Home Forums Discussions Problems DEEP THOUGHHTS by Walter Handy

Hot, we broke the record of over 40+ days with over 100 degrees. A relief for diminishing mosquitos population and no bat around. That life Bert, bats been hiding from the heat here in Dallas.

Yeah, we are going to Vegas for fun in a couple weeks and hope to win something large enough to quit 'family' practice. I have been more active in the clinic and saw slight improvements... thanks

I told one of my new staff, a premed graduated, that it is ok for female to enter medicine but need to aim for working part time only. Yes, I am old and stubborn.
To work part time, either to have lots of money, no medicine student loan, or our life partner makes more than enough then more money put into bank account won't bring in more satisfaction.

Practically I think most of us obsess with money else medicine practice is not that bad even with EMR.

Bert you might change my post title again to 'life/work/money not balance' ...

So talking about money, if you accept Medicare, please do not afraid to use AC6, despite all those neg posts out there.

Have you not read my other post in 'general discussion', '18 big ones for dummy', we did launch our AC6 in June and registered EMR with Medicare. I just read today that for first year you don't have to achieve the meaningful use target to receive 18K. So doing your best for 90 days and generate the meaningful reports. If you wait then you would miss this year money, only 4 more mos. Compare this meaningful hassle with treating difficult patients then you would feel much better. 40 bucks in your pocket to treat one difficult patient (other 40 bucks gone into administrative cost) compared to 18K in 90 days, 200 bucks a day.

Our PCs setup are simple and I did not buy ready to run PCs. Installed from scratch including OS. We did experience some slowdown with AC6 then I upgraded all our PCs with better CPUs, single core to double cores or more, one gig memory to two gigs, still using integrated video. Only my doc opens Eprescribing, she got two tablets and one desktop, and she is not complaining.

I'll pass that on to my spouse/partner, Walter. It's what she periodically tells me. Then we laugh, and go back to being doctors.

Another hot afternoon.
We are still in the record heat, almost two mos without rain and over 100. My car temperature indicated 108. We lost power at closing, and a patient came in, demanded to see doctor. She said she walked in before, working far away... why she not being seen this time.
When we first started, many walk ins. The front desk told her even the office opens... then I had to talk to her, she was not persuaded and said she going to email her lawyer...asked for my name to put down on her note. Another difficult patient, looking to see if they can get something out of docs 'deep' pockets full of EOBs, many with zero amount paid to provider.

Today Steve J stepped down and I am thinking of same as admin chief of a 'solo' doc practice. Help me here, please. What is your best office manager salary range? We had our 'office manager' for almost 4 years now. She likes to complain but good, can handle most of clinic admin stuff and dealing well with patients. Currently we are still paying her hourly rates in the range of 11-13 per hour. If you read my previous note, one of doc in our area paying his office manager triple. That girl is that good.
We are thinking of switch our 'office manager' to the salary base, almost equal to 22-24K a year. I don't know if we can afford a much higher range but we'd like to pay her a 'good enough' salary. Do you pay yours much higher, or same. I'd like my doc see less then 20 patients a day.

Well, first, does she make $11 or $13? Does it change weekly? Seems it would stay the same.

Second, I don't think "girl" is that good to make triple that? That would be over $60,000 a year. You can hire a NPN for that.

If you are paying by how good they are (which is always a good idea to some extent, then pay your best MA according to how good he/she is and pay your biller. I would say the one person you would want to base their pay on by how good he/she is would be your biller.

I may be missing something, but not too sure where an office manager makes or breaks your office. I think an office manager who is 10 out of 10 helps your office less than a biller who is 8 out of 10. We don't even have an office manager. Now if you are talking about an office manager/biller, that is different. Then, she/he should be making well over $12.00. The national average for an office manager according to payscale.com is $40K per year.

I also hope your office manager is unable to or doesn't go on this board.

You need to check state labor laws. We can't salary someone in alaska unless they have hire/fire authority, can set their own working schedule, or similar powers. "Office manager" for a small practice doesn't qualify; a more realistic title is "person wearing many hats". I agree with Bert that a Biller is worth a lot; a receptionist not so much

Right now, we are paying her 11/hr plus medical benefits plus 2 weeks vacation and overtime. We started with 1 Back and 1 Front, 4 years ago. Newer hires come and go, but these two still with us. We are thinking to give her a raise to 13 or more soon.

Our front girl likes David said 'wearing many hats', but she is excellent, currently going back to school part time. I have been out of office for mos at times and she could keep the office running smoothly (holy c, simple running AC 3,4). But those hourly employees mentality seems like that 'hourly'. Probably in TX, they don't care if you hire hourly or salary, our friends, husband and wife doc team, just like you Dave, told us that their 'hourly' employee time had been over longtime ago, now all salaried employees. One full time and one part time might be less costly but not worth it in the newer EMR time. Data lost is hard to track. They forget to enter data or enter them wrong or not checking their messages.... we all know now that techno causes more problem and stress.

