Home Forums Discussions Problems usability issues with version 6.0.9

I really don't think everyone is being fair to stylnchris. (stylnchris if I am going to take your side, you need to use a signature with a name )

The last five or six posts are saying the same thing. Can't afford better system, don't need to especially with AC and can't afford IT.

styl is a new user, and like me when I started was shocked to see the setups people use. It isn't that it has always worked, it is that it has a better chance of failing and will never work as efficiently even though it works well enough.

We have all heard patients say, "I have never had a flu shot and have never come down with the flu," This is poor logic.

Styl is saying that your data is your whole career and as such it should be on a server-grade system. If you choose not to due to funds, that is fine. It is just reality. I think saying that AC is kind of a DIY program makes no sense.

As I said to Styl, he hasn't had the benefit of reading the Peer-to-Peer wars and the fact that like the Brother vs Any other MFC is a useless argument.

I also need to state once again that AC is not the only software you use. A server allows all software to run better and safer.

If I may speak for Styl, he is not saying don't run AC on a P2P, he is saying it scares him to think of it. I think there is no wrong here.

Exactly. You can run a server with a server operating system and do it in a Peer to Peer fashion + have all of the benefits of a real server.

I suppose this conversation will always end with us agreeing to disagree. In part that is because we have different personalities and different levels of "risk tolerance", to use an investing term. Many of the arguments for a more robust system center around disaster planning. We have a fairly simple and inexpensive system of onsite/offsite/online back-ups, and a disaster plan that has us up and running in an hour in the event of most eventualities. It is a plan with which I feel completely comfortable, but one which might make Bert shudder and lose sleep. That is not a criticism of either of us, just a reflection of different priorities and comfort levels.

Bert, I think I have to take issue with your statement "I think saying that AC is kind of a DIY program makes no sense." Actually, I find that ironic coming from you, the guy who has been the king of "doing it yourself" from the beginning. Not only do you know your network in and out, you have actually developed FAP and other programs to make AC function better. That is "DIY" from the hardware, software, AND network side. I think that this is a two-edged sword: it is good that AC CAN be DIY for many of us, but it is a barrier to more widespread use of the program. I am hopeful that someone (Indy?) will develop a straightforward, turnkey approach to installing and implementing AC that will not require so much time, energy, and IT knowledge from all of the docs afraid to jump into the EMR pool.

One way that AC differs from the eClinicals, Cerners, etc, of the EMR world is in the LACK of hardware requirements. The first thing most EMR buyers hear (after "$10k per provider to start and $500 a month") is "you need a new server...and operating system...and upgraded clients". They are not told that FIRST- it is an unpleasant surprise that comes later. I like the fact that AC can run just fine on an inexpensive network that is easy to maintain. I think it is a selling point.

Somebody should do an "AC for Dummies" book. We have had more issues upgrading to V6 than V5 but they were not AC issues. They were hardware and networking issues.

Here, here! Where can I order "AC for Dummies"?

I think you have been reading it here. Written by and for dummies.

Did you see the final post in this thread? Since the crashes involved the Crystal Reports rx writer in many instances, this may be worth trying. Best of luck, and post back if you try it -- it will help us cowards who are waiting to upgrade.

I have to (as usual) agree with Wendell. The future reimbursement possibilities for all of us small practice docs is looking bleak. We have to be frugal where we can, and having experienced both the IT-supported (Medical Manager) and self-supported (AC) EMR/PM scenarios, I can control expenses with AC better. And having gone through a few "near-death" experiences with office hardware and software (including a hurricane), I have a good feeling that my backup methods are sufficient.

As to providing my staff with different computing environments via a server domain, it would take too much effort on my part. And they aren't interested -- I see that "deer-in-the-headlights" look whenever I usurp one of the staff meetings to roll out a new feature. Most common response when I finish up and ask for questions: are they still going to be able to get home early enough to pickup up the kids from practice.

