Home Forums Discussions General Discussion Imported Items

I cannot find the thread but I know it has been discussed before. My Imported Items folder is very slow to open. It is currently at 8 GB. Anyone found a way to speed this process up?
Also, I have one computer in which it takes way too long to open the script writer. The others are not so bad. Any thoughts?

Because Imported Items are accessing the file system on your computer, (as opposed to the database files that are cached into memory) things that affect disk I/O are a big deal.

From a maintenance perspective, you can check to see if your disk needs defrag'ed, as that can slow performance.

One client practice has ~65G of imported items, and we are testing out RAID1 of solid state drives(SSDs) for the imported items.

Defrag the server or the client?

I'd start with the server because that is where the files are being served from. It wouldn't be bad for the client either, but that won't impact performance of AC like defragging the server does.

One other trick that you can try on the client machines is to setup a search for "*.tmp" files, and remove the TMP files as they get indexed into memory (depending on several factors), and can also impede performance.

I do clean up the clients fairly regularly, defrag not so often. Will try that, thanks.

Leslie,
When you get a chance, could you give us some follow-up on this. Every now and then, someone posts about II being slow to open, and relates it to the size of their II file. I wonder how widespread that problem is, if it is really related to the size of the file, and if a defrag fixes it.
We have 28 gb of II, and no issues. I sometimes wonder if we should worry about minimizing the size of the file.

Jon, defragging did not help. Import Items are still very slow to open.

Leslie,

Are you using an Intel or Broadcom NIC card on the server or any of the client machines?

And since we are asking questions....

It happens the same on all machines?

I assume it happens when you open II when you are in a chart; how about when you open with F9?

And did this develop gradually, or it suddenly started?

It is worse on the laptops in the rooms (all fairly new) but it is generally slow everywhere. On one laptop the script writer opens slowly but not on the other stations.

Leslie,

Are you using an Intel or Broadcom NIC card on the server or any of the client machines?

What do is the significance of these NIC cards?

These particular cards have certain settings which can significantly slow down your network. If you have WIN 7, have you ever noticed that the first time you click on network after a reboot or first time in a while, that the computers on the domain take a while to load. Of course, this is possibly only happening on a domain.

QoS is particularly bad, but offloading, etc. are terrible.

For those having networking issues with ePrescribe and II opening, you can try the following using an elevated command prompt to change unnecessary settings on your network card:

Disable Receive-Side Scaling

netsh int tcp set global rss=disabled

Disable Task Offload

netsh int ip set global taskoffload=disabled

Disable Add-On Congestion Control Provider

netsch int ip set global congestion=none

Disable QoS

Go to NIC card properties -> Advanced -> Settings -> QoS (delete)

Related blog articles:

http://blogs.technet.com/b/networki...-offload-on-viewing-network-traffic.aspx

http://blogs.dirteam.com/blogs/sand...patible-networking-with-server-core.aspx

http://support.microsoft.com/kb/951037

http://msmvps.com/blogs/thenakedmvp...ld-kill-this-feature-for-the-masses.aspx

Leslie,
Were you ever able to resolve this problem?

AC is well aware of the imported items opening very slowly and they assured me they are working on it (spoke with programmer).

Steven,
Thanks for the response to this. I was asking because I wanted to know how Leslie is fairing with the problem, and if she found a solution.
Also, because as I said above, intermittently people report that their II are slow to open. They attribute it to the large size of their file, and I wonder if that is the case. Any word from the programmers as to whether or not this is more of an issue with a larger file?

Jon,

No this has not been resolved. It is slow on some stations and even slower on others. On one W7 machine it is very, very slow and unstable while on an XP machine (configured the same way) it is much better. However, on that XP machine, the Prescribing window is very slow to open while on the W7 machine it is fine. Go figure. I am still on 5.0.29

Pretty much the same for us. Anyone with a large number of imported items is very slow, sometimes imported items window will disappear behind another window, forcing me to re-open and wait... wait... wait again. Several parts of this program deserve a real makeover by a real software team, not someone who picked up database design as a hobby.

