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Would using DisplayFusion take care of this situation? This is a subtle issue that is nagging, but it occurs with every edit, use of address book, electronic signature or use of the patient portal with Updox. I have to jump back and forth between screens.

This issue is a nuisance, not unlike having the Dragon Bar on the top of the screen, needing to be minimized with every encounter and having to move the AC box down to complete the task. JBS solved that issue for me, and I cannot believe how not having to do an extra few clicks with every encounter improves my disposition!

I am of the opinion, these extra steps, if identified and negated may lead to nirvana.

That's exactly what DisplayFusion does. Initially people would use the software to have a different wallpaper on each screen, but it gradually evolved into what it is now. I promised JBS a video on it as well. I must upload it soon.

Sandeep,

That will be great. And is that the free or paid version?

The paid version gives you the multi-monitor task bars.

Ah, a kindred spirit.

"In the Buddhist tradition, nirvana is described as the extinguishing of the fires that cause suffering." But that was before needless clicks were invented.

Jon,

To keep with the Chromebook theme I was thinking of nirvana in the Google dictionary sense---"a state of perfect happiness; an ideal or idyllic place."

Now for something completely different......

One of my long time friends and confidante, who also happens to be from that other part of society, an ambulance chasing lawyer, had an interesting perspective regarding the duplicated larger chart projected in the exam room. Engaging the patient in the process of viewing and developing his own chart, and then documenting this at the end of the note, is extremely beneficial and protective from a medical legal perspective. I have not been documenting this at the end of the note, but not a bad idea.

Sandeep,

My daughter and I made some short videos today regarding my office set up with the chromebook, and plan to share these at the upcoming San Diego event, and if well received, may post these at a later time. If not, may have to redo the videos or think of other ways to get the message out.

http://www.medscape.com/viewarticle/821584?src=wnl_edit_specol&uac=176037MV

At the recent MMA (Montana Medical Association) leadership conference here in town, this idea of medical scribe was discussed. I agree with Art, in this piece on Medscape.

I suggested to the MMA audience the use of technology, such as the Chromebook attached to a large screen TV, engages the patient, and in my opinion is much more cost effective than a scribe, and improves the patient doctor relationship in this technological age in which we find ourselves.

I think the patients appreciate the opportunity to view, mold, and create their own chart, and benefit from the projected data lines of BP's, BMI's, Weights, Lipids, and HgA1C's. I have found the patient doctor trust enhanced and the mystery of the EHR deflated with this type of scenario.

So before adding yet another staff member with a need for retirement and health insurance, think of some way to engage the patient with the EHR with the technological gadgetry currently available. IMHO, this set up not only maintains but accentuates the patient doctor relationship in the exam room.

I had difficulty with the chrome remote desktop application today. On my Chromebook, I was unable to center the open window by one finger scroll horizontally or vertically. This feature has been a time saver, so now have to put cursor over top of open window, left click and drag, instead of using the one finger scroll to center the open windows.

This inconvenience has forced to me to have a back up plan and one I should have been using, the VNC viewer for Google Chrome that uses the intranet and will be used only on local network. So will try it out tomorrow, but my initial toying around with the VNC viewer this evening has me wondering why I had not done this sooner.

So, will likely save the chrome remote desktop for out of office remoting, and VNC viewer for in office remoting.

I have reported this issue on the Google chrome OS line to see if there is a fix to this problem.

Chrome Remote Desktop, after the last update, will no longer work with multiple monitors. This is extremely inconvenient, and I hope gets fixed soon.

However,the VNC viewer, supports my dual monitor, and yesterday was extremely impressed with the functionality.

I was able to display on the right screen images of the CT demonstrating pneumonia, and on the left screen, display the type written report from AC, and slide back and forth with ease to display to patient and spouse on the 24 inch TV monitor.

This was received with such appreciation and so easily done, that I am planning to just make this a routine part of the visit, displaying the images from radiology studies for those patients interested. Something I have not been doing.