Bert in his usual 'cool' did tell me to have new iPad toy to play with but even my hands no longer having that steady grips. I slipped my coffee cups more than one, imagine an expensive techo toy like iPad, it is heavy and not like books, $600-800 a drop.

A satellite clinic to improve cash flow and lessen/increase doc stress?

We just back from a mini Labor day Las Vegas tour. Poor me, I lost couple hundreds and my thinking of let my doc quit for a while and coming back working part time did not come through. However travel in style, staying at penthouse suite on 37 floor of a five star hotel. Most the time we are not that extreme, for instance another CME coming up in October, still in Las Vegas but special rate for docs, 50 bucks a night, lowest class rooms!!! How is that...

My doc got home and fell ill, I forgot where I parked my car and had to call for Airport parking service. They came and drove me around and finally found it, a high end car but stupid, it needs to know when boss get lost, even that he parked at a different parking lot. DFW airport is huge, A,B,C,D,E terminals, each has it own multiple parking garages. Departured at A terminal, but arrived at C terminal and Labor day two first parking lots of A were full. My doc knows me so well so she did write down where i parked but I lost that note!!!

A good exercise for a 'young' senior citizen, I walked two parking garages, up and down multiple times. Most man doesn't want to give up that easily. But I had to. Too much stress already and two day vacation causes even more stress. We had to reschedule full load of patients for another day. Charts and labs built up again.

I am thinking of open another satellite clinic but read a couple posts about the AC weakness. How about a centralized call center and recruit a newly mint doc. Luckily to break even first year, but things should get better in a couple years for a 'under served' smaller town, then my doc can have a partner and we can take longer vacations.

I just discovered about 30 folders in our imported items with missing or empty files. Luckily we have backups and hard copies (rescanned if needs to) but anyone know how to re import from backup with those subfolders. I re-imported manually with AC dated file option. Some patients with about 30 scanned items. A restore using a week old 'full' backup is not doing good because of newly scanned in files.

Daily offsite backup is only with exclude images/imported items option. A full backup with imported items almost 10 gig. The maximum upload rate available in our area is 70 kb per second so to backup a 10 gig file is out of question. I am doing full backup once a week with off site backup box unchecked. We are thinking of shredding all those paper folders to save some office space but...

Any suggestions how to deal with backup larger files off site? i don't want to do it manually anymore and the hassle of check and uncheck AC 'upload securely...' and advanced setting 'exclude' this exclude that' and monitoring them. No budget for a T1 or T3 line ( 250.00 to 1000+ a month fee).
The heat in TX last two mos almost double our monthly cost (1000.00 a month).

Need to consider very carefully before starting your own solo in the current market.

Not sure exactly what the setup is. When you say you have backups, do you mean .enc backups? That would not be good as you would have to restore everything (which is OK, but not ideal).

This is a very simple process. Forget about offline backups to the cloud. Forget about AC. Just get a good backup program. WIN 7 has a decent one or get Acronis and back them up by themselves. You can even copy and paste them.

Can you tell me how you managed to lose 30 files or folders out of the 10GB? That seems weird. If you didn't do it, who did?

Also, if you have mission critical data and no bandwidth, use an onsite backup such as Iron Mountain which will FedEx your data overnight.

I would consider backing up to external hard drives. You can get a terabyte for about $70. Buy several, then physically take one off site at least once a week. Bert can better advise you on plan for this. WIth that slow of upload speed, I'm not sure how you can do offsite backups over internet , even with incremental backups. I get 0.5 Mbs upload over DSL for like $30 /month. Even so, incremental backup takes about 3 hours everynight (I have a 1 GB .enc file, including imported items )

Agree with Ken. First, no matter what you hear about the dramatic floods and online backups and take homes, backups in your office are the best by far. You have your data right there, and it's fast.
As Ken says, get some eSATA drives (6Gb/s), do two or three. I do five for every day of the week. Then take one home twice a week. Finally for good measure, do the offline. Remember, most offlines do not use VSS or open file. Many back up one file at a time so the whole database must be taken. You want byte by byte or even better, block backups.

One good way to do it is to have your main computer with OS and data, then have a 2TB drive in the computer and do an image every night using Image for Dos. This gives you a PERFECT image.

I have them all :), you name it.. external hard drives, internal hard drives (multiples OS boot), take home dvd, Acronis, Home Server, AC off site (100 meg file every night). But still not enterprise level .... little guy setup....

Yes enc. backup Bert. I had backup from Imported last week. Not yet backing up for this week.

A full restore is only when nothing else possible. i don't like full restore at all. I had RAID before but 2 drives failed, then motherboard failed. A restore from backup not good if changing over to a different motherboard, MB getting obsolete quick too. At one time I did buy an identical MB but did not test it... then when needed the untested one not working, and that model discontinued...Talking about uncertainty.. anyone physics undergrad?

what good is RAID if PC going bad? If you are not that lucky then 99% redundancy still not doing you good. But my setup is almost invincible. I did explain it in my other post. Multiple backups at the clinic, another full setup at home, identical config main computers with multiple OS boot. The most is one day data lost, still that not affordable ( 25 charts to reenter )

Probably multiple OS boot is one of best backup options also.

