Home Forums Discussions General Discussion AC in multiple offices

Good point . I appreciate your advise
Thanks

Just as a side note. That's with it optimized for a dial up connection. It's still really good. You might see some improvement if you switched to low speed broadband. You can easily run multiple sessions of remote desktop even on a DSL line.

Mohamed,

While the upload speed may help, you are still limited by your bandwidth no matter where your data is. If you put your data at the office with cable and, thus, more bandwidth, you will have to access it from the office with your slower DSL.

LogMeIn Ignition won't make any of the logistics and connection faster; it will just allow you to bypass opening your browser to access your office. But, once you connect, it will be the same functionality.

The simplest solution for a non techie is a set of parallel computers in remote office and connect computer to computer using JumpDesktop or LogMeIn. Say you have Receptionist, Doctor, and Exam Room1 computers in in main office and remote office and then you install JumpDesktop on all. Your Amazing Charts database can be on main office Doctor computer. Then, in your remote office, connect Doctor to Doctor, Receptionist to Receptionist and so on so forth.

I installed SBS2011 server in my main office, but it is a lot for a non techie to maintain and I regret spending so much money and time looking for solutions to server problems. If you hire an IT guy, it will be even more expensive. A good Windows 7 Pro i7 with 8-12 GB RAM will make a good main computer, works as well as SBS2011 server. For me logMeIn is a lot slower than JumpDesktop, but it also works.

I purchased several refurbished Dell Optiplex 755 with Windows Pro for main office and refurbished HP Pavilions with Windows Home for remote office. You cannot remote into a Windows Home computer. If I were to do it again, I will not install Windows server. You want to spend your time on seeing patients, spending your cognitive energies on solving medical problems, not on tools solving computer problems.

SBS 2011 Standard is not for beginners. That's a full server solution for small and mid size businesses up to 75 users. It's a big waste of money if you have no plans to use Exchange or SharePoint which is why Essentials was created. Managing domain records, email records, SharePoint databases, etc. is usually above the level a techie and more of a server administrator's job. If you think Standard is hard, imagine how much work it would be to set up everything from scratch following best practices. Yikes. SBS Standard gives you a lot of bang for your buck if you actually utilize the included features like Exchange, folder redirection, centralized authentication, etc. SBS Essentials gives you Server 2008R2 functionality with the simplicity of Windows 7.

Level Of Difficulty:
Windows 7 < SBS 2011 Essentials < SBS 2011 Standard < Server 2008R2

For the latter 2, I wouldn't even recommend it without an IT guy/professional.
Windows 7 is easy enough but leaves a lot to be desired.
SBS Essentials is a little difficult but we have an online tutorial dedicated to AC.

Sanjeev,
I understand what you are saying and periodically make similar points here. I believe that your priorities are close to those of the average physician. It is not a matter of right or wrong, simply a matter of personal interest and preference.
I agree with both the specific recommendations in your post and the general concepts you describe.

There is a strong shift in the AC user community as adoption grows, and that is to folks that are not interested in technology.

It is pretty obvious that folks became a Doctor because they want to practice medicine, not technology. We are increasingly contacted by Doctors around the US who want to adopt [or continue to use] AC, and just want it done; much like they might remodel an exam room.

My estimation is that *everyone* of them could do it, they just would rather focus on their practice and patient care.

There is a Doc on this board who sat down at one point and figured out how much time he put into setting up AC in his practice over a year - the final tally was just north of 200 hours, and however you price that opportunity cost (we've heard $50 - $140 per hour), his opinion is he would do it differently, and just farm it out. Not about intellect, rather a life/priorities choice.

Folks increasingly want someone else to "put the magic in the box" and keep it there; they just want to see patients.

I bet at four hours per week, they could get some incredible IT.

That really was part of the frustration for him; he is a meticulous guy, and everything was self-taught, so part of that is burning through lots of hours learning OS structure, AC, permissions, network fundamentals, hardware configurations, etc.

Whether the Doc takes the time to see more patients, more of the outdoors, or more of their spouse/family - it just becomes a choice.

Bert and I had an idea for this magic box haha.

Yes, literally "thinking outside the box". I think the idea has merit under certain circumstances. For example, this would only work if your entire office staff travels with you (you don't want two databases going at once).
If you use Updox, you can basically access your fax machine wherever you go, importing, etc. in the satellite office.
I see security as the main issue, but it is not insurmountable. All those people who are carrying back-ups home on a drive (especially if they carry their Imported Items) have the same issue; I would think constructing a secure set-up on a laptop would actually be easier.

I would have to say this is the most offensive statement I have seen on these user boards to date. You have the nerve to come onto these user boards and make a generalized slam like this against physicians?! You do realize sir that it is ILLEGAL for me NOT to collect copays? If all the physicians you deal with drive a Lexus, then most likely it is because they are the only ones who can afford your service. The number of BMWs sitting in the physician parking lot at the hospital has been few and far between, with lower reimbursement and more and more "necessary" ancillary services that the government now mandates.

