Home Forums Discussions Problems Would you choose AC again?

I have to agree, "easily accessible" is the exactly opposite of the trial periods of most other EMRs. Same for finding out the price for that matter.

What does it make you think?

Newfane (15 min north of Lockport)...

I am looking at Praxis--was ready to sign until thank god realized how expensive upgrading my server would be (2/3rds the whole cost of mine and NP software licenses)...their user board seems to have lots of hardware and slow speed complaints. Our regional system Medent seems to be loved by all I've spoken with lots of bells and whistles-- but has a HUGE pricetag...not sure it's doable while still paying on my Allscripts MyWay lease. I may be asking too much, but really am scarred from my previous EMR experience and financially having a tough time due to their terrible clearinghouse issues. I want to love the next system and be satisfied with it for the long haul!
Tx for all the input. Seems like you have a cohesive group here.

My live demo struck me that their wasn't any sort of transition for different staff workflow...like how the nurse tells me PT is ready for me and how I let them know pt is ready for them/checkout and especially my biller. Doc on webinar said I could highlight day or week and send them as attachments to message to biller that they are ready to be billed/reviewed. WHAT? Our he suggested i manually type next to each pt 'ready to bill' or 'ready to checkout'. That seemed really ridiculous and basic as to how it should flow seemlessly to biller/PM system. Any thoughts on that??

Wow Praxis! We demoed that for about six weeks. Didn't know it had all those problems. The concept processor and the bell shaped curve just seemed very cool.

As to your questions, please give me carte blanche here -- just trying to help. There are so many ways to use the application for communication. I have long since given up thinking my way is the only way. But, I still tout it. One thing is I have never quite understood the way some people's work flow goes. First, I think that a lot of people try to make the EMR do too much work in the communication. Some will see the patient, then send the chart to the nurse with orders, then he or she send it back, then the doctor sends it to reception. The chart is everywhere. Most of these are sent with the chart not signed off. No wonder so many lose the note.

It always seems as though these work flows are for offices as large as a football field. Here's how we do it. (Again, just one way). We never use the chart to communicate to anyone. And, we only use messages for patient messages: Jane Smith needs more Vicodin. Is that OK? Which I answer. What we use for everything else is a network instant message. These are fast, HIPAA compliant, can be sent to one or more people and best of all, you know when they open it. So, I am in my office and my MA sends a message and it pops up and says 2 and also has a notification sound. I send it right back without having to type anything, and she knows I am informed. I then go to the room. I see the patient, print out any meds or eRx, x-rays or blood tests (printer in rooms), and sign off the chart. Now this is because we don't use the Superbill on the EMR. It leaves a lot to be desired. A PM is in the works. I put the flag up for immunization or nebs or whatever. If it is a WCC, she knows it is for shots and she is aware. Anything else, I simply walk down to her station and tell her. Neb in room 2 or whatever. Personally, I am not big on using the EMR to let her know as she could be in a different room or in the front office, who knows. And, I will say the biggest issue I have with AC is the fact that messages aren't refreshed, so she could not see that message forever. Now if I am seeing a baby who needs an O2 Sat, I can use the instant messenger, and I will see that she received it. And, she comes to the room while I finish up. Again, verbal communication before I leave the room. If she doesn't answer, I just message the front desk, and they always know where she is. There are two good instant messengers. We use ipmsg. they are both free.

I guess you use the billing part of the program. I surmise this, because your post makes alerting the biller seem very important. For me to try to help, I guess I need more info. Our biller takes Thursdays off, so any quick notification isn't important to us. And, I guess I am not sure why. Everyone on here knows I abhor paper and am as digital and computerized an office on here. But, we do use paper Superbills. I generally walk these down as I think the patients like it, but it gives me more communication, and they know that anything they need, such as a signature or the Dunkin' Donuts card, will be handled quickly.

If you do need to use the electronic method for your biller, then sign off your chart so it's done. Then reopen it, click on Forward Chart (bottom right) and send to your biller. You can even type a message.

Now, since I don't use this part, I may be giving bad information. Maybe she needs to get the chart before it is signed off.

Hope this helps.

The price for the Oracle Database Software alone exceeds my total setup costs for a new server and installation for an entire office! The hardware and software needed to run it isn't cheap either. Dual processor server with SAS 15K Drives, etc.

Total price for us was 500 dollars.

Speculations, really. Not necessarily exclusive. It makes me wonder if you know something about the recent partnership that I don't. Or if I'm just being obtuse and can't see what is in plain sight. Or if something not directly related to AC has made dour your perception of AC's appreciation of community input.