But still the hassle of imported items restore. Even I am not that sharp anymore but delete files in 30 folders? The folders were there but many files missing. I tried AC support today but they were not available, to see if any way to trace how those files being deleted. AC has the utility to check for missing links and make a report, and import missing files (browse for files to be imported but not sub folders)

So the missing files cause either by AC or the free SyncToy program from Microsoft. I've been using SyncToy with 'Echo' option for years (means nothing to delete). I have to manual sync our AC to hard drives, at least once a day, my Acronis also running twice a day full system drive backup. Delete while under... early dementia onset? haha... I need to see one of our AC docs. Bert and James are one of our Sql server expert here, so my questions is any log to trace imported items? any utilities available for sql express? No budget to upgrade to full sql and I passed the point to play with codes. AC is not fully SQL implemented as it still keep imported items staying outside of sql security and redundancy.

Walter, I am not sure I am following all of this. (Well, actually I am sure I am NOT following all of it). I am trying to imagine how selected items from a tiny percentage of your imported items folders could be lost.
I am also trying to understand how you discovered the problem. Could you please explain that, and explain how you know it is only 30 folders, and how you know which folders are changed? It might help others to help you if we know this.

The audit log which you can enter through administrative options might be helpful. You can filter the log in various ways. For example, if you know which folders are missing items, you can sort the log by the ID number of the patient (which is the same as the number of the imported items folder).
So set the dates of the log to include the date when the items were deleted. Then sort the log by patient ID number, and look at the activity for that patient to see if you can spot a description like "deleted an imported item".

Thanks Jon, I am going to try your suggestion.
Our receptionists happened to look at a patient imported items and AC reported missing links. Then they found couples more. I ran AC utilities to repair missing links then they generated a 20 page list (only about 30+ folders, some completely empty, some with few left).

Quite a mystery as only 30+ out of 4000+ folders. I don't think Synctoy would delete them as what echo option does is only to sync from my main computer folders to backup folders. This little program is quite effective and free. AC has missing files repair link options means files missing are not that uncommon .

No, missing files IS uncommon, almost unheard of. It's the links that can be missing. That is why you have the utility program.

I have them all :), you name it.. external hard drives, internal hard drives (multiples OS boot), take home dvd, Acronis, Home Server, AC off site (100 meg file every night). But still not enterprise level .... little guy setup....

SOUNDS LIKE YOU HAVE TOO MUCH. WAY TOO COMPLICATED.

Yes enc. backup Bert. I had backup from Imported last week. Not yet backing up for this week.

.ENCS SHOULD BE BACKED UP NIGHTLY.

A full restore is only when nothing else possible. i don't like full restore at all. I had RAID before but 2 drives failed, then motherboard failed. A restore from backup not good if changing over to a different motherboard, MB getting obsolete quick too. At one time I did buy an identical MB but did not test it... then when needed the untested one not working, and that model discontinued...Talking about uncertainty.. anyone physics undergrad?

WHY IS FAULTY MOTHERBOARD AND COMPUTER A FULL BACKUP'S FAULT. A FULL RESTORE IS WHEN YOU LOSE ALL YOUR DATA. YOU DON'T HAVE TO RESTORE IT. IT'S JUST THAT A FULL BACKUP WOULD CONTAIN YOUR LOST FILES.

THE IDEA IS TO CHANGE YOUR HARD DRIVE BEFORE IT FAILS AND REBUILD RAID. SOUNDS LIKE YOU NEED A HOT SPARE.

what good is RAID if PC going bad? If you are not that lucky then 99% redundancy still not doing you good. But my setup is almost invincible.

NOT TO BE MEAN, BUT IT SOUNDS AS THOUGH IT IS NOT INVINCIBLE.

RAID IS FOR REDUNDANCY, NOT BACKUP. RAID WON'T GET YOUR FILES BACK. FILES GONE ON DRIVE 1 OF RAID MEANS FILES GONE DRIVE 2 OF RAID.

I did explain it in my other post. Multiple backups at the clinic, another full setup at home, identical config main computers with multiple OS boot. The most is one day data lost, still that not affordable ( 25 charts to reenter )

NOT SURE HOW MULTIPLE BOOT WOULD HELP. I THINK 24 HOURS IS PERFECTLY ACCEPTABLE. IF NOT, YOU NEED CDP. YOU ALSO NEED BACKUPS BACK AT LEAST ONE TO TWO MONTHS. MINE GO BACK A YEAR. THIS IS THE PERFECT EXAMPLE. WHEN DID YOU LOSE THOSE FILES. COULD HAVE BEEN FIVE MONTHS AGO.

Probably multiple OS boot is one of best backup options also.