You would appear to have the same mentality as my accountant and insurance salesman and just about every one else, believing that all physicians have tons of cash and know how to do nothing other than medicine. Then the usual tactic is to scar the pants off the said physician, convincing him how he needs to purchase all this insurance/computer hardware/retirement plan/etc to avoid doomsday. JamesNT, you may be the best IT man in the world, but after a comment like that, you have zero credibility in my book.

And thank you Jon for you post on doing this and "spending NO money" - this is the reason I have been using AC since version 3. AC has always been about the fact that just because it costs more doesn't make it better, and we can't solve all our problems just by throwing more money at them. In Mohamed's situation, people are talking sbs2008, terminal servers, user cals, I mean, come on people. To use an analogy similar to above, that would be similar to me seeing the teenager for his ingrown nail and ordering an MRI, bone scan, 4 days of IV antibiotics in ICU, and an amputation....

I'll jump off my soapbox now, I need to get home anyway...hopefully my 2001 DODGE CARAVAN will start this time...

Steven,

What I made was not a generalized statement. Read the first 11 words of my comment - which I'll post here in case you missed it:


Now. Let's take a very close look at those words. In fact, let us highlight some of them for clarity.


Those three words are very important. By your reckoning, I am making a generalized statement about all physicians. What we in Statistics would refer to as "the population." However, that is patently not true. My statement includes a qualifier that limits, quite severely in fact, the scope of my comment. It limits the scope of my comment to a tiny fraction, if that, of the population of physicians. The wording by very definition refers specifically to the population of physicians that I have actually interacted with. Obviously, since I am but one person and there are tens of thousands of physicians spread across a vast geographic - namely the United States - it would be quite impossible for me to interact with the entire population. I probably haven't even interacted with a tenth of a tenth of a percent of the population.

And, as if things couldn't get any better, my comment has a "Where Claus" where the scope of my comment is limited even further! So now we get to bring some relational algebra into this mix. Let's take the entire list of physicians I have interacted with (that tenth of a tenth of a percent I spoke of earlier). So even out of the entire list of physicians I have interacted with, we are yet limited further to just those I have had that experience with! So most likely a small subsect of our already small subsect. You could, of course, [censored]-u-me that the entire list of physicians I have ever dealt with has given me that experience, but I would not recommend that.

So, yes, I have had that experience. But, no, I am not saying all physicians are that way. I can't speak to that since I haven't met them all.

By the way, I would like to point out two other flaws with your statement.

1. I am not the person on this thread talking about terminal servers, CALS, and all that. In fact, the clear majority of comments on any thread on this forum where there are recommendations about going Small Business Server, terminal server, or racking up CALS are not made by me - and you even pointed that out in your post. I mostly talk software development.

2. A couple of others on this thread agreed with me or made comments similar to what I said. In fact, the quote you gave includes a comment made by someone else that I was agreeing with. Yet I am the only one who caught you ire.

I find it curious that you chose to zero in on just me and that I am the only person who lost you respect.

JamesNT

Hi Steven,
Don't be too hard on James, he seems to be a good guy, very helpful. He may have been a little strong in his example, but he has a valid point of view.

I agree with you, we are keeping AC simple, peer-to-peer, and I do all the IT. But I understand the arguments made by others for servers and professional support, I just have not gone that route.

But I certainly appreciate different points of view.

BTW, I am currently driving a 1988 Jeep Comanche. Which I maintain myself.

Gene

Steve,

I understand where you are coming from but only because I think you took James' comments out of context. And, since his comments were in reference to mine, I have a pretty good idea where they were coming from.

James is a super guy who has helped me a lot. The IT tech I referred to has always told me that many IT people aren't always the best people persons, which is why they go into working with motherboards, and doctors generally have good bedside manners which is why we do what we do but aren't very good with computers. And, when I say that, I don't mean setting up a switch or installing RAID, I mean a full fledged network set up flawlessly.

In a nutshell what James and I were saying is the following:

My IT friend always wonders why people who are sick choose to go to very good doctors and do what is best for them even if they can't afford it or at least what they can afford, say CT vs MRI, but yet doctors, on the flipside, choose to (many, not all) to leave their critical data on rebuilt HP computers from eBay. (Please no firestorm from those who do.)

All James was doing was giving a more direct analogy, e.g. for us doctors who do make a decent living (harder and harder), tend to skimp on technology, probably because we survive by watching every penny.

I think if James is guilty of anything is possibly using the wrong words or expecting us to understand his full meaning.