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I went to the praxis website to learn more about it. One of it's central premises is that templates don't work. I like templates; however, I do recognize that if done incorrectly, they can lead to problems. Just seeing the "templates don't work" line made me a little less receptive to their message.

How well does the concept processor work? It seems to me that it might not work well for the finer details/descriptions that go into encounter documentation.

What does it make you think?

Mario:

Speculations, really. Not necessarily exclusive. It makes me wonder if you know something about the recent partnership that I don't. Or if I'm just being obtuse and can't see what is in plain sight. Or if something not directly related to AC has made dour your perception of AC's appreciation of community input.[/quote]

No it has nothing to do with Pri-Med or anything sinister. I, like others, have been using AC so long, singing its praises, helping other users, that we/I feel we have a right to criticize sometimes. I think AC listens, I just don't think they do anything with the feedback. I would ask anyone to name five things that have been suggested that have been incorporated into AC since v4. I don't mean things like the slow down of eRx or the TSP800 melt down. I mean small things that would make a big difference. The users on the board have made it clear that the letter writer in its current existence was unacceptable. This is basically the same letter writer saved in HTML since the program started. Yes, finally, a new and improved one is becoming a reality. I know developers will say that it isn't just one line of code. Understood. Then tell us. Here is a classic example. When you print a lab requisition, the documentation in the chart is:

ORDERED/ADVISED: - Custom Order (CBC
ESR
CMP
LDH)

Why do we need Custom Order?
Why is CBC on the first line?
Why do we need parentheses?

It is all about what is important to the developer and what is important to the end user. For me, formatting is huge. For the developer, not so much. But, if a hundred users are telling you the same thing, edit the line of code that puts parentheses there and tell the program to put the first lab two lines down.

Small thing: Allergies:

When you update allergies, you will get:

(Updated by BERT on 01/18/2011 12:53 PM) Formatting again. Do we need the user name? Possibly, if it is a medicolegal issue. From my point of view, no.Do we need the time? That's crazy. How about Updated 1/18/11. Does it really need to be red?

Now some would argue on the latter. OK, fine. That is where 500 users send in recommendations on that, and the developer selects what they want.

Please don't get me wrong. Amazing Charts is the best EMR for the small office there is. Unfortunately, the government came along and wasted two or more years from development. Now v7 is the same. When I was looking at the last update, there were many, many changes. I found I could only use one.

If you took a poll, I am sure 50% would want a PM and 50% wouldn't. I am of the latter, and that is not AC's fault. I just think it would be really cool if we could focus on making AC leaner and meaner and bug-free (close) and continue to improve it based on the suggestions of actual users. But, that hasn't happened. Which is why I say we haven't truly been listened to. That's my only frustration with AC.

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Bert:

Wow Praxis! We demoed that for about six weeks. Didn't know it had all those problems. The concept processor and the bell shaped curve just seemed very cool.

Mario:

I went to the praxis website to learn more about it. One of it's central premises is that templates don't work. I like templates; however, I do recognize that if done incorrectly, they can lead to problems. Just seeing the "templates don't work" line made me a little less receptive to their message.

How well does the concept processor work? It seems to me that it might not work well for the finer details/descriptions that go into encounter documentation.

Templates are great. I use them all the time. I think the problem with them at times is I find myself documenting a referral to cardiology for an arrhythmia and the exam says "normal rate and rhythm."

I think the message is good. You have to show off your product. I think the bell shaped curve is amazing. To base your note on the exam line: Right ear red and draining and have it pull up a note from among 50 notes and then edit it, saving it in the curve so that next time you get an even more similar note is a great concept. And, since the note that was pulled that matched your initial information was close to being identical (the more you use it, the more it becomes identical), it automatically prescribes amoxicillin at 80 mg/kg/day divided bid and Ciprodex drops. You can edit the note and add the comments you were referring to. You always edit the HPI using placeholders, etc.

Now, this was based on a one month demo over nine years ago. The learning curve is steep. You basically practice on one patient after another with a tutor on the phone. But, I am in no way pushing this EMR. I don't know if it works or is slow or whatever. Robert Lowe, the president, is cocky as hell. I just think the idea is very cool. I have always said, the are all the EMRs in the world and then there is Praxis. Again, if I bought it, I may come running back here with my tail between my legs. So, right now, I most likely would purchase it again. It is still the best. I just want the features put in.