PLEASE EXPLAIN WHY BOOTING TO MULTIPLE OS IS A GOOD BACKUP ISSUE.

But still the hassle of imported items restore. Even I am not that sharp anymore but delete files in 30 folders? The folders were there but many files missing. I tried AC support today but they were not available, to see if any way to trace how those files being deleted. AC has the utility to check for missing links and make a report, and import missing files (browse for files to be imported but not sub folders)

IT IS THE FILES THAT ARE GONE. NOT THE LINKS. AC HAS NO WAY OF TRACKING WHERE THE FILES ARE. THE MUST BE MOVED OR DELETED?

So the missing files cause either by AC or the free SyncToy program from Microsoft. I've been using SyncToy with 'Echo' option for years (means nothing to delete). I have to manual sync our AC to hard drives, at least once a day, my Acronis also running twice a day full system drive backup. Delete while under... early dementia onset? haha... I need to see one of our AC docs. Bert and James are one of our Sql server expert here, so my questions is any log to trace imported items? any utilities available for sql express? No budget to upgrade to full sql and I passed the point to play with codes. AC is not fully SQL implemented as it still keep imported items staying outside of sql security and redundancy.

AGAIN I THINK SYNCING DATABASE TWICE AND BACKING UP WITH ACRONIS TWICE IS OVERKILL. AC LIKELY DID NOT LOSE YOUR FILES. NEITHER DID SYNCTOY.

AC CANNOT PUT IMPORTED ITEMS IN SQL. SQL CAN HOLD 4GBS. MANY USERS HAVE 10 OR 20 GBS OF IMPORTED ITEMS.

PERSONALLY, I WOULD JUST TAKE THE LOSS AND MAYBE MAKE A NEW BACK UP STRATEGY. MAYBE JUST COPY AND PASTE YOUR IMPORTED ITEMS FOLDER.

SOUNDS LIKE YOU HAVE TOO MUCH. WAY TOO COMPLICATED.
.ENCS SHOULD BE BACKED UP NIGHTLY.

A little over killed but not that much. During my 30 years of IT former life dealing mostly large projects, I learned many hard lessons. Nothing is 100% foolproof, things might turn sour at last minutes.

AC backup has 3 paths to 3 different folders for backup and then send the backup file to a cloud drive somewhere. So I set one path to an internal hard drive backup folder, 2nd one to another folder in a different partition, same drive, the last one to a hardware encrypted external. This to set to run once every day and also to AC offsite backup (100 meg files in about 15-25 minutes). So this done automatically. To restore from an AC offsite backup we need to call AC and they might be not available or off hours.

For offsite backup to work, I have to exclude imported items and 'check' off site backup option. I only do full backup with imported items once a week, the .enc from 100 meg goes up to 10 gigs. This full backup would be used to restore a 2nd system. So both systems identical and exchangeable, not a real 'system' hot swap but 5 minutes switch over. How about that.

WHY IS FAULTY MOTHERBOARD AND COMPUTER A FULL BACKUP'S FAULT. A FULL RESTORE IS WHEN YOU LOSE ALL YOUR DATA. YOU DON'T HAVE TO RESTORE IT. IT'S JUST THAT A FULL BACKUP WOULD CONTAIN YOUR LOST FILES.

THE IDEA IS TO CHANGE YOUR HARD DRIVE BEFORE IT FAILS AND REBUILD RAID. SOUNDS LIKE YOU NEED A HOT SPARE.

We have two level of backups here. A full computer backup and AC backups ( one full backup with imported items and another with charts data backup only ). Before win7, blue screen of death were more common (we still use XP), a restart might come up with 'NT loader not found' fatal, or a faulty board, a capacitor melt (now a day MBs use solid capacitors with much higher life span).
If system fails, Raid set up become useless.
If you happens to have another identical system then you could bring over you RAID drives and no interruption. If you don't have an identical config then with a switch over, RAID hard drive might be able to boot up your system but with their different chipset setups for old system, the stability is no longer there and mysterious errors happen. A full system restore would also include AC to the latest backup

Acronis software comes into play here. I only set Acronis to run full sytem back up twice a day, once at night and once during lunch break and the backup file is with an external drive. Aconis works well. I did a full system restore in about 20 minutes. To loose only half a day work if system fails.

With windows 7, Microsoft gone a long way. RAID is for redundancy also a good system back up option. Duplicate data entry or faster data entry per disc writing/reading limitation. But like you said garbage in, garbage out, if file missing then all drives do same, but if data corrupts then a hot swap would recover it, not with 2 drives fail. A system with one bad drive might not be bootable next time but you can hot swap the bad drive then a next restart be ok. With simple RAID, you have an extra identical data storage. RAID would not help in my case of missing files but help while you need an extra media to store data. I partitioned my hard drive, 2nd partition also to store a backup folder.