I think James would be one of the most helpful users on the board if AC would turn him loose with the sa and password and help users with the ssms. I am sure he has those, but he can't openly advertise.

He also does not solit business through AC and does this on his own free will.

So, I would ask you to reread it and maybe look at it a little differently.

Obviously, you haven't searched enough of James' comments. This one is quite mild. I have a top ten list.

Sorry, James, had to say it.

Thanks for all your help.

Well, I am too tired to go back through the thread, but if I recall correctly, it would be impossible for two databases to co-exist. All of the employees would be in the same building. I thought the premise was: two offices -- only one working at a time.

I think Greg's idea has tremendous merit. I would have said so earlier, but I didn't want it to take away from my brilliant suggestions . I can't think of one now. I will leave it up to Sandeep. But, what if there could be some type of device -- computer, nothing James Bond, that you would need for the information to be useable.

Have to agree with Steve - JamesIT - it is ILLEGAL for me not to collect a copay... so those signs are there courtesy of your government, not a form of greed. Just an FYI. You're attempt at humor is... well it isnt... humorous
In terms of lexus/bmw etc.. those are just toy cars my son plays with. It's obvious the conversations you've "been in with" with physicians arent in a medically underserved area of Appalachia Ohio. I'm just trying to make it day by day. I'm so grateful Jon has given us this program to use for a reasonable cost and I don't need to employ an IT person. General computer knowledge is just fine.

on topic
I agree with the two offices solution of just putting database on a laptop or using the FREE online portal.
Joni

Steve and docjoeknee (Carroll?),

Disagreements happen. We all know that. Does either one of you think I honestly am going to get on a public forum for the sole purpose of insulting someone? Of course not.

It's true that in my travels I have dealt with offices that were clearly plush with cash but wanted me to get them the cheapest P. O. S. I could find to run their company. And, of course, when whatever piece of crap I obtained for them breaks, they demand to know why it wouldn't run like a well tuned Cadillac.

However, it's also true that I have worked with doctors just like you. People in small solo practices in poor areas that are at the absolute mercy of Medicare and/or Medicaid. They have patients galore that fail to pay their bills. Despite the office being out in the sticks, the landlord of the building wants to charge inner city rates. Believe me, the list goes on. For doctors like this, I have gone out of my way to help them. I've done free work. I've pulled strings with Dell to get parts replaced even after the warranty period had fallen off. And it doesn't stop there.

As far as my comment about collecting copays goes, I just plain forgot about that law so making that remark was a mistake on my part. My apologies.

I think it would benefit the board greatly if we figured out how to get along.

I'm game if you are.

JamesNT

Bert,


Arguably my greatest flaw.


Yeah, I probably had that one coming.

JamesNT

I think James has shown over time that he is appreciative of hard working physicians but is aware that some physicians do not have their priorities straight.

That is how I viewed his original response and all his subsequent ones.

Can he be somewhat abrasive, sure, but aren't we all. Most of the time it is either tongue in cheek or possibly being tired.

Remember, his advice here has been free and would be the equivalent us being actively involved in a consumer medical site but trying to answer questions and be helpful without the risk of being sued.

I'm sure we all know docs who would be just as he painted them, penny pinching for the practice but must have the bling. Nothing wrong with having bling, but I prize quality equipment. Penny wise and pound foolish. Then when there is a problem, it would be his fault for providing the POS machine he was told to buy. Most docs are not this way, just as most patients don't scream and curse at the front desk. But they do exist!

I think this tangent has dragged on.

OK, then, let's talk Bears vs Lions. Well said, Wendell, as always.

I have two offices. They are not both working at the same time and so we take the practice with us, generally as a backup. Anyone billing or scheduling in the office that is not seeing patients, can just log in remotely to book the appointment or find info needed. It has worked well for us. Backups are much quicker since version 6.3. Logging in remotely is just too slow to manage office hours. I guess it would be an issue for multiple providers but it really would depend on volume I imagine.
Nancy

Were you logging in using Remote Desktop or LogMeIn?

At first we used Remote Desktop and then we used Logmein. Both way to slow for documenting encounters.

That's quite interesting. I've had a few people who didn't even realize they were on remote desktop as it's usually pretty responsive. You may want to double check your settings. What is your upload speed? Perhaps you could post a video using CamStudio (free).

I'm really out in the boondocks. Lucky to have Internet at all much of the time. Things are working well for us right now. Heck...lucky to have electricity. We often go hours without electricity....fortunately not lately.

Yikes. Do you have a generator at the office?

RDP is good for low bandwidth Applications. What's your speed on http://speedtest.net

The biggest downside I see for getting outside IT help is that you are dependent on someone else. The doctor next door to me has not been able to see patients since yesterday afternoon because their server crashed and the IT guy who does their service cannot come in until until today afternoon - about 28 hours after the crash of server. So they have been unable to see the patients. The office is closed!