I agree. This is very, very frustrating. EMRs should save time, not take more. I could generally find a paper report in a chart in under 5 sec. There is nothing more frustrating than sitting in the exam room in front of a patient staring at a blank laptop screen.

I thought that was what the price increase was supposed to get us

Looking at this (and some prior threads on the same topic) there are several ideas floating around: a bug or limitation in AC, a networking issue, the size of the II, wireless. Although it has been discussed, I don't see the answer to this: Leslie and David, if you sit at your server and open a patient's II on the server, is it equally slow? (If so, that should eliminate all the discussion about network slowdowns, cards, and wireless, right)?

I predicted this a year ago with CCHIT and MU and PM. There was a time when every provider chose how he or she were going to run their (it should be his or her, but I will substitute the wrong pronoun for sake of time) own practice, whether it meant 10 minute appointments vs 30, doing suturing or not, or using an EMR. Those that wanted to use an EMR wanted to use it to help patients, had some "love" for computers and decided what things they wanted to track with their EMR. Then, as always, the government came along and had to get involved and try to make every physician use an EMR by promising them thousands of dollars. Along with this, though, were certain requirements which, on one hand, may be helpful but on the other hand may not. For me, I have decided not to do the MU. Mainecare pays me $50,000 annually anyway for P4P. But, worse than all this, every EMR company in America had to stop what they were doing to make their EMR compatible with MU. Not only did this mean losing a year and a half of important development and neglecting issues with the software, it only added to them.

When I researched EMRs years ago (and I looked at a lot), I came across AC. The fact that it didn't have a PM didn't stop me. In fact, it was likely much cheaper ($250) because of it. Sure, this means sales of AC were restricted to those who didn't mind using Medisoft, Lytec, Medware or whatever for billing or, more likely, already use it. But, you have to have a niche. A company has to decide are we going to compete with EMRs that have a PM component, or are we going to stay with our niche: the one to five group practice who want an affordable program that can work the way a doctor works and chart fast. In order to keep that niche, a company would have to make sure their product was very good at what it does. It seems to me, given all of the awards and #1 votes AC has garnered, Amazing Charts and Jon have done something right.

In my opinion, what has happened is in the rush to get out MU and the diversion of working on the PM, v6 was possibly put out too early with the script writer and TSP issue overlooked.

I don't know. Maybe I need to delete this message. The big question is how many people would buy the program without MU and how many would have jumped ship if we did not have it. I sort of feel like because of the $44,000 (certainly a tidy sum), we and AC have followed the Pied Pipers in Washington, and we are paying for it now.

Is there anyone on here that can actually say, "Damn, I was practicing really bad medicine before MU came along. Those guys in Washington really got it right. Is there anyone putting up signs in the exam rooms stating your visit will now be meaningful thanks to the government unlike all your meaningless visits in the past?"

** I have no idea if in the future Medicare or the government will require MU for all reimbursement.

** I don't use support much. When I do, they have always been prompt and helpful. Today I needed them, and I couldn't get through. Even my email bounced back.

Jon,
IIs open fine on the server. My set up is wired, dedicated server, clients on a domain (well, that is the way it is supposed to be...there are some domain issues as Bert and Indy can attest).

Bert,

I too did a lot of research before switching from SoapWare to AC. AC had such a nice "small town" feel. I think I miss that the most. I also believe that AC is losing its niche. Jon B and I had our first argument about this at the Branson conference.