NOT SURE HOW MULTIPLE BOOT WOULD HELP. I THINK 24 HOURS IS PERFECTLY ACCEPTABLE. IF NOT, YOU NEED CDP. YOU ALSO NEED BACKUPS BACK AT LEAST ONE TO TWO MONTHS. MINE GO BACK A YEAR. THIS IS THE PERFECT EXAMPLE. WHEN DID YOU LOSE THOSE FILES. COULD HAVE BEEN FIVE MONTHS AGO.

PLEASE EXPLAIN WHY BOOTING TO MULTIPLE OS IS A GOOD BACKUP ISSUE.

If system fails, software or virus related, the second boot can start up Windows and use the AC backup file to restore AC, almost no disruption in clinical time, so multiple boot almost same as Acronis but no need for a startup CDs, more works involved those. I am no longer multiple boot since I upgraded my servers last year. Most the time virus infested drive only effected the primary boot.

AGAIN I THINK SYNCING DATABASE TWICE AND BACKING UP WITH ACRONIS TWICE IS OVERKILL. AC LIKELY DID NOT LOSE YOUR FILES. NEITHER DID SYNCTOY.

AC CANNOT PUT IMPORTED ITEMS IN SQL. SQL CAN HOLD 4GBS. MANY USERS HAVE 10 OR 20 GBS OF IMPORTED ITEMS.

PERSONALLY, I WOULD JUST TAKE THE LOSS AND MAYBE MAKE A NEW BACK UP STRATEGY. MAYBE JUST COPY AND PASTE YOUR IMPORTED ITEMS FOLDER.

Hence AC not strong point. By using Sql express, AC not able to include Imported Items. A full mySQL probably better option. To leave out an important data section not fully logged and enclosed is a serious security and HIPPA risk.

I've been dealing with data intelligence and tetra (1000 Gig) size databases then were norm. A mere 4 gig data limitation is not a good excuse for AC despite its lower price usage cost. I need to look at Audit log per Jon suggestions to see if anything pointed to me. Copy and Paste not working for imported items. AC does not recognize copied files, I had to import them and doc to sign off all those reimported files (another option available to sign off all not yet preview imported items)

To run the AC missing links utility might be not a bad ideas once a while

Walter,

There is no option other than a pre-packaged free Express database whether it is 2005 or 2008. You can't just tell 3500 users, "The next version will require you to go out and get SQL Server 2005 Standard at $500 plus CALS, plus they would have to install it. You would lose 2500 customers in one fell swoop.

I out source my billing for 6% to a small company. SO when i get more it matters to them! She also sends me monthly on who we bille,d who paid, who we didn't get paid right form, who we are appealing.

I suggest trying a small billing company. We of course keep our own system too, but we dont do the billing

The Adirondacks are a really beautiful place to go camping.

Who do you think will win the Superbowl this year?

Dallas Cowboy
I went thru Audit Log per Jon advice... nothing there pointed to anyone in the AC list. Only one delete I made per staff request, extra scanning in. So my clinic deletion mystery remains.
I have to think a good way to backup Imported Items regularly, more than once a week if we are to shred all paper docs, many hospitals doing same after one or two weeks. That what EMR is for, getting rid of papers. But papers last forever not like electronic media. After 5 years or so, once popular electronic media getting obsolete then the need to transfer to a new media. Very time consuming and annoying... and data lost or unaccounted for (happened at large institution everyday) .. not easy to steal or throw away a room full of papers....

Bert

An NFL team

Gene

@Gene You could get good odds on that.

Walter, just get an inexpensive backup program like Acronis and back them up nightly.

Wonderful idea, i forgot about Acronis. Excuse my stuffy brain. Need to go to Frys to buy a 1 tetra exernal. 10 gig a night, would be filled in 3 mos. Delete them and do it again. Better to be safe, 2 externals, Acronis runs it sequentially? overkill?

I have five. Plus a few more.

I just scheduled my Acronis to run every night. But still thinking about the deletion mystery. Windows security is weak, there programs to hack in. So if I did not delete those missing files nor AC then someone did have access to Program files/AC/Imported Items. AC only requires admin authority to import/delete items but not to exclude deletion outside.
If something like missing files happened to us then certainly would happen to others.

I forgot how long Medicare requires docs to keep records, 7 years?. But after 3 years, docs can charge new patient fees.
A typical scenario, one patient disappeared for 2 1/2 years and came back, they said they had not been sick for sometimes. Open their med records, just like in X files, imported items were gone. Then her lawyer requested her medical records of her injury over 2 years back.

Externals not as dependable as we might think. For Bert, more than 5 of them... manufacturers guarantee 1 to 3 years but not their data contents. Uneasy feeling.

I personally think we need to keep paper records and put them in empty paper boxes ( saving pennies ), then put them away either in basements, attics, stock rooms, and mark them (like Cold Case series) ....that would be the safest way to save data. Seems we are in shorter terms, fragmented bits and bytes, what happening 10 years down the road. Many of our forum docs been practicing for decades they should know better. When time comes, just call a security shredded service, they would come and haul away part of your life and destroy it for good (surely this would cost money, but you will be millionaire then). I read an article, if you could start to put away 100,000 now, in 10 years your chance of being a millionaire would be 90%. AC again Monday.