I also had another patient comment on the TV screen being matte and poorly reflective. With his business he is using dual monitor screens, but just bought TV's that do not have a matte finish but reflect window and lights more so. He said he wished he had gotten the matte finish for the screens. Something I had not thought of but lucked into.

Jimmie, are you timing the visits to see if this is now taking longer and, therefore, affecting your productivity?

Doctor Mel,

No, just working out the "bugs". I have been really impressed with Chrome Remote desktop (CRD), until the multiple monitor support went south. I can switch to single monitor display on my desktop, but then the screen on my Chromebook is too small to be efficient with AC and Updox opened at the same time. I have to maximize and minimize windows too many times.

The VNC viewer I think is a bit snappier, and works better with Citrix/Meditech for radiology imaging projection on the large TV screen than the CRD. I have it only on the local network for now, but for the paid version, then I will be able to remote over the internet securely. The scroll between screens horizontally and vertically is faster than CRD, so am trying to get use to this change. One thing I like a bit better on the CRD is the ability to tab out and get onto the internet with another tab on the Chromebook and then tab right back into the CRD window. With VNC I have to close the app to get to the internet.

The 2x RDP client, I think, does not support multiple monitors, but will have to research this a bit.

So, I think I will likely do the VNC viewer 30 day trial for the ability to use both intranet and internet features with encryption, while travelling to the south this week.

However,to be efficient with the Chromebook in the exam room, IMHO, you have to have at least dual monitor support with your remote app.

I think I am noticing improved patient satisfaction, easier intake/data entry with new patients, less stress with add ons, and saving trees with less printing to paper, with the TV display/chromebook/dual monitor remote support in exam room.

I need to make a couple of corrections about VNC viewer.
It is easy to minimize the screen and tab onto the internet without closing the application,

The first 30 days the trial allows the Enterprise, Personal features, which allows encrypted internet features.

The personal is 30 dollars one time fee and yearly cost for support is 1/4 the 30 dollar fee. And the enterprise is 50 dollars and support 1/4 that fee.

Both intranet and internet dual monitor support work exceptionally well.

This will replace the chrome remote desktop for me.

Jimmie: If I wanted to implement a display screen in the exam room, where should I go from here? I am already using a laptop - would I plug in a large TV screen with HDMI? What kind of interface are you using and can it be wireless?

This may or may not work with your laptop.

On your desktop, right click desktop, click on screen resolution, extend displays, click apply, and then keep changes for the dual screen monitor function.

I use wireless on the chromebook, and use the intranet function behind the firewall with the local network in the office, for the remote desktop application-- VNC viewer.

HDMI to HDMI cable 10 foot x 2 with an inter connector if you need more than 10 feet--I got at costco

At least a 24 inch TV with 1080 resolution with a matte screen. I got this at costco.

Wall mount moveable arm.

Get your remote desktop working and you are in business. Just do some research to see what remote desktop works best with your OS on your desktop and laptop--

I recommend at least dual monitor capacity on your desktop to translate that to project xrays on your TV in exam room--sliding back and forth between screens is much easier on a small laptop in exam room, and displays easier. If Indy has time I will demonstrate this feature on a video at San Diego if there is enough interest.

Chris, this is why Amazing Charts is really leaps and bounds above any other EHR, to be able to display so nicely in the exam room. It is not only intuitive for the doc to use, but the patient can makes sense of their medical information quite easily.

Are you able to access Google cloud printers via 2x? I'm having difficulty seeing the printers I've enabled for Google Cloud, when logging into AC (Cloud based version) via 2x (using Chromebook). Any thoughts appreciated!

SartellPeds,

I am not using AC cloud based version or 2x remote desktop for chrome. So I am not quite sure. If I understand you correctly you want to print using your chromebook remoted into your desktop running AC in the cloud.

Are you using any local desktops on your local network behind the firewall (intranet) to run on site printers in your office?