But what also ticks me off is that the government is now forcing us to use an EMR, collect their data, and Eprescribe in order to get paid what we are owed. And yet, the Army base at Ft. Knox will not accept escripts or faxes and each medicine has to be written and hand-signed on a separate paper script. Medicare will not accept electronic signatures for durable goods or minineb meds. How stupid is this? As an Internist, not taking Medicare would bankrupt me but I am so ready to tell them to shove it. But I also predict that, if doctors decided they were no longer going to participate in government programs, Congress and States would then pass legislation mandating it as a prerequisite for obtaining a DEA and State medical license. In the end, we are screwed (take that however you want.) Every day I think more and more about running away.

Leslie,
I feel your pain!
You stated: "But I also predict that, if doctors decided they were no longer going to participate in government programs,..."

I have two suggestions;
1)politically, join GOOOH.COM and help really change the government.
2)Think about how much better it would be for THE PATIENTS & doctors if ALL physicians in the United States were to refuse to accept payment from anyone but the patient; No Insurance & No Government - actually meeting the needs of people instead of being puppets to support the GREED of INVESTORS.

Leslie,
We all feel your pain. The only solution is to return to a direct cash pay model. We need to say "I am mad as hell, and I am not going to take it anymore!"

Instead of using our energy bashing AC, I think we need to band together with Jon B. to get through this rough period, see how we can help, and continue to have AC meet the needs of us "little guys (and gals)". Yes, we are frustrated with the bugs in Version 6, but I sympathize with the task of trying to meet these governmental mandates. I do think AC may not have been viable going forward if it did not try to include these criteria. Individuals can choose to use them or not. I still respect the core values of kind capitalism and fairness as espoused by Jon B. I think he has to allow others to help, and stop trying to do everything himself, which is an impossible task. We all have a vested interest in the continued success of AC for the good of our patients.

I have loved AC and this user board for the sense of community that it has provided for me as a new user. I no longer feel quite so isolated in my solo office.

Donna,

You are a better gal than I. I think I recall you have been in practice about the same length of time as I but it seems to have worn me down more than you. Trying to get doctors to agree on anything is like trying to get a donkey across a creek. Big difference is I can usually get my [censored] to cross the creek with a chew of hubby's tobacco....wouldn't work with doctors.

The censored above is obviously assinus equinus

Wait leslie, What kind of chew? I'm about ready to jump to the latest AC 6.*. I am using 5.029 and it's working well, but I am thinking about the "pot of inflated dollars." I could use the cash. Am I jumping into a barrel of something not quite ready for prime time?

If we were jumping of our own accord it would be different but we are being pushed! I get so irritated when I hear people talk about the extra "stimulus dollars" we can earn by jumping but, in reality, this money is not anything extra. It is money we have already earned but will be docked if we do not jump. And you can't even tie a bandanna to a stick and jump a train anymore because...oh yea, there are no more trains!

Having the same issues with II and erx.
Wish Cash Pay was an option because of the
poverty and my patient population (mostly older and
very sick).

I am quoting myself, since none of my comments made it into the discussion. I don't mean I am being vain about it, but I don't want to repeat myself.

I get in trouble, because in r/l I generally say what I want and don't really care what people think about it. Here goes a few.