The future? -- it's interesting to read some blog posts from EMR users who have given up on both local IT and self-management. This could be the next big EHR trend. Is AC ready?

Little bit of trivia - one of the first "Dummies" authors was a classmate of mine in high school. He and I both tinkered with the mainframe; he changed grades for money, while I did stuff then backed it up (paper tape !ha!) and made it disappear while the district staff tried to find it. He got caught - I got a scolding [no evidence]. He went on to make millions, I went on to keep writing software and then complete systems.

No regrets, but I smile every time I see a "Dummies" book.

As my Italian Grandmother used to say, "Were your ears burning this morning?" I just had to read further up the thread. Such wisdom, I miss her dearly.

While I wouldn't have guessed it three years ago, our client base is far more geographically diverse these days, and I have become accustomed to helping folks in facilities I have never seen.

I had an epiphany as a result of ACUC and the interactions this year, and I understand better a calling on me for this season of life - I'm in the Provider Care business.

IT is pretty common to take delivery from a hardware vendor (Dell, HP, Cisco, etc), configure for a client particulars (location, network, software, remote support)and ship it on to the client where they can "plug & play".

We'll have an announcement next month about some things that we will be offering for folks who want to use AC but find technology a frustration/distraction/hindrance.

In the mean time we have actually found an interesting [and unintended] use for the secure computing environment that we have built - testing AC conversions of practice data so that Providers can try out the new version remotely with their data. It is easy enough for us to recycle/re-provision as necessary, and it doesn't impact the operation of the practice.

Here I was thinking that I was going to RI a couple of years ago to give a quick presentation on basic security and enjoy the waterfront.

There is some middle ground in the professional IT/ DIY discussion.

I agree fully that someone in the owner's circle should have a full handle on all aspects of their system. IT people are just one more potential failure point, and someone has to be able to bridge until they could be replaced.

That does not mean, IMHO, that that person should spend be the one actually dealing with each issue. I know how to vacuum the floors, but I make more money if I let my janitorial service actually do it while I do medicine. But, if they go on strike, I can vacuum.

There are plenty of IT services around that are not "corporate IT departments", but typically a couple of guys who rent themselves by the hour. We also have a fairly knowledgeable staff member ( actually the wife of one of the IT guys ) who can help with a lower level issues. If something breaks during the day, my staff member has a go; if she can't fix it quickly one of our IT guys logs on. Failing that, he swings by. All the while, I keep doing my job. Total cost even for more complex issue was $100. And it was done to current professional standards. And I didn't tear my hair out. And my partner and PA' s were not yelling at me to drop everything and fix their problem. I can play with the computers all I want then in evenings and on the weekend, and feel technologically fulfilled without disrupting business.

We each spent in excess of $200,000 getting to where we are. $100 spent to let me bill $400 just seems like common sense

Wow, was I misquoted. When I say DIY, I mean the person who builds his own deck after watching a Home Depot video. Comparing that to a top-notch, incredibly talented programmer who took a year to develop a program is NOT do it yourself. If you use that definition, then Windows is DIY by Bill Gates.

Thank God for David Grauman who understands the place for IT. Posts or others notwithstanding, I have never heard of anyone talk about an IT person who seems dependable or worth a damn. If the IT person doesn't have MVP after their name, they probably aren't someone I would want to use.

To quote John's blog story, here is the IT person she chose to help with her mission critical data:

Therein lies the problem. Like using a five year old computer for your databases that is shared with your receptionist, using an IT person who is "small potatoes, albeit "pretty smart" and capable.

An IT person should most of the time come from a reputable company. I ended up not needing this company, but they refused to take on my company without doing a complete walkthrough and understanding the network, my topology, my server, etc. They needed the program (key). These were Microsoft people with 24-hour service. The important thing here (if I may guess what David is thinking) is that when they do things, you are allowed to learn from them. They should be able to remote in.