If so, the you should be able to hook them up going to this site...
https://support.google.com/cloudprint/answer/1686197?hl=en

For any PHI I use only the local printers behind the firewall (intranet). For teaching materials and non PHI I will print on my local printers using Google Cloud on occasion if I am not remoted into my desktop with VNC viewer (intranet) option.

Yes, that is exactly what we are trying to do. I am able to print using Google Cloud Printers on everything except when I remote into our cloud-based version of AC using 2X. From there, I am unable to see any of the printers I've enabled for cloud print. However, this kind of makes sense...just wondering if there's a way to do it or a work-around.

Using Windows-based RDC, I can choose to include printers as a 'local resource' available once the connection is established. From what I can tell this isn't available with 2X & Chrome...

Appreciate your thoughts!

I had an event happen yesterday during a pre-op exam that is worth mentioning. I was doing my thing and going through the Past Medical History with a patient. And she wanted a copy of just the Past Medical history, and I told her I did not know of a way to do that. With the projected screen she walked me through how to do this by clicking on the file button in upper left corner of the Past Medical history screen when the letters are expanded and print to exam room printer.

This reminded me recently when both Marty PA and Wendell were showing me of fascinating ways to use the F keys.

I suppose to a certain extent I have been in a vacuum, so it is quite nice to learn new ways of doing things, but having the capacity to learn from patients on the projected AC chart was not one I ever anticipated, but will take any day of the week.

If I have one more patient tell me, "I want you to take this the right way, but this is the first time I feel like I have had a real exam."

I think I am on the right track with this and hope others can develop a way to have a projected screen with AC in the exam room.

But capturing the moment and engaging the patient with this humble set up has been very therapeutic.

There is something non-tangible but very much appreciated by patients who have been part of this new process, but I think getting them involved in the "record keeping" and "data interpretation" helps with the "buy in" of suggested treatment options.

A special thanks to John Squire, Charlie, Trish, and Heath in helping out with this video.

https://www.dropbox.com/s/bdjafgkkedgkkly/Dr%20Jim%20Legan%20%281280%20x%20720%29.mp4

One aspect I do not point out in the video, but what is really nice while traveling or from home, my desktop is replicated, usually with Updox on the right and AC on the left, so working off site on the Chromebook works quite well with the VNC viewer internet feature, instead of the intranet connection used at the office.
So handling faxes, messaging to and fro with patients, sending letters to patients works exceptionally well with the dual screen capacity.

Very cool Jimmy!

Thanks John.

It may be a bit easier to see the video by clicking on the You Tube icon on the Amazing Chart site, rather than right clicking and copying and pasting the above link.

I should have demonstrated printing with my VNC viewer remote driving my desktop, with my exam room printer(intranet) versus using Google cloud printing outside once disengaged from the VNC viewer (internet).

John (Howland),

I have not jumped into the AC cloud yet, but this thought is rattling around in my head, and thinking a similar system for an AC cloud user should work just fine.

One of the biggest criticisms of the Chromebook is lack of processing power and inability to print effectively.

However, if your main office computer is synced to your AC data base in the cloud. And you routed your printers through this microsoft based computer with the processing power, so that each of your exam rooms and office has a printer.

I think the idea of a desktop in every exam room, really becomes quite redundant. Why not take your "desktop" (chromebook with VNC viewer)with you into every exam room outfitted with a large flat screen TV and printer.

The biggest weakness of the Chromebook, small exam rooms, and being a bit on the frugal side, has led to this scenario in my own office except my AC data base is in my office computer and not in cloud.

This set up, including 3 printers, one chromebook, 2 TV's, cost me about the same as my HP laptop just 2 and a half years ago.

So, I not only have a very nice intranet based system in office that mimics my dual screen desktop, but anywhere I go, I can function as if I am in my office.

I was recently out of the office for 3 working days, and did not call my nurse one time. With Updox on my right and AC on my left screen, I could sign scripts, send lab results with letters, sign off mammos and paps, edit 02 orders, message nurse, in essence do everything to keep the office going using the internet feature of VNC viewer to duplicate my desktop.