Bert:
after demoing praxis for 6 weeks what was your thinking? Looking thru their online user board it seems the users love the notes and ability to document but the hardware speed and cost seemed a big issue. Since I am not a big computer techie, this intimidated me. Looking at AC it seems alot of users are also techie and combine alot of programs/services to make it work well for them. I'm concerned I may not be technically up to that. Conflicted arrggghh!!

It seems that works well for you...with my current MyWay system the chart is divided into tabs and the final tab is called 'plan'...it has when I want to see pt back, any patient Instxns I can choose or type in free hand, additional notes as an addendum to chart (this is where I type in orders for my nurse such as referral recs/reports I'd like but don't have, what other things they need like EKG, pt education materials etc etc. there is also a sect for notes that are private and don't become part of the medical record.
The rest does become part of the record so when I see pt back I can see what info I gave them or requested etc.
For me, if this info is not critical to see before they leave and nurse is with another pt or on phone I can just go on to another room and know it will be done for me to review before I sign off on the note.
From here there is a way to designate the note 'ready to review or not ready' for my biller. Any chart ready to review auto flags for her to review and bill. Then billing isn't held up if I want to tweak the note further before signing. By saving the note it auto changes status so receptionist can view and check out pt as well as printing them a summary of the visit.
It seems you could see more patients or be more efficient if you didn't have to physically 'escort' or verbally hand off each stage of the process but that's just my outside opinion.

Patricia,

It really is not that difficult if you (or someone you know) puts a little effort into it. Frankly, I look at the price differential and think "this is a no-brainer to at least try." And just think, 6 years ago it was half the price. Compare that to what it costs to try out some others...$6K for the first "provider," and we'll give you a 50% discount on each additional! That's $3K each. You could just get AC for 3 providers for $3K. And spend less money on hardware to operate it... start off using your existing hardware (if any). It may not run as fast as you want, but it will probably run OK.

I'd say if you can buy a copy of MS Office and install it yourself on your PC, then you can probably install AC by yourself. If there is an unexpected error, call tech support. So do it on a weekday, perferably in the AM just to be safe. Really, the tech knowledge to install and use AC is not what should hold you back. This should be a reason to pick AC over other systems.

Patricia,

Here is the answer to that. And, it comes from friend with 35 years of Microsoft computer networking. He tells me almost on a daily basis of how people, like doctors, try to do too much with their network. There is a saying that I will screw up:

Always do what you do best, leave the other to the rest.

And, I don't have to hand off the superbill. I can leave it on the door.

Well, I will agree with Bert. Don't try to do too much. Don't try to setup oh one of those MS Server 20XX systems by yourself if you aren't ready to get into it. But most folk can do the little peer-to-peer with a little help from a $20 "how to" book. If you know an IT guy person that can support it for you on a call basis that's good too. Even pay someone to run some cabling so you don't have to depend strictly on wireless. It's a pretty inexpensive initial setup.

Tx to all...!!

Most likely yes, but will prefer it with PM. Currently using EZclaims for the past 2 years. Not impressed by their billing report catalogue. They also are little help when you call about how to get decent billing reports. Most of the "helpers" seem to know very little about billing!

There are several folks on the board that are very knowledgeable, but I wouldn't let that dissuade you. Most of our clients that use AC are not interested in technology, and use us in those instances where they want/need something technical done. Which, once things are correctly setup, is not that often.

Properly setup, AC is neither expensive or difficult to operate.

Many of the folks on this board are ingenious, as they have found a variety of tools to enhance AC, but they are not mandatory.

For a practice coming to AC, the one additional tool that is *almost* mandatory is Updox. If you don't have/want to run your own fax-server, want a patient portal, or need to support multiple locations, there isn't a more cost effective tool around.

It is buried in another thread somewhere, but as cost-modeling experiment I figured that when you sent your tenth patient correspondence you were break-even on Updox for the month. For the sake of argument, if I am off by 100%, it will take you twenty patient correspondences to break even.

If you have already used an EMR, you have, at least in part, already conquered the larger task, which is going paperless in your practice.

In comparison, AC is relatively inexpensive, straightforward to implement, and low-maintenance.

I agree with Indy. You have to think about a certain bias. Those with a lot of computer knowledge and/or AC experience will post the most about these areas.

Those that have the least amount of computer knowledge are going to post asking questions of the above.

This tends to make it seem as though if you have little experience you must need computer gurus to figure it out.

If you can connect your cable or whatever modem that is installed by your cable company to a LinkSys router then to a switch, you are pretty much set. Connect all the computers to the switch, install AC on each computer, choose a computer to be the "server" and connect them.