Don't know about the paper. Seems like you would be going backwards, but overall, would be even more security.

With a good hardware firewall, not using admin/administrator for a login, and good passwords that are given out by you and not made up by your staff, the chances of someone hacking into your network are very slim. Especially if port 3389 is NEVER open which with the advent of 2008 for servers it has no need to be.

You have to ask yourself the question? Which is weirder?

That those files are missing? Or that someone would hack into your network, browse to those folders knowing what they were and taking them.

It's WAY more likely that users have permissions on the NTFS side that allow them to delete files. But, again, why would they?

A friend of mine in IT for over 33 years once told me (and I know this sounds ridiculously simple). But, when you are trying to fix something or figure out something weird or strange, there is always a simple reason once you find it.

Personally, I would tighten up security, look at the logs and then let it go. And, back up your II better.

Problem always same, budget concerns. Friends complain about high IT service fees. I can tell that most AC members are in the same situation, trying to control costs. To go along with AC reasonable operating cost, we have to wear many hats ourselves. Are we going backward in our small business model? Work the farm, fix the farm equipments, waking up early..., but old farmers they went to bed early and have a full night rest.

Bert, you are perfectly right about simple causes. But my security concern is short term. Our IT security is not that bad compared to some local friends. We have a small, locked networking and server room. Not that many AC docs lucky to be in my doc situation, to have a very dependable, low level, handy consultant and pay him only three meals a day.

Talking about dependability, yesterday, my 1 mos old S. hard drive and another W. external failed, same day, yes. I just talked about how dependable storage media last week. I mostly buy things based on buyers feed backs but there always a small percentage of dissatisfaction because of failures.

At the start of Solid State drive mania. I was so in love with them, they amazingly fast, load applications in less than an eye blink. Recently Microsoft just announced Windows 8 could load in less than 8 sec, but that old new. With SSD, my test system was ready to go in about 5 seconds. After couple of SSDs later , the latest was Intel SSD that I used in my AC 'server', mysterious crashes happened, some information that I read telling that SSD not that perfect even if their claim so impressive because of solid state memory still governed by its controller or its manufacturing process. Always be prepared.

I just setup another test system running 6.010 on windows 7. I restored it every couple nights using 6.09 backups, to run database tuner every time. It has been stable for last 2 weeks. Ready to upgrade this weekend. Seamless switchover because of my multi system setups. My test system can be promoted to 'real', any problem then switch them back. AC support is not that available when we need them.

For couple minutes after reading on ' why tech support ... ' post in the problem discussion made me feel young and in a competitive mood again, thanks to Bert bragging and others.

Almost impossible in most budget conscious working environments to have Bert's setup. Money is no object here. I bet Bert just sold some of his Apple stocks. Bert, you also need to get a large passive LED 3D with 2D to 3D conversion to hook it up to your 4000K+ HDMI output computer. AC would look so impressive and you might forgive its faults. Then sell some more facebook stocks to trade up to ...higher end EMRs. I think Bert would move back to AC because nothing for him to write about then.

From Bert: (The quote option not working with different post)
Quote:'
I know this may sound like I am bragging, but it is necessary to brag to refute your post. I just happened to two months ago purchase all new computers for the office including the one in my office. I upgraded my RAM to 24GB and have SQL Server 2008 Enterprise utilizing 12 of those GBs. The computers all cost over $1400 using OCZ SSDs with SATA III connections giving them 6Gb/s throughput. They ALL run Intel i7 2600k processors. They ALL have 8GBs of RAM. They all run WIN 7 Pro. They all have WEI scores of 7.6. (7.9 is the highest). My computer is $2500 and that is at a 40% discount. I won't even list its components. We use CAT6 cable, an extremely high end switch. The computers are locked down so that no staff other than me can download ANY software or surf anything on the net other than what I deem necessary for the office to run. It is all protected by ESET NOD32 Antivirus. Oh, and the server is a Windows SBS 2008 running on a Dell 2900 Edge Server. My computers boot from BIOS to CTRL + ALT + DELETE between 9.3 and 11.4 seconds. ' end quote

I had the most fun with the 'what ups with tech support' post in this problem discussion since the last 4 years. You have to read it.
One thing we need to remember that AC needs to move forward to survive. AC is small and being small not much can't be done till someone taking over, even Jonathan might still retain his president title. I don't know if his passion to built a great software is still intact after 10 years. An enterprise level software, the direction AC is going is getting too complicated for a smaller company. AC needs fusion of capital or to be bought out by higher end EMRs.

We have many tech experts in our forum, even they are docs but like I said before in other posts, docs are special breed, because they are smart, always there exceptions of course. They can out program a 'good' programmer and be equal with 'great' programmers. Jonathan is one.