So through the frailty of an outdated small office, a device without processing or printing power, the solution has worked much better than I ever anticipated.

So effective, I would replicate my current setup in a heartbeat, just as I have it, with the caveat of possibly transitioning to the cloud at some point, maybe....

I am drumming this incessantly with the hope of some young docs coming out of residency hearing my cry from the wilderness... the tools are there and very affordable and much more user friendly (I suspect) than the ones utilized in the ivory towers of residency.

And maybe nudging some not so young docs to try out, but John, I thought of you and just wondered with being outfitted with AC in the cloud if some portion of this solution may work for you, if you have such a need.

Not only are the tools affordable but what they afford you in the exam room or out of office is quite impressive.

I think this link works better than the above link I posted to see the video.

https://www.youtube.com/watch?v=Dudm0-K9UE4

I hope to get another video out soon comparing the Google cloud print feature and how I print using the Chromebook in the exam room.

Two of the weaknesses of the Chromebook, not having much processing power or internal storage, I think is one of its greatest assets when used as a thin client (using it to remote drive my office computer). I do not have any patient information on the Chromebook, so when I take it out of office or home, there is less security risk.

Using the Chromebook as a thin client with the VNC viewer intranet feature at the office, allows me to use my office computer's processing power and storage. So when I have the Chromebook in the exam room, it appears to the patient that the Chromebook is running the printer. I cannot tell any difference in time printing in exam room with the Chromebook remotely running my desktop versus printing from my desktop to local printer.

However, on the video there is a noticeable difference in time printing using the Google cloud print feature, which is quite sluggish at times.

I realize the Chromebook is not for every one, and out of all my partners only 1/8 adoption rate.

However, whether one uses local in office storage or cloud storage, I think the Chromebook if used as a thin client attached to a local computer for processing power to run the printers and access the data base is a very useful tool.

If you add the HDMI port projecting to large TV screen feature and internet VNC feature to have your "desktop at home" one has a really versatile 279 dollar device.

I cannot let the statement about only 1/8 partners adopting the Chromebook pass, without a comment, since I am one of the partners. Years ago, before ever using an electronic medical record, I had a lap top in each of my exam rooms so that I could show patients educational videos from DVDs or from the web. When I instituted Amazing Charts about 2-1/2 years ago, I incorporated all-in-one large screen desktops in each of my exam rooms, so that I could show my patients their blood pressure and weight graphs, growth curves, x-rays, CTs, etc. Because my desktops are hard wired to a server and each has a dedicated printer in the exam room, I do not have to spend time plugging and unplugging a laptop into the system, risk dropping it etc. I did incorporate Jimmie's idea of a separate HDTV for easier reviewing of data, by the patient. This set up is much more expensive than what has been outlined by Jimmie, with use of the Chrome book set up, but has worked very efficiently, with minimal headaches, for the most part. I agree that, if one is operating on a shoestring, the Chrome book idea is a good one. I am of the opinion, however, that it is worth spending the extra money to have workstations and a server.

Our office structure is such that since we are a limited liability partnership we have a creative milieu in which we can individually tailor our practices how we see fit. It has worked quite well over the years, so we can learn by trial and error and share our failures and successes quite succinctly with one another. The adoption rate comment was just that, an observation, and not a criticism. The one partner who has incorporated the Chromebook does not even use AC.

However, I think the system I have gravitated towards is a bit different compared to the workstation server model Doctor Mel uses. I would argue it is more than just a cost issue for me, but an avenue of exploration of trying to enhance my efficiency with a durable, easily replaceable device for point of contact with the patient. The unintended consequence has been the large screen "interactive TV" phenomena, that I am having fun with learning to do things differently each day depending on the needs of the patient.

I would like to add a couple of additional thoughts.

I am not sure what the mean time between failure is of the HDMI port of the Chromebook, but one consideration is to buy one of these devices to reduce wear and tear. I may just get one and keep it plugged into the HDMI port of the Chromebook so this will take on the wear and tear instead. I still think avoiding the Chromecast dongle is the way to go to avoid leaving a chart up on the TV monitor when leaving the exam room.

http://www.amazon.com/Monoprice-8in...eywords=hdmi+female+to+hdmi+male+adapter

Also, I got hand holding from my local IT guy for setting up the VNC viewer but here is the link.

https://www.realvnc.com/products/chrome/1.0/connectguide/connect4.html

I may have to do a bit more research to find the best HDMI to HDMI gadget, to save wear and tear. Also I ended up getting the Enterprise version of VNC viewer for chrome so I can maximize encryption to 256 bit.

The issue has been raised about the frequent inserting and pulling out of the HDMI cord on the Chromebook causing software issues.

The way I have it set up in my exam room, I think reduces the likelihood of an electrostatic discharge. The TV is plugged in and often times is off, as it turns off automatically after several minutes. The Chromebook is powered by the battery, and I do have the Chromebook on when I hook up the HDMI cable into the Chromebook.

I think the wear and tear issue is potentially more problematic, and will be getting the HDMI extender (as indicated above) so will hope to have some feedback on this issue more in the future. But a 5 dollar extender is easier to replace than an HDMI port in the Chromebook.

I think the unknown is how often or problematic the potential(?)software issue on the Chromebook or TV will present itself, if ever.

However, I have no patient data on either device (Chromebook or TV), so both are quite cheap and easily replaceable, so minimal downtime if a problem develops.

I think it is a manageable risk at this point, otherwise powering off the Chromebook at each coupling would be impractical.

I maintain the advantage of projecting AC on the large screen TV in the exam room, far exceeds the risk. I am knocking on wood, but nearly 4 months into this set up and no issues yet.

There is an additional dimension of this whole process that I am glimpsing and is becoming more apparent as time goes and at the risk of discussing while my ability to convey is somewhat in the gestational stage, I think, should be addressed.

The office visit, chart, desktop, Chromebook and TV terminology is rigid and what I am experiencing is malleable, expansive and fluid, and transcends these constructs.

The opened AC chart flows between the dual monitored desktop, Chromebook, and TV, and in fluid motion is not unlike a back and forth conversation or a balanced dance, that invigorates both patient and physician. I have been at this for 21 years, and I have never been able to replicate this effect with paper charting or the laptop/office desktop scenario.

I will have to do some more observing and whittling on my thought process but the office visit, with the portal takes on a similar dimension, where the office visit goes beyond the actual physical office space but includes the portal access to the patient's smart phone several days before and after the visit.

The same goes for the paradigm shift in how the office flow now occurs with secure messaging surpassing phone traffic, and messaging directly to my nurse bypassing the front office phone. I have taken on more traditional nurse roles, such as med reconciliation, and handling the prescriptions, but this allows her more time to schedule, shuffle paperwork, to do away with the traditional secretarial role.

But this malleable, fluid, expansive change of the AC chart has to be the most dramatic of all the changes I have noted since starting all of this in 2011.

I think my anger from 2011 when I felt I had no choice but to go electronic to avoid the penalties is being assuaged by these unexpected but pleasant developments in the office thanks to folks smarter than I coming up with all of these great tools. The trick is figuring out how to get the tools puzzled together to maximize one's work flow.

First day with the HDMI extender. I think it will take a bit of getting use to having the 8 inch cord dangling when walking back and forth from office to exam room, but I think certainly will work. The connection of the extender into the Chromebook HDMI port fits snugly and stays put quite nicely. I attached the 8 inch HDMI extender first thing this a.m. and left it in place and removed from the Chromebook after my last patient of the day. So just one in and out exchange will certainly save some wear and tear on the HDMI port of the Chromebook and want to give a shout out to Stephan on the twitter feed, who got me thinking in this direction.
Once I place the Chromebook on my computer stand in my exam room, it is easier to attach the end of the HDMI cord from the TV to the 8 inch extender. There is more room to work with and I can hold the extender in left hand and TV HDMI cord in right to make an easy connection.