Finally, there is Microsoft themselves. Yes, they overcharge. But, they will start working on your computer immediately if necessary, their support (once obtained) is unbelievable, and they ALWAYS fix the problem or they will refund the money. While this may make some shutter, I had one support tech who figured out the problem but needed hours to fix it (on the same $250.00), said to me, "Bert, go home and get some sleep. It will be fixed in the morning."

David is dead on. Have someone you trust. Do it yourself when possible, but have the expert come in when needed. By expert, not the 17 year old in your practice, who learned computers at 9 ears old and excels at Call of Duty.

My biggest frustration with AC is the way the versions roll out. All of my other applications come out with rock solid versions every year to three years. I don't have to worry up uninstalling or installing over and then updating all of my client software. I don't have to use database tuners. And, then I don't have to do it all over again when nine bugs are four in the product. And, most of them realize that if there is one particular issue causing problems, e.g. ePrescribe and TSP800, they make damned sure those are workable when the product comes out.

And, John, I apologize if I am being a smarta... I just can't help it. Remind me, if I have a thyroid problem, not to use Dr. West. Do not most of us print out our Superbills the night before? Does he only have one printer? And, why do they watch a technician fix a scanner for three hours? Why is a scanner vital to a practice moment by moment. It all goes back to solo practice and the money. For my money, Dell is unbelievable. You don't pay that much and you can get five hour support. I don't mean on the phone. I mean a live Dell technician, level whatever, WITH the hard drive in hand or whatever, with your computer likely fixed in under two hours.

No, I understand & I agree with the gist of what you said. However, I have no inside connection or skill to tell me who is a good IT person. And Dell and Microsoft will not want to take a crack at an AC problem, or an internet problem. So many of us, probably most of us, have had frustration with IT help, either cost or inability to fix the problem.

So that leaves at back at Dr. West's outcome. I think David said it well -- why spend $400 of patient time on $100 IT problem. And if the not very technologic Dr. West can dump off most of the tech stuff by using a cloud solution...well it makes sense for him. I suspect for many others as well.

As you referred to above, it's very tedious to install & reinstall every bug fix version. What if AC could work on the versions, and push out the solutions when I log on every day? Most of us can keep an internet connection going. And the rest goes away.

Well, first, I have been lucky to get incredibly good online support in Networking, SQL and Hardware by going to Experts-Exchange. I have 505 posts there and have met some great IT people whom I trust explicitly.

As far as finding IT people, it's the same as finding a good MA or a good contractor. You have to work at it and use word of mouth. My point is not that Dell or Microsoft can fix AC, they are an example of good, dependable IT that will cost some money. The issue is, it isn't usually AC as too many people on here are way too quick to jump to, it is their server, their main computer, their network. As Rob (network person) always tells me (in my domain environment), it is DNS, DNS, DNS. Not AC, AC. We need AC support for glitches in AC. Dr. West needed It who could fix his printer and scanner, neither of which had anything to do with AC, but according to him, resulted in a lot of downtime.

I think if you found a company, not a 23 year old solo IT person, who specialized in Microsoft and were Microsoft-certified with all the credentialing, they would be your IT. They would come out and look at your network. They would start at your modem, go to your router/firewall, look at your switch, follow the cables to your RJ-45 jacks, checkout the NIC cards and use a fluke meter to test all connections and connection speed. They would then know your system is set up correctly and, more importantly, they would know your system, just like you know Mrs. Jones and her thyroid issues. You would be able to call them after hours (for an extra fee), they would promise in the contract to answer the phone or send out a tech that day.

As to your final statement, I have often wondered about how great that would be. It would be like Firefox and, actually, like my three programs where Ed just adds a new update to the web. The next time you open F.A.P. or Firefox, you are told an update is available. I trust Ed. I certainly trust Firefox. I just assume that both have updates that improve the product. These also must use one-click web installs, which AC does not use.