Also, a good tip is to go to your local college that has a computer science course and ask the professor to ask if any students want to run Ethernet cable for $10.00 an hour and pizza. Works all the time.

Patricia,
I'm totally not techie and have managed. :-) The tech support with AC is really good. Today I tidied up my "junk room" while Michael spent over an hour fixing stuff for me. I didn't need to know anything about what he was doing...I just had my cell phone with me and computer screen in sight so I could run over and put in passwords when he needed it.

I'm also using updox to make life easier and, again, tech support is awesome. You can totally do things yourself but you can also be dependent on tech support. Meg (at updox) and I are getting to know each other way too well, but any time I want to change something with updox or the patient portal, I call her and she logs on remotely to help me.

Having experienced multiple EMRs, I'd say AC may not be in the golden age for the techie people who like to work with programs in the beta form, but for those of us who are non-techie, it's great!

Ty!!

Templates make me feel that I am being forced to provide MacDonald's burgers to a person that deserves a thoughtfully prepared meal. I cannot honestly say I have EVER done approached two patients exactly the same. Being expedient does not make something quality.

Above post edited to reflect the fact that I did not write that quote. It was a statement by Mario to me.

I understand that, but cannot you also say that a patient coming in for a quarterly blood pressure check NEVER has the same physical exam from visit to visit? And that no two people have the same (negative) family history or ROS?

It's true. It was I who blasphemed!


I'm not a doctor. Nor do I know many doctors. [ethos points -5]

But I'm pretty good a analyzing processes [ethos +1], and I think that if something can be done more quickly with the same end result without compromising the integrity of what was done, then it should be done that way. I understand that you think that templates compromise integrity. I partly agree. Going through the same list of objectives for every patient is not only McDonald's-esque, but also inefficient and a non-use and mis-use of a doctor's talents and time. The key is designing templates the right way: to allow input from the doctor where it is needed, and to eliminate not-important rote tasks. I think templates are especially useful for wellness-checks. Wellness check-ups demand, at least partly, a systematic approach to assessing a patient's health.

Being of quality does NOT make something slow/NOT expedient.
Personal Aside: As obvious as it seems to me now, this was a concept that I heavily struggled with in the past. I thought that doing things in the old ways, which for a unit of work usually require more attention to detail,concentration and effort, was a display of discipline and fortitude. And to a certain extent, it is. But why not exercise that same discipline and fortitude to do MORE than what you would ordinarily be able to do.

In my mind, the correct use of technology (and templates) is the difference between using a glass bottle of ketchup to put ketchup on the burgers VS the cool squeeze gun McDonald's employees currently use. Technology (and templates) can also be mis-used.

If templates make you feel like you're being forced to provide a McDonald's burger, perhaps you a trying to make them do too much for you (make the whole burger vs help you squeeze ketchup).

Just to be clear, we use a lot of different templates, and usually they are very generic, fragmented and allow for plenty of staff/doctor input.

Finally, Jon is a doctor and from what I can surmise from his post above, he thinks that in some situations a template can be useful.

I don't see a "custom order" lab order test. And I tried placing all sort of orders, and they seem to have printed out fine. Am I missing something?


The allergies thing really doesn't bother me at all. It takes up a small amount of space and I don't find it disruptive.

___

Overall, I agree with your assertion that there are a lot of small things that could use improvement. Personally, I would love to see a more robust Reports tool and a more flexible HM section.

You state that the community recommended improvements haven't happened. Some have. But maybe not enough.

Yes. You are missing something, lol. Lab orders section. Far right tab. Type in customer orders. And, before we had this convoluted lab section, we had a simple one. It did the same thing.

This is part of the reason it is hard to make changes based on user ideas. The best thing is preferences and options. But, I will make an analogy from JBS' autosig of stop useless clicks. Mine would be stop unneeded verbiage.

Mario, you must remember that as an Office Manager, you have much less of a reason to write a script. I am not sure if you are an MA/Office Manager, but even if you are, my guess is I would write 15 scripts to your one. Without using the script writer, it is hard to comment on whether it is distracting or not.

Keeping things smaller and less obtrusive makes them less distracting and allows for other windows/boxes to be enlarged and show more. The only reason it should ever need to be red, would be if it turned red if there were an allergy listed. As it is, the red contributes nothing. And, are you really going to tell me you need the time. Why not add seconds?

I think I may recall two. But, if you ask me right now, I couldn't name one that has been incorporated into AC.

Jon, Mario

I have no objection to using a template as a blank form, or even for a routine physical. But AC encourages using templates for the history. For example, you will have a hypertension template that goes "Patient denies headache, syncope, SOB, epistaxis, chest pain or peripheral edema." All very tidy and right-clickable. But, when Mr. Y comes in, and you ask, and he says he gets occasional nose bleeds in dry weather and his ankles swell a little at the end of a long day of standing at the parts counter, what do you think happens? It is "pretty much negative", so you go ahead and use the template. It is going to take as long to edit as to just do properly from scratch. And, if you have every possible combination templated you won't be able to find it, and/or it will take longer to find than to dictate from Dragon. And, it is pretty close. But it is not correct. And thus begins the slide to a worthless record.

In the good old days, I always charged a 99213, always looked the patient in the eye for the whole visit, always dictated a short note in less than a minute or two, always could understand my last note and get up to speed in 20 seconds or less, and didn't know there was a better way.

Now in the quest for justifying a 99214, I struggle to see all my established patients on schedule, and really enjoy having new patients so I can relax and just listen and talk. You know, be a real doctor.

Really, the only improvement is in being more thorough with check lists or templates. But, readability and succinct summaries are now unnatural and scant. Actually, the best improvement is being done with the note when the patient and I leave the exam room. I don't want to go back to a stack of charts on my desk!

I try to type several sentences at the beginning before I start clicking, as I don't want to dictate later. I end up with a page and a half of enough facts to make a CMS auditor want to skip my practice.

I think the goal is to combine a section of hyper-variable text with all the pertinent positives and negatives that encourage you to think of less obvious diagnoses.

What I want is a program that allows me to see trends and quickly summarize them. The program knows all of the weights and vital signs enough to graph them, so it could alert you and concatenate a paragraph and make some suggested clinical summary sentences for us to choose or customize quickly. Shouldn't AC alert you and make it easy to document when a patient is below BMI and losing weight for the last three visits, or the blood pressure is high and climbing, or the pressure is low and dropping while the pulse is climbing? AC has the data so why should we have to take 5 minutes trying to make a paragraph about it.

Diabetics could be tracked for at least the glycohemoglobin, osteoporosis for their t-scores, thyroid for their TSH, etc..

The database can be used to document progress in the note, instead of just display it. It could lead to better care,

and a full two page, definitely 99214 note

I understand David's reluctance about templates. We all receive badly templated notes from other docs, which carry over incorrect or dated information or conflicting statements. And now that patients are getting to see much of their medical records, this will surely become an issue for careless documenters.

Although it is just as common to read a dictated narrative full of boilerplate jargon -- think of your average surgical op note. Not colonoscopy notes though, Jon, those are always a great read. I never know what's around the next turn.

But there are templates...and there are templates. A well thought out template, customized by pertinent Dragon-dictated text, can serve as a comprehensive framework for good documentation. And for those Medicare-required chart statements to qualify a patient for everything from diabetic test strips to home health care visits, templates are a lifesaver.

Dan,

You may know of this already. But the little graph tab by the vitals is a wonderful little gadget for me. It takes only 3 clicks, and I can print up BMI, BP graphed out over time and hand a paper copy to my patient which is a wonderful display of those two parameters at least. This is extremely helpful for my hypertensive and/or diabetic patient or those that need a bit of urging initiating BP meds. I agree if one could do that with the DEXA, TSH, and Hemoglobin A1C's with such ease would be fantastic.

I would, but like any good business person keep my eyes open all the time for options that make my work easier and my bottom line better. The price is right and the support is excellent. These USER Boards made it possible to get my new practice up and running 5 years ago. We are also blessed to have the G.A.S. (Guardian Angel Support).
I am sorry that AC has chosen to try to build a PM instead of building on a really good EMR.
AC doesn't meet all my needs and I am open to other possibilities. I feel a little vulnerable since the Pri-Med became the owner, but glad to know that Jon will still be involved. Pri-Med puts on a great free program, but you are definitely herded through like cattle there (and at that price they have a right). The that cattle mentality has caused me to look more seriously at other options.

Followed the twitter link from AC to this article http://www.familypracticenews.com/v...es/c4a566b652e61e4e116c4e4d4090f579.html
Maybe it is all inevitable but does give me the creeps some and while I just reupped my AC yearly fee the integration of Primed/AC is still concerning

Disturbing.

Vicki, would you care to elaborate on why you find it disturbing, and koby, why the creeps?

