do they purchase those for your use so neither side gets banged on those? We are so wanting to get out of the present insurance carrier control and cheat you model. If you don't mind, please tell us some details... Thanks much.
Paul

Paul,
I have spent the past four years starting a clinic at Paul Mueller's Stainless Steel fabricators. I was paid $135 per hour without benefits and took care of 1200 employees and their dependents. I worked with a company called Care ATC out of Tulsa. The practice was enjoyable, but I lacked control and this was stressful.
I was asked to put in a bid for the Ozarks Technical College earlier this year, I won the bid and entered the contract on my own. I am paid $40 per employee per month. The college provides me with a beautiful office in the Allied Health Building and I provide a turn key product that includes all furniture, equipment etc. I also provide all routine lab (lipid panels, chem panels, CBC, TSH, PSA and UA's); I contract with a lab in KC (LabCorp)and estimate $2,000 per month in lab costs. I pay the salaries for my receptionist/office manager (my wife) and my nurse (a Missouri State University grad student in public health who is a licensed physician in India)along with all insurance premiums for liability. The 455 full time employees and their dependents receive unlimited office visits, office minor surgeries, routine lab, and EKGs. We bill their insurance companies for other labs, PAP smears, path specimens etc. I provide tetanus, strep tests, and flu tests, but the college pays for flu shots. Routine childhood and adult pneumo immunizations are provided by the health department or paid for by the patient. We are open for patient care four hours per day three days per week. We arrive an hour early to do blood draws for physicals and to finish up EMR records (I have learned to dictate my charts with Dragon and forward them to proof read them later before I sign them). I anticipate that we will add the part time employees within the next 6 to 12 months. I do not anticipate becoming rich, but, so far, this has been a very enjoyable practice.

Jim,
I am a new registerd user on this board and currently evaluating AC for my wife's (an Internist) here in Oklahoma @ Texas Border.
I am not a doctor but work in Software industry, though currently taking a break from it and helping setup the practice that is a year old.
While browsing this board the first time, Your business model intrigued me to ask more details and questions if you don't mind answering.

1) Is this contract an exlusive one or do you also see other patients from the community?

2) What is the possible size in numbers of patients in this pool of 455 employees.

3) How many from this pool you see everyday?

Based on your info. 455 * 40 does not add up a whole lot...If you don't mind sharing more info, please let us know here or I can be reached by email at bryanmedical@gmail.com.....I have a business mind and therefore always look for ideas to improve or get in something new.

Thanks,
IB

Are you kidding? 40 times 455 x 12 = 218,400

Subtract $24,000 for lab fees.
Subtract liability insurance
Subtract $15 per hour for the MA x 12 x 50 = $9,000
Anyway you look at it, paying your wife is basically free.

There are some other charges with the some of the procedures I can't quantitate.

That still seems to come out to $165,000 annually as an estimate. That for 12 hours of work a week. Even radiologists and anesthesiologists don't have it that good. I would certainly take it. Of course, I may be erring on some of the numbers. And, my guess is the number of full-time employees will only go up.

Jim,

Burning the databases to CD should work on any computer. I am not sure exactly what you are doing or why it doesn't work. On some CD burning software, there are settings at the beginning or more likely at the end that allow you to use the CD ONLY on that PC or on all.

I estimate approximately $2,000 per month for lab, $1,000 for my nurse, and $2,000 per month for insurance, equipment and consumables.
The twelve hours per week so far is more like 30 hours as we are in the office every day, but it may settle down a bit. Currently, we are averaging around 15 patients per day three days per week. The previous company I worked with charges $45 per employee per month to see a employee population that includes all dependents. They provide salaries to the physician, receptionist and nurse along with an annual health risk assessment (lab, BP etc.). They do not provide daily lab, or any of the clinic furnishings, equipment or daily consumables or insurance. By eliminating the middle man, we provide more service and allow the physician more control (less stress). I have a few patients, mostly friends, that I see in addition to my regular practice. We anticipate adding another 450 employees plus dependents to the practice within the next 6 to 12 months (part time employees at the college). The college also has 10,000 students (non residential) that may be added in the future. Hopefully, the plan will be a win/win for the college and for us. The Springfield area has a deficit of primary care access and the college is considering self insurance; the emphasis we are placing on prevention should pay off for them.

Bert, IB and Paul,
Most companies with over 500 employees are self insured and adding an on site clinic is rapidly becoming the norm (approximately a third of the companies on the East coast have on site clinics).
An on site clinic allows employees to clock out, have a clinic visit, and be back on the clock within 20 minutes. This compares to four hours at a traditional clinic when you include transit time etc. The routine preventive medicine (hypertension, hyperlipidemia, diabetes diagnosis and manaement, tobacco cessation and cancer screening)has been very cost effective. Estimates range in the 3 to 6 dollars per dollar invested. Additionally, the on site clinic has been the most treasured benefit of the employees and should significantly improve the employee retention.
We advocate annual history and physicals (the companies like to refer to them as health assessments) on the patients' birth month. We do quarterly general reports (no names)and guarantee to our patients that they will be seen on the day that they call if they are acutely ill. This is a model that allows for primary care autonomy. Many companies are interested in on site clinics to improve employee health and to control health care costs; I suggest offering a turn key deal (companies do not like surprises):
A fixed amount per employee per month to include spouses and all dependents.
The company supplies the office and utilities and you provide everything else: All employee salaries and benefits, all office furnishing and equipment (approximately $20,000 for me), all insurance, all routine lab including annual physicals, all EKGs, all office procedures (minor surgery, PAP smears etc.). The companies will also insist that you indemnify them for all liability.
In my opinion, it is important that the employer values the benefit to the employees as a priority over financial savings.
I am not much of an entrepreneur (I chair several not for profit public health committees as a volunteer), I do wish that I had discovered this model earlier in my career (I will be 60 next month).
Jim