The issue would be exempliefied by, ironically, you and me. Neither of us have jumped to 6.09. Why? Because of ePrescribe among other things. I just wouldn't be all set to update the program that way. And, I would have to trust all of my users to do the same (again where GPO on a server would be useful). Going backwards is not fun with AC.

Well, not exactly misquoted...just misunderstood.



You can see from the blog that he did his fellowship at the place we Maryland grads sometimes refer to as "that East Baltimore Medical School". No guarantee of tech savvy (or common sense, for that matter) comes with the certificate. And Bert, you worried YOU were being a smarta**!


Or what if it wasn't AC: what if it was someone we trusted with technology issues who would run AC on his own servers, only upgrade when he felt the new version was stable, and leave us to simply deal with stripped-down hardware providing internet access from our offices. Could that work?

That is a great idea, Jon. The posts are coming in fast and furious even on a weekend.

And Jon has that eRx incentive check burning a hole in his pocket, too. Real dedication to his Board Buddies!

Yeah, I would think he would send a bottle of wine are way. And, maybe help pay for that server he mentioned.

Hey can I post somethig off topic? Just a mini-hijack? It's pretty cool.

Wine at Tahoe, for sure, courtesy of Medicare and eRx.

Server? To paraphrase a great movie, "We don't need no stinking servers!"

And Bert, ASKING if you can post something off topic? What has gotten into you?

Well, last week I installed a wireless router that is isolated from the network. It is just for the patients. They love it. And, it makes the time go more quickly for them. It serves two purposes for that very reason. It's very cool and costs next to nothing.

We will have to entice Bert to come to Tahoe though. It doesn't appear that he has voted yet.

But who would be crazy enough to do that?

We were counting on you, Indy.

I'm a boss at Call of Duty

Bert, how do you know that they won't download porn and bootleg movies and get you hauled up before the FCC?

He can use his own DNS server or OpenDNS to filter out certain websites. iPrism by St. Bernard Software is often used in corporate and academic environments. A bit overkill probably.

Because Bert is smart, he had the router connected to city backhaul - it isn't his drop. That's what I get for hanging with JBS.

The same reason Starbucks and Borders and I could go on and on. At some point in life, you just have to trust people. The same reason I have never worried about lawsuits and have never been sued.

Actually, it is pretty well locked down.

I can neither confirm nor deny the existence of a enterprise server in a multi-homed, fiber cross-roads, secure location equipped for such an eventuality currently under test.

Nor can I confirm nor deny that such a beast is in a secure session to the server next to me. [Hot Saturday night date!]

If it was Bad Company 2, then we would have something to talk about. Too busy to use my BF3 closed Alpha login. grrr.

Once Modern Warfare 3 comes out, I will probably disappear for a month or two. Ha.

Wow.

Looking at the big picture...

How many applications when updates come out do you have to mess with hardware acceleration or do remote login to get them to work? Prescribing on version 6.09 is flawed. We shouldn't have to upgrade to a quad-core in order to get the software to work.

I am going to call my Dell IT expert in India to see if they can fix the problem :-)

The siren call of off site servers is very, very strong. There are a few folks locally running e-Clinical works like that. The local power company (!) hosts the servers, deals with the backups, offers wonderful IT, and maintains the fiberoptic cable (!!!) to their offices (the only fiber show available in town.) They say it is reliable and blindingly fast. It costs something like $1,000 per month per provider. It's enough to make me wish I were an interventional cardiologist....

I dread bottlenecks and single-point failures. Despite my best efforts I keep finding them; the last one was that I found our big UPS supply could not be bypassed easily if it failed (which it did), leaving me stringing extention cords in the dustbunnies at 7:45 one Monday. The internet connection is one I can't control.

I checked out World of Warcraft one weekend a couple of years back. I became aware of this great sucking sound, which I realized was my mind getting ready to depart my body, leaving an empty husk staring at the screen forever. I escaped just in time. I don't even want to hear about more recent games.