Actually, I think this is how it ought to work. I find random conferences pretty worthless.

When I first started using UpToDate I thought it would only be to look up weird things. Then I looked up something I thought I knew. I was totally shocked to find that I was totally out of date. I mean really humiliated. Now we make it an office policy to look up everything. Really everything. Treatment of UTI's. Treatment of sinusitis. Current best practices for hypertension.

I just was audited by the state Medical Board to verify my CME. I looked up one six month period of UpToDate, and had 268 hrs of CME fro that period alone. All of it was related to patients I was caring for.

My only negative comment is that the UpToDate window in AC is ugly. I have to expand the window to use it, and it often does not remember my login, so I end up using Internet Explorer in a separate window and losing the documentation in that encounter that I looked something up.

David,

I have been using UpToDate for years. I find it a great resource and actually diagnose patients in the room. I also send many patients a one-month's subscription.

I agree with how much I learn from it even on simple things. When you say it is an office policy to look up everything, do you mean if you saw a sinus infection at 9 am, you would still look it up at 3 pm? I am not trying to be a smarta...., I really want to know your system.

Well, not quite, Bert... even I am than troubled with OCD. But, if it had been a few weeks, I would.

Let's take sinusitis. I had often been treating it with azithromycin. But, last week a study raised concerns about long QT interval and arrhythmias. . So, I need to refresh my memory of what better treatment might be appropriate, or require everyone presenting with sinusitis to get an EKG. Things like sinusitis I only see every few weeks. I don't look up hypertension every day; but I do check "what's new" in UTD regularly. The trouble is that despite things like daily mailings from the ACP about new studies, I miss stuff, and I don't know what I don't know. My initial collision with UTD was so humiliating as to my ignorance that I had only two options; decide it was all a lot if ivory tower BS, I was pretty well trained, and I'd keep UTD for weirdomas; or face the fact that stuff changes so fast that it is impossible for me to be sure that I am doing it right without looking it up.

I agree. Another good reference is Lexi-Comp for medications. It clearly lists drugs that have new found adverse effects and azithromycin is on the top of that list. Zithromax is one of the most successful antibiotics of all time taking on an almost "cult" status and certainly has made Pfizer all the more richer. I think possibly because of Mycoplasma, it became the go to drug for pneumonia, although I prefer Augmentin or a cephalosporin with a proven lobar pneumonia. Zithromax will never go away given its almost universal use for Pertussis especially with the last two epidemics of the last two years (which likely didn't reach Alaska)?

The anecdotal information on Z-pack's inability to treat sinusitis well came from my pharmacist who told me when his customers received Zithromax for sinusitis, he would tell them he would see them in two weeks. Somehow he did this without making the physician look bad. Or maybe he spun the story a bit.

What I find shocking is that a healthcare system, which is supposed to be the best in the world is so slow to learn new but straightforward things such as the fact that when Zithromax is used for the treatment of streptococcal pharyngitis, the dosing is 12 mg/kg/day for five days and not the 10, 5, 5, 5, 5. It must have been at least a year before the pharmacies stopped calling to correct my dosing, and the doctors in the ED still make that error.

On a side note, I hate making the diagnosis of sinusitis given that in pediatrics it is almost always made by history. Parents become quite adamant that their little one with three days of symptoms of cough and the "yellow, green runny nose" is sinusitis or, as they put it, siniitis. Early in the day, I am able to convince them to wait, but late in the day when I am too tired to fight, I will at times give in.

So question for you and UpToDate. If I use the AAP recommendations on the diagnosis of sinusitis, which is the signs and symptoms of an URI that lasts more than ten days, if I wait 10 days to treat the sinus infection of the child that I saw with the same symptoms at three days, did the child suffer with a sinus infection from day one?

Sorry everyone. I know this is a bit out of order.

Mario, this is in no way a criticism of your statement. I agree with you. But, in a more global sense, can you name any time in the past 20 to 30 years that doctors demanded anything?

Jon,

The creeps because I am a paranoid type and while I invite the 'focused CME' aspect I let my mind wander to..."realtime E&M management survaillence via the cloud and immediate claim denial/medication denial by the integrated (gov/ins co/EMR/drug manufact complex)", can you tell I'm from the 60's.
Yes I know the full integration is years away maybe decades away and that we docs are an inventive/resilient type.
For me individually it prob won't matter, not going cloud based, not chasing MU.
I am still believing in Jon B and that whatever redheaded stepchild AC becomes there will be patient care benefits in it for us.