Home Forums Discussions General Discussion New to AC and seeking advice on hardware

Hi everyone,

I'm a solo practice Internal Med doc and we are about to join the AC ranks. I'm wondering what type of hardware to use: a tablet, laptop, macbook pro/air or ipad. I like the idea of creating the progress note while I'm in the room with the patient. Having a touchscreen seems to make sense along with using templates. I really like the reliability of Macs, but I'm open to other suggestions. Also, my nurse will need something portable as well and I'm wondering what would best for her.

Appreciate any advice and what has worked best for other users in solo practice.

Touchscreen is a bit overrated. At the moment, AC isn't very touch-friendly. With mac/apple, you'll need to use some sort of remote desktop application like a Terminal Server or AC in the Cloud.

You can get hybrid touchscreen laptops for cheap nowadays. I've seen the Inspiron 15 hybrid touchscreen for as low as 400. Several practices have requested touchscreens, but most have found it inefficient compared to a regular keyboard/mouse. I have one practice with Ergotron arms and fixed desktops in every exam room. After a while, they didn't use the touch screens at all. They are a good size at 23 inches and have free range of motion. So my advice would be to make sure you find it more efficient than a regular keyboard/mouse.

Thanks Sandeep!

We are planning on using AC in the Cloud. The thought of using fixed desktops in each room has been a consideration, but I've resisted that idea because i thought i would use Dragon for those times when i need to step out of the room and dictate (right now I do that for physical exams and when a personal letter is requested). After reading some of the other forums about the problems with Dragon and AC, I'm now reluctant to try Dragon.
Thanks again for the input!

Just make sure you factor in the trade-offs for each type of station. I detailed why tablets/laptops are a poor choice for staff in this post: http://amazingcharts.com/ub/ubbthreads.php/topics/60932/Re_Chromebook#Post60932

It's more appropriate to use what is best for the situation rather than all tablets or all desktops. Make sure you have sufficient screen real estate to get your tasks accomplished. If you can give us a better idea of your workflow, we can make a better recommendation.

I would talk to JBS, DocGene, or ryanjo about Dragon since they use it on a regular basis. The majority of the reluctance to use Dragon is that they charge significantly more for the Medical version. The medical version adds little functionality and you are essentially paying to remove the EMR Restriction they implemented in later versions. $100 for the Premium and then almost $2000 for the Medical.

DRM1,

I echo Sandeep's second paragraph above. I envisioned my nurse taking in a laptop and doing the intake and vitals. She now has the laptop functioning as a desktop with an additional screen. If I had to do all over, I wish I had just gotten her a desktop.

However, for me the Chromebook with a defined strict narrow conduit to remote to my desktop and mirror the 24 inch TV screen has worked quite well, the Chromebook screen at 14 inches is a bit small but functional.

In my office I have a desktop with a 22 and 23 inch dual screen, but I only have one nurse and 2 exam rooms and no physician extenders. Simple and sweet.

Welcome DRM! I am glad you could join us. I think you will find AC has the best community out there in addition to its other bonuses.

You certainly could use Apple hardware. I only have one desk transitioned over to an iMac on a trial basis, running parallels, and it has been fantastic. I enjoy the excellent built in, free dictation capabilities. I also enjoy excellent stability without the annoying crashes I'm so familiar with using PC's. Further, the customer service from Apple is award winning: Dell - not so much!

That being said, the rest of my network is Dell. AC does not need a ton of power, so if you are solo just keep it simple. A higher end desktop for your server (maybe the new Mac Pro?!) some desktops or all-in-one for your nurse and reception, and a laptop to take in the room. Touch screen is too slow - you need to type. But you can keep the typing to a minimum with abbreviations, quick keys, and templates.

A lot of it depends on the setup of your office.

1) I, and I think many others have a preference for hard wired internet. It is faster, more reliable and more secure. But it requires running lines to all the exam rooms and computers.

2) While Apple products do have the edge in reliability, PCs are pretty reliable and more easily fixed. Since AC is dependent on Windows technology, you have to involve some PC's. I don't actually find PC reliability to be a major issue in the office. The more complex you make it, the more likely it is to break. Using Parallels or equivalent or remoting into a desktop consistently is increasing your complexity.

3)If your nurse has a place to chart now, put a computer there. Or, she can chart in advance of you in the exam room when she places the patient into the room. You will also need another computer at the front desk.

Thus, hardwired PCs are probably your best bet. Larger screens are better (or dual screens, see other posts here) Yes, you can do it with laptops, but smaller screens, wireless and increased theft risk will become barriers. I have used tablets, and thus touch screens, but find the keyboard to be annoying and the size small. Apple can work but again, you are either running virtual or remoting into a PC.

Now this scenario is for on site AC setup. AC in the cloud will release the requirement to be Windows based, I think. While I have looked at the cloud product, I do not have enough experience to apply the above information to that setup.

I agree with you in general, about simplicity, but I just have had ZERO problems with running Windows on my superior hardware. I also agree with hard wiring. We did wireless for a while, but it is much simpler, faster, and more reliable to run ethernet wires between your computers. Have tech install a switch and router and run it around the crawlspace/attic. All of this may not be needed with cloud based, but I have not used that. I run hard wires back to the "server." My system slowly evolved, and I am thankful for this ability. Now I wish I had just started with a separate computer as my "server", living securely in its own closet with the wires physically running to the switch. I have never seen a need for the added complexity of a true server, but others on the board advocate their use.

I want to advocate for laptops in the rooms, with wireless connection.

The slowdown caused by wireless is almost unnoticeable, though sometime I put the laptop on the base and run it wired.