To build something better, most the time you have to scrap the old and build a new one. AC being small doesn't have the resource to do that. So a patch here, a patch there, adding couple additions trucking in from elsewhere, connecting to another .... using patch copper wires instead of fiber optic wires and wires hanging high above instead of burying it underground.

Back to programming, do you think AC can afford the most skilled IT architect for a million dollar a year salary... probably not... so Jonathan needs to involve himself as AC tech lead. That time is longer gone with the degree of sophisticated and he is not that young anymore. Think about Bill G at start of MS.

So enjoy AC while you can and be ready to convert when times come or to the point you want to jump. But even then headaches still abound. Can you eliminate bacterium by advice patients to taking full course of antibiotic? full course or half course, bacteria sill there and would evolve to more deadly strains. So ultimately we need to design a perfect human body with disease resistant body to survive or perfect program to avoid headaches.

I just watched a documentary about alligators. Evolved thru million of years, most deadly bacteria mean nothing to alligators. Florida docs know this best.

I knew of some local docs willing to pay 10 K couple years back and go with larger vendors. Same like Bert's new system upgrade. We are fooling ourselves to think that old time still with us.

David is still one of my top favorite docs in the forum, per his new quote about a rich man needs to be satisfied with his lot. My addendum to that is when that rich man is no longer satisfied with his lot then buy a new bigger lot and be ready to be taxed more. Any doc in the forum taking high blood pressure pills?

My solo doc EMR working environment is hostile, frustrated, bored, exhausted ... Since when docs became typists, office workers, repairmen, own psychologists, EMR addicts... all rolled into one?

Only talking for ourselves here. Yesterday, I received a big envelope with a long list of patient names doc from one of biggest ins carriers asking my doc to look at what tests/procedures have been done or recommended. They are kidding. To do that my doc has to look up patient last name, first name, no name...then click on a 'super quick to response' AC tab,.... It would take her at least couple days or so to go thru that hundred name list. I am thinking of put this envelope into our 'rewarded' shredder (once a while my doc filled out a form and she received some rewarded points eligible for gifts... might be that one of her stress relieving techniques)...

EMRs or AC lifestyle not for human. We are analog life forms, not that organized but long living organic system, not robots. Robots can live in their digital environment because they are designed to short live, working 24/7, and ready to shutdown when they are overloaded. EMRs would create a perfect healthcare environment for robots. Long ago and far away, most docs desks and his office floors piled up with forms, magazines, samples....EMRs and techno advances supposed to eliminate those paper jungles and make doc and patient life greener.

Primitive typing/clicking causes serious long term health problems. But no researches yet available to see how this long term health problem plus the long term multitasking efforts effecting docs' health. Consider these, treat patients, involve in their complaints, check billing codes (are you ready for ICD 10 coding next year? ), recheck carrier rejections, file thousands of forms, fix hardware/software.... Not too long ago, 30 or 40 patients a day not much a problem. Imagine 30 or 40 charts to enter plus other chores now. A latest report saying that in the 50s, something like 40% debt per disposable income ratio now 120% or more. In one of those medical economics journals article couple years back, a small group practice wanted to improve their clinic cash flow and invited a medical consultant to do a study. The consultant said not much could be done, their clinic expenses were in acceptable ranges, only the group had to see more patients, like more than 23 patients a day....

Solo docs at the current financially strapped situations (those established docs are exceptions, they are ready to enjoy long term vacations, their hard working years are over) forced to see more patients to meet expenses plus a so so material satisfactions but their work/life balance per My projection is 80/20%. Eighty percent of their time devoted to patient care and EMR addiction. One of our friends in Florida, spent 30 minutes at night to eat and watch news (same time) then went to sleep.
The myth of medicine lucrative and prestigious profession overpower human logical thinking. We are not that ready for health technological advance per current awkward human's usability.

Wow, it has been a while. Seems I been losing interest in most things. Really you can not imagine till reaching...

I just rebuilt our computer system, not like dreaming systems in a forum latest post but quite capable, in my opinion. And I'll do it again in about 2, 3 years...
Let give you an idea of our very inexpensive 'triple redundancy newer system'. Solo practice is not getting any easier... need to control cost to the max unless you want to be a partner of larger group .

You never know. Docs don't take care of themselves good enough in a solo stressful environment. Recently in my area, two young docs passed away in their 40s. So the less to worry about expenses the better.

Brand 'new' 'servers', I did not go for a real server with sever OS, too expensive and complicated. I bought two refurbish quad Xeon from Dell. At the cost of 300.00 each, win 7 pro. Corporate system life cycle is around 3 years, those quad xeon systems would last 6 to 10 years. The truth is that not much snapping performance difference from our old XP. I'll get in more detail on this.