Lesson learnt is the computer configuration in the office should be simple enough that you can fix most problems yourself without the professional IT help. Fortunately, AC Main Computer on a good Windows 7 (i7 with 8 Gb) on a peer to peer network functions well - as good as Windows 2008 or SBS2011 server.

My advice is to keep it as simple as possible that you can fix most problems yourself and are not reliant on outside vendors.

It does not work overall (the network) as well as a server OS. If someone breaks their leg, should they fix it themselves right away or wait two days for an orthopedist.

You hire an IT who can be there in 24 hours. Dell will be there in four hours. Many doctors can't fix a P2P and many doctors can fix a server.

I respect your opinion.

An IT professional would have a disaster recovery plan. Some even have tiered plans depending on the type of emergency.

I will agree a server system is more complex. Sometimes it's the only way you can meet certain security measures is through the use of a server.

I've said this before and I'll say it again. What really matters in terms of reliability is the hardware. Spontaneous software failure is extremely uncommon when you have a dedicated computer/server. Most software issues arise from users executing programs on a dedicated machine that they shouldn't be. Keeping a dedicated computer minimizes this error significantly. But everyone still keeps backups just in case. Full image backup can have you up and going to an exact image of your computer from the previous day.

I don't what you mean by server crashed, but there are a few possibilities.
-If we have a hard drive failure, RAID covers us. The system would still run with no down time. Can be used on P2P or Server.
-If we have a PSU failure, redundant power supplies cover us. The system would still run with no downtime and you can replace the and unit at your convenience. Can be used on P2P or Server.
-If we have a memory error, ECC RAM corrects and stops a blue screen/crash/reboot, uptime is maintained, and data loss is prevented. Can be used on P2P or Server.

Prior to virtualization, the main way to defend against motherboard failures was quite expensive. Often involving a second high priced, identical server. With virtualization, we can jump from computer to computer with little to no downtime. There are other enterprise techniques like failover clustering but that gets complicated.

When we say server, we usually mean computers with these safeguards in place. Whether or not you want P2P or a server is a different issue.

I know people like to use personal experience to indicate they've never had issues without all these safeguards. Congratulations, you're one of the lucky ones. While I personally have also been as lucky with my computers, I know many others who have not been as lucky. I'm sure if you search through the archives you'll find similar stories of disastrous crashes.

That complexity argument about server parts is frankly bogus.
If you can put a piece of bread in a toaster, you can swap a hard drive in a hotswap case. Same holds true for redundant power supplies.

If you were on on a desktop, your hard drive fails what now. Open up that computer replace the hard drive and restore your backup assuming you have a full system backup. If you don't, you have to reformat, install drivers, updates, and programs. That takes several hours. Unlike your buddy up there with the hotswap bay, you have to be familiar with opening up the case, switching out the hard drive, changing the boot order, installing windows from scratch, finding drivers, etc. He just pulls out the bad drive and slides in a new one in an easy access hotswap bay.

Thanks Sandeep. Was going to PM you. This, I think, is the perfect analogy.

You need a boiler for your house which costs $4500. Your friend who is pretty damned good (has installed over 50 of these) puts it in. You come home at midnight, and it is freezing. You call your friend. Good luck. And, you can't get too mad because he saved you 10%.

Or you use a real, certified plumbing and heating guy. I went this route. Yes, no 10% discount. Yes a warranty after one year. But, he comes to the house within two hours of any emergency.

The whole deal is getting a fully certified Microsoft MVP with a contract who has to come fix your server within 24 hours. We all know how to have AC on another computer with last night's backup we can switch to.

The other thing is I wouldn't let an IT professional set up my network without watching. If he wants job security, let him go down the street.

It's expensive, but I alway have 25/5/4 hour warranty with Dell, with 24 hour on weekends. I have met my IT support once.

Hi Sandeep,

How about this for a peer-to-peer hardware crash:

Pick another PC on network
Restore AC from onsite backup to that PC
Redirect AC path to new PC on all other computers.

I had to do this once, several years ago.

Gene

That's assuming your average user knows how to restore it. So take data from your backup assuming it's up to date. Copy it to the other computer. Run restore. Make it the main computer and reinstall AC with SQL. Share the folders and Change the path on all the computers to the new one. You might've left out the parts where most users don't have SQL installed on their other computers. You have to set that up too. That's also with all the sharing working right the first time. That's just for AC not including any other programs/shares that you might have.

Option B with RAID. Do nothing. Insert drive in slot when it arrives.

Gene, I just said that above, lol.

That works for me, too.

OK, so you beat me by 7 minutes and 26 seconds!!!

Happy birthday.

Gene

Me too.

Somehow I think your "simple" is my "unbelievably complex"

The scale is different for us mere mortals.

Gene