What is your thought in regards to buying another Chromebook and leaving one in each room, turning them on and off as necessary, rather than carrying one Chromebook back and forth? I would think that it would be as easy to turn the Chromebook on and off as to repeatedly plugging it in and then unplugging it. A review of the way in which you connect to the main computer via the Chromebook would be of interest.

I timed the following:
turn on chromebook --7 seconds
sign on chromebook --7 seconds
sign on to VNC viewer for chrome--25 seconds
sign off VNC viewer for chrome--8 seconds
turn off chromebook--6 seconds

unhook or hook HDMI extender to TV HDMI cord--1-2 seconds

It would be less efficient to have a chromebook in every exam room and turn on and off and sign on and off to VNC viewer in my opinion.

I plug in my chromebook and turn it on first thing when I arrive to office. When I am ready to see the first patient I sign onto VNC viewer for Chrome using the intranet connection, so that if internet connection is lost, I can still drive my main computer. My nurse sends me the chart, on my office desktop I open the patients chart and have the graph of weights up on screen. I then unplug my Chromebook and carry into exam room and set on computer table, plug in the HDMI extender end to the TV HDMI end, turn on the TV and the patients chart is ready to go with weights visible on big screen TV. After I finish with patient, I unplug the HDMI extender from HDMI TV cable, and carry the Chromebook back to office (TV screen goes black). I then set my Chromebook back on my office desk and plug in, and use Dragon to finish my note to complete the HPI and summary section, the ROS and EXAM I template out. Sign off the chart and print up my super bill and send the office summary to Updox inbox and my nurse sends to patient portal.
When lunch hour arrives, I sign out of VNC viewer and sign back in when ready to start seeing patients after lunch. At end of day I sign off VNC viewer.

This works extremely well. I very much like having two operating systems to balance my workflow, any internet searches I exclusively use the linnux OS on the Chromebook, and use my Microsoft OS for HIPAA dependent patient care (office desktop or VNC viewer for Chrome replicating desktop) except for when I search Up to Date embedded in AC when printing up patient information while in exam room.

Sorry so long winded, but hope this helps.

Here is a recent ChromeBook2 review that also covers the other shipping versions.

The biggest take-away is that the latest Samsung ChromeBook2 now has a full 1920-1080 13" display and almsot 9 hour batter y life.

http://www.engadget.com/2014/05/30/samsung-chromebook-2-review/

Here is a picture of the HDMI extender I keep attached to the Chromebook to reduce wear and tear on the Chromebook HDMI port.

For those interested I did make a few more videos about the Chromebook/TV/EHR approach. One can either click on you tube icon on AC website or click on the following link.
https://www.youtube.com/user/AmazingCharts

I am quite new to you tube, so please take that into consideration when watching.

"If the one who is to act wants to judge himself by the result, he will never begin." Soren Kierkegaard from Fear and Trembling.

I want to thank all of you for bearing with my intensity and help on this Chromebook thread, but I think I have stumbled into a system that works extremely well for my workflow. I think that this set up or a modification there of, with at least a large screen linked to a device that controls the main data base and is managed by the doc really works.

I think we are extremely lucky to have the Amazing Charts EHR to project the health information to the patient. What I do not know is how other EHR's project, but I think AC can be a prototype to other EHR designers, as I think over the next several years this will be the push for "patient engagement".

I do not think I am leading anyone down the wrong pathway here, but will be interested in feedback if others do try this set up to let me know how it works out.

I think I will be moving from the chromebook theme to explore the social media arena a bit more and will add new insights on the chromebook from time to time.

Jimmie,
I am impressed that you were able to use Updox (which I have not tried yet) and VNC viewer/chromebook to operate your desktop computer remotely while out of town. I may have to try the chromebook/vnc viewer for just that feature alone. Like you I am not on the Amazing Charts cloud.
Greg