Migrating from XP 32 bit to Win 7 64 bit was fairly simple... except the problem of lab interface.... to continue

I was just reading some of your old posts. You mentioned resubmitting forms to insurance companies being a major chore. I am wondering if outsourcing your billing would be beneficial. Also, with doctor having such hard time financially, I would really look at coding. Is the doctor doing many level 4 visits? Under-coding causes serious financial problems while wasting time.

Walter,

Regarding your request from the insurance carrier for information on the patients test results: the insurance companies are allowed access to the patients' records during the time they are with that insurance company. In the past, they would send out a worker to go through the records and get the information needed. They then learned that if they sent a request to the doctor, many times it would be filled out without charge. Hence, their extraordinary requests to do their work for them. Your 2 options are billing them the time and not providing info until bill paid, like a standard records request. Or making their worker come to your office to retrieve their own information. Do not be fooled into doing the insurance company's work for free!!

I wonder if your busy doctor would have time to come on here and discuss some issues directly?

Thanks Boondoc, Catherine,

I did recommend her to go online with any questions, but... I think.. that would be her last... resort.... never like to communicate online, still has trouble with her blackberry after all these years....

We are still outsourcing our billing, after 4 years things seems going well, the rejection rate is low. I told her to just ignore most of the forms and letters they keep sending. Patients not taking their medications, patients medication lists..... My girl mindset is still in the 60s ...

Wayne did say something about that, female doc cares more.... haha... she might want to talk to Catherine sometimes or ask Catherine to come to Dallas on her next vacation...

She types extremely fast, and very efficient in her charting now but I really think she mentally, physically exhausted (we have two young kids, 20+ years late!). I am pushing her to go for a partner or a PA, NP then she can work part time only.

To work part time whenever you wants to and not to worry about financial would be heaven...

She is still keeping her hospital visits.. she likes the challenges of difficult cases and coordinates care efforts. Common cold, old ages, diabetes, difficult patients, prescribing something then being rejected because not in the allowable lists, ....days in and days out... to some is too much...and she is one of those minors.

I need to go back to my tech tips for those who want to upgrade their XPs. A triple redundancy system at a minimum cost and peace of mind. I don't know why I did not think about it before as it is too simple to do. Good to let those old people retired. Go for simplicity.

We always have three 'main' computers. Probably that is old school, not too many eggs in one basket. You are doing same with your money why not doing same for your 'money' source?

In my previous posts I did mention about using home media server as one of our central for all backing up. It is cheap less then 100 bucks and can be put on any 'weak' computer, with a large 2 Tetra hard drive or more, as it doesn't require much CPU power.

I also use Acronis for local backup. In Win 7 or 'higher end' Server software, backing up feature already built in.

I tried both Home Media Server and Acronis and found that both are good but Home Media Server is more convenient. Using its boot disc, I could recover a crashed computer or clone a new one in less than half an hour.

Only four simple steps then you could implement an enterprise level AC system.

1. Do a full back up on you current pc with imported data included and copy the back up file it into a high capacity flash drive. I think for most solo docs, 16 gig flash drive is sufficient.

2. Install a 'fresh' Win 7 Pro or Ultimate in a newer computers. Personally I haven't seen CPU utilized on our system running more than 10% except when I doing a imported data sync. Our old XPs using quad core q9660 with 4 gig, the new ones using quad Xenon 10 gig. After all windows upgrades, install AC. Most the time if you install AC on a freshly OS without any extra or antivirus, you would see that the install is trouble free. If you upgrade from an old computer with lots of software already installed... the level of complexity mitgh be ten fold with unexpected errors. At the current software design, bugs can not be eliminated in a mixed environment.
As my brain is only 1/10 as good compared to years back, I prefer a simple, less problem route.

3. Start your AC program, as it was blank, you might need to fill in first couple pages to make sure everything is running, SQL server connected. Then do a restore from your flash memory back up file in step 1. You don't even need to close your AC while doing backup that way the sql server port is still opened.

Now you have a brand new computer running AC with latest data.

4. configure your media server/acronis/windows' backup funtion to accept the new AC computer and do the new back up.

connect another new computer with same hard ware config as your new AC. Don't use a different hard ware config computer even it might run ok initially. Do a recover on the newer computer. Now you have two identical clone AC computers. You might want to do a third one and keep it safe at home. So three identical computers. Also need to rename your 1, 2 in your network.

Throw in bunch of external hard drives for more fun, now you have an 'enterprise+home' level system.

Have you heard of any triple redundancy system that crashes before? Nope, mathematically that is still possible but very rare. Double redundancy crashes? a lot.

I am confused. Are you saying you have three different computers including the main computer? You are taking a backup of the main computer and restoring them to the new computers all with SQL installed?

You are then using the two new computers to connect to the main computer? How would that give you redundancy? You may have equal computers at the beginning but you will be reading and writing data to SQL on the main computer. None of the data on the new computers would be affected (I hope). Therefore, you would not have any redundancy after the first day; the first note even.

Each computer cannot save and receive data to and from but one SQL server. You can only have one AC instance.

Or, am I reading this wrong?