1. Do NOT go to v6 unless you absolutely want to sell your soul to the devil for this stimulus money. This should have been put on the board by AC. It has "showstoppers." This is a programming term for a bug that absolutely doesn't allow you to release a program. There are two huge issues with v6. For many, there will only be one. But, if you can deal with this then you will be happy with v6. And, yes I am Bill Gates' doctor . When you view the video (and this is a quick opening of the script writer -- it's embarrassing in front of patients to wait 10 to 30 seconds to open) be sure to look at the check marks for DEA and License. 'Cause they won't be there the next time or will they? As for the TSP800, it still doesn't work. I created a workaround (that's my middle name), which works, but it still means printing a letter to the Star Printer which is four inches wide when you forget to switch back to the TSP as the default.
2. I wish every day that the government hadn't come up with this whole MU thing. I recall thinking, it better not go to new EMR users and not me, but now I wish it had skipped current users. It was awful that I had to see > 30 patients a day this week to make up for the dreadful Medicaid reimbursement, but I spoke with a doctor today who used to see in the 25 range, but now sees 15, because visits take longer while he checks off this and that. How is that better medicine.
3. Obviously, I didn't get to Admin by ripping AC or not being a strong advocate for the program. But, you are correct, Jon can't do it all himself. But, what are we supposed to do to help. We have already created a culture on the board that helps this EMR and physicians more so than any other EMR board. While EMRUdate isn't affiliated with one particular EMR, try going there and finding any love. We have had three AC user conferences which went a long way toward helping AC with ideas, etc. And, we have put together "The 81."
4. While my guess is it would have been tough not to add MU to the product, I, personally, wish the PM had never been started. I realize there are 50% that think the other way, but I think staying small and concentrating on what AC did/does do best is what made it #1 in many categories
5. It is sad that we can't get together as physicians to, if not go all cash, at least get the reimbursement right. Likely, as a group, we would have to be one of the most powerful union around. Sure, the government could take away DEAs and Licenses, but could they do it from one million physicians at one time? But, it's hard to organize when you are seeing > 30 patients a day when you are looking at a drop down box for smoking that contains five of the silliest multiple choice questions ever. Why not do you smoke or do you not? If you do, then quit. If you don't, then good for you. My favorite is "Unknown if ever smoked." Smoking affects the lungs, not the brain. Most patients ought to recall if they have smoked or not.

So, I will go on the record and state that I do not intend to do MU. I refuse to use interactions that make the script writer even slow AND makes it look like a Christmas tree.

So, I came up with a silly acronym: DAMU pronounced Damn You (govt). Doctors Against Meaningless Use. I am naming myself CEO. I am going to ask Leslie to be the Chairperson of the Board.

I wouldn't use AC if my E-prescribing were that slow, ridiculous. Had no idea it was that bad!

That's on a good day. What I don't understand is 1) How could AC watch that on their computers and still release the version? Are you saying that it worked flawlessly every time they used it. Certainly, when doing in house testing, there may be minor bugs that go undetected or aren't showstoppers. But, one would think that the prescription writer/ePrescriber would be one of the top three or four modules of the program, and 2) What were the beta testers doing? This must have been happening to them.

Is this video from your crazy computers with the 560Ti and SSDs? My Celeron and P4 (with hardware acceleration disabled) are faster than that. Maybe you should do the same.

I have been using computers for over 20 years. I have never had to disable hardware acceleration to use software. If disabling hardware acceleration were the key, then AC should turn it off during install. Yes, it is on one of the "crazy" computers, which is why it is so scary for others.

Exactly. The day after v6 was installed, my dad's staff went crazy with the slowness of ePrescribe. Everyone on the board said they were seeing improvements with new graphics cards, that's when it hit me to disable hardware acceleration. No problems since then. Personally, I think they need to re-engineer the code for ePrescribe. I mean if it lags in a machine like yours, I have no idea how that could've slipped by the development team.

Probably cause you're not on it.

Very well said Bert. I can only believe that the accolades AC has garnered are mostly from users familiar with the way it used to be who still hold out in hopes it will one day be that way again. Many years ago on this board I warned people to be careful what you wish for. Bigger is not always better. It disappoints me so much that I see many of my predictions coming true. I still recommend AC to colleagues but not with the vigor I once did. At this point (something I never thought I would have said) I would go back to paper in a heartbeat. Now, not all of this is AC's fault and, in fact, most of it is the fault of the government. But, given that the program has been forced to add all of this meaningless crap, it may have been a better business plan for Jon to not have tried to tackle the PM. Instead, put his emphasis on fixing the nuisance things. I would liken it to a doctor trying to give his patients his full attention while also playing the stock market on the room computers. There is a time and place for everything and I personally think AC has lost their direction to that place. Sorry, Jon. I still love you!

And Bert, I would be most honored to serve as your Chairman (I was never a women's-libber) of DAMU!