My patients are now able to schedule allergy injections on line through Appointmentquest. To help facilitate this, or just to pass the time in the waiting room, I've considered providing wireless internet access at the office. My network E2000 Linksys router can be set to also "give visitors simple and password-protected internet access" ostensibly keeping the "private network" separate and secure. Any thoughts as to is this truly an option that won't compromise security of the office network, HIPAA, etc?

Most new wireless routers do have this nice feature for visitors. I have one at home (D-Link DIR-655 Extreme N Gigabit Wireless Router) and it is very handy.

At the office, my router doesn't have this feature. My workaround is to have a fonera box (about $50) (www.fon.com) plugged into the network. It is isolated. I just post a generic ID and password in the waiting room so patients can use it for free. Most don't but appreciate that it is available.

I have read through this whole thread -- it is very instructive, but several questions pop up:
1. I have used whatever cheap box computer is available at the moment, along with the latest (starting with Windows 3.x)peer-to-peer networking for medical billing for the last 16 years, and for EMR for the last 6 months. We have had crashes, but none un-recoverable, and backup gets easier and easier. I'm sure that in a multi-doctor environment this would not work, but it does for me. The slowest part is not the hardware, it is me! How could I improve my experience with a server/client setup?
2. After reading about all the advantages of "server class hardware" I went to my favorite supplier, Newegg http://www.newegg.com/Product/Produ...ctSimilar-_-59-115-007_1_AG-_-59-115-006 who offer the Fujitsu PRIMERGY TX100 S2 Intel Xeon X3430 2.40 GHz 4GB Memory Tower Server with Windows Server 2008 for $1000. Is this what the experts on the user board have in mind? Would I be better off if I got that and put AC on it? Could I also put my billing program and "accounting" program (Medware and Quickbooks)on it, and would it improve performance or reliability? Maybe I am satisfied because I have just adapted to poor performance -- I'm certainly willing to spend a little money if it would really help.
3. What is the difference between RAID 1 and RAID 5?

For the record, I don't have any serious problems with speed in AC6.09, although there are some really strange bugs, which I have generally learned to avoid (for example, you can't print the "daily batch" file because every note prints with the name of the first patient in the queue, and if you try to resize the window with a mouse while looking at an imported file the whole program freezes.)

The most serious flaw for me in e-prescribing is the fact that you can't transmit any controlled substances -- even schedule 4 or 5. This is a DEA issue, not AC.

Subject 1:

@Ches I would not use the guest feature of a router in a business environment. The guest feature is for home use. The key is you do not want the Wi-Fi on the same network. With the guest feature, while they are controlled somewhat with a password and some restrictions, they are a small hack away from your data. If you have static IP addresses and multiple ports in your cable modem, you can use a different static IP and a different subnet (your regular network is 192.168.1.x, then you would want it on 192.168.16.x or whatever different third octet). This essentially makes it like it is on an entirely different network down the street. If your modem has one port, run it into a $45 switch BEHIND your main router. Then run patch cords to your main router and to your wireless Wi-Fi. When you configure your wireless, use a different static IP as your public address, use the same default gateway and likely a 255.255.255.248 subnet (depends on your ISP).

I know nothing of the fonera box. Sounds cool. I don't know if it is isolated. I will trust Ken. But, if it uses the same subnet, I would be wary. I am surprise people don't use it more. Where I am, we don't use wireless, ironically we only do for our patients, but the next door office does, and people try to get there all the time.

@Tom First, let me know where I can send you a case of beer. FINALLY!...the first person to ever have acknowledged that there are other programs than AC on a computer. You have truly made my day. Now, point by point:

1. This proves the point. What are crashes. We all can have them, even with the best of servers, but crashes are unacceptable. They should not be accepted as part of having inexpensive hardware. How could you improve with server/client. Once again, are we walking server/client or one with a domain. Think of a Ferrari. Certainly better than a Corolla, but if you can't take it out for a 100 mph spin, then it gives you nothing. If you have a domain, but you don't know how to leverage GPO or Active Directory, it won't help much at all. Backups are better to some degree. Networking in general is better. I apologize if I made server class hardware out to be that much better, but it is much more stable. You can share folders on workstations, but you can share them more easily on a domain. Not many on here run two drives in RAID configs with all of their shared folders on the second drive isolated from the rest of the server. You share that one partition and everything is shared, then you can put permissions at a granular level or vice versa. Don't get me wrong, this can be done on a workstation as well, but not many workstation motherboards will allow you 20 to 64 GBs of RAM.

2. Don't purchase that computer. I would get a Dell or HP and I would buy DIRECTLY from the manufacturer. And, you need their warranty. The will be their for you. Given that Server 2008 generally runs in the $500 range with five user cals, the server must not be that good. Don't forget about the CALs. I will help you with any question you have with one caveat: Buy SBS 2008 or 2011. I prefer 2008. But, a small business server will give you much more than a standard for a small business. Exchange Server, itself, is worth $1,000. Throw in the greatest, most least appreciated program ever, SharePoint, and you are set. It also comes with SQL Server if you get the premium version.

3. What is the difference between RAID1 and RAID5. I love the wording. If you asked "What is the best RAID, you will get, 2 to the 5th power of answers. In a nutshell, RAID1 is a mirror. Two hard drives which in real time contains the exact same data. So, if one dies, you simply pop in another drive and your RAID controller will rebuild the RAID while you work. You must take into consideration that you lose 1/2 of your total hard drive space, but who cares when hard drives cost next to nothing. A RAID5 doesn't use mirror to be redundant. It uses parity. You need at least three drives, but can use unlimited. Here is how RAID5 works: You have, say, five drives. Four drives will contain your data, while the fifth drive will be your parity drive. It contains no data. All of your data is spread across in stripes across the four hard drives. Parity allows the bits 1 and 0 to use a 3rd bit to provide partiy so that in the event that one drive crashes, not only can your computer continue to run, but by adding another drive, it can be rebuilt. Best article I have seen is http://riceball.com/d/content/raid-5-parity-what-it-and-how-does-it-work but that is way more than you need to know. You can lose one drive in a RAID5 whether it ia three drives or nine drives. Lose two and you are toast.

You can use RAID1 as your entire setup or RAID5 as your entire setup. Personally, I use RAID1 for my OS and RAID5 for data. A very popular RAID that people are using is a RAID10. A RAID10 takes two mirrors and stripes them so you have two RAID1s configured in a RAID5 config. Here you can lose two drives and be fine UNLESS you lose two drives in the same mirror, which is unlikely. A RAID0 is two RAID5s mirrored, not typically used.

A RAID10 gives you increased performance and redundancy.

One thing I have not mentioned is hot spares and hot swappable spares. Hot swappable spares is a hard drive that is the same size or larger which can be swapped with the bad drive while the server is running. Just make SURE you are swapping with the bad drive. Even better is a hot spare, which sits in the computer and instantly replaces the bad drive and begins rebuilding. You will notice the speed slow down, but it will be rebuilt overnight. You can get a global hot spare for the RAID1 and the RAID5 and one for each. It is a good idea to have all drives be the same size and brand as well as the hot spare. You should have another drive ready to replace the hot spare. I know, TMI.

The advantage of a server/client or server/client domain lies in its ability to give you better redundancy, some increase in speed, less chance of need for maintenance, etc. I don't think you will see a measureable increase in speed in your programs.

You can use ePrescribe with Schedule II and Schedule IV and V, although I don't know where they are with the logistics. I think of it as weddings for DEA. The saying for weddings is:

Something borrowed
Something new
Something old, and
Something blue

while the DEA wants:

Something you have
Something you are
Something you know

Absolutely stupid, given ePrescribe is likely the safest way to prescribe. Just give us a password or one of those little things that change passwords every eight seconds. Please.