Being able to move around in the exam room and not being tied to a large piece of hardware is important in my practice -- sometimes I like to sit next to patients, sometimes across from them, and sometimes there is a whole family in the room, that requires creative seating.

I use a Lenovo x201tablet. Old piece of equipment bought off EBay -- I have three of them. Zero problems. The nurses use x201's (not tablets) -- also bought off EBay -- also Zero problems. I have an X230 Tablet at home that I also take on the road. Also Zero problem.

The benefit of a tablet is that you can use a stylus as a pointer-- often easier than the trackpoint (can't really use a mouse the way I move around and sit in different places) and you can mark up UpDox faxes from nursing home and pharmacies, etc. with the stylus, as you would a paper fax. Pharmacies and Home Health accept the handwritten signature, where they won't allow a signature image -- they call that a "stamp".

Dragon works well on the tablets - you just have to learn how to use it.

We have a server-based system, but I'm sure a regular desktop would work as well -- as it did for quite a while before I put the server together.

I have no experience with the cloud -- but anything in the cloud is scary to me. Internet not always reliable, someone else has the data files, and how do you access all those image files in "imported items" in the cloud? With our internet speeds, we would wait all day for x-ray and lab and consultant letters and whatnot to download. And uploading them would be worse.

Yep I use a tablet in the exam room; like the portability and the ease of taking it out of room and not worrying about a screen lock/ keyboard lock having to be applied when patient in room alone.
Now if only AC was written for touch screen/gesture technology. Perhaps we can start a email campaign since I get no reply whatsoever from either support or our pres on the issue.
Maybe start another thread about touch screen, sorry for the unintended hijack.

If you have reliable fast internet, I recommend the cloud. I have been using it for 6 months or so and I love it. Then you can use just about any laptop anywhere and have access to your records. I trust AC to take good care of my data. In fact, I think the data is safer in their hands than it is in mine.

I want to thank all of you for your thoughtful input. Each of you has given a valuable nugget of info for me to consider.

Presently, we have PCs at the front desk and at the nursing station. I have a MacBook Pro. We do plan to use the Cloud. The comments about wireless vs hard wiring are something we will have to consider. If we don't like the slowness of the wireless then hard wiring it will be!

It sounds like many have found using PCs in the exam rooms with large screens is the way to go. It sounds like it's possible to run the Mac along with the PCs without any serious issues?

Thanks again for all of the helpful comments!

DRM1

I am running the Mac with no problems in the PC network. I have thought about a large screen in the rooms for patients to look at their lab results: currently printing on paper for them.

What about cost: my understanding is the Cloud service costs about $39 per seat in addition to the maintenance costs?

Just when I thought my path was clear, Tom has to make the case for tablets :-)

Supporting his case is the frustrating realization that each user in the office can only sign on to one computer at a time (unless a user logs on with a Mac and a PC-then they can log onto two computers simultaneously). With the $39/month charge per seat we are trying to keep the number of seats (users) at a minimum -three to be exact (front desk, nurse, myself).

Our office has three exam rooms (third room used only one day/week), the nurse's work space, the front desk and my office. So five computers and three users. How much of a hassle is it for the nurse and myself to constantly be logging on and off throughout the day?

" Pharmacies and Home Health accept the handwritten signature, where they won't allow a signature image -- they call that a "stamp"." This comment by Tom prompts the next question which is How much of a hassle is it signing Rxs, lab orders, etc. with just a mouse? It seems a touch screen is needed for such endeavors.

Once again, thanks to all for the helpful comments!

DRM

Sandeep,

I did follow your link...sharing your comments about increased productivity and screen space strikes home. Loss of productivity and time is one of our greatest concerns. So I'm trying to balance all of the options with the needed functions of a solo practice to make sure I understand all of the pieces.


Thank you.

DRM1 --

I don't use a touch screen.
The x2xxT series are extremely competent computers, with Wacom pen-based screens.

You can write on them almost like paper -- you can read your handwriting saved as an image file (so it works in updox to mark up faxes and return to pharmacies, home health, hospice, etc.) and if you want, it will read your handwriting and turn it into a text file, so you can actually write your notes and put them into AC.

Also, you can sign on to as many computers as you want if you have AC on a server or main computer in your office. You just can't have more than one chart open at a time on any computer.

However, if you are in a room, logged in on a laptop (or a wired desktop if you really want that extra hardware) and also logged in on a machine in your office, you can remote (RDP) to the office on your laptop, and then have two charts open simultaneously. Sometimes that is actually useful. Just takes practice to keep straight where you are if you have a lot of windows open.

DRM, just to be clear about what Tom is saying (or at least, what I think he is saying): with 3 users and 5 machines you can just log in with RDP or logmein from the exam rooms to the offices. Besides the advantage of opening two charts simultaneously, this also makes it easier to work with the 3- $39 licenses.

Tom and JBS,

Thanks for the clarifications...really makes me wonder if it is easier and more affordable to run AC on an office server. Tom would you recommend anything more current than the old Lenovo's that you currently use?

Appreciate all of the great input guys!

Tom and JBS,

Thanks for the clarifications...really makes me wonder if it is easier and more affordable to run AC on an office server. Tom it doesn't sound like remote access on evenings and weekends is a problem for you is it? Why do you have three tablets?

Right now I'm weighing the convenience and portability of a tablet with Sandeep's comments regarding increased productivity with multi-display.

Right now I'm leaning towards PCs with multi-display in the exam rooms. Use a tablet or Macbook pro remotely or when the mood strikes in the office. Dual screens for the front desk and the nurse station.
Go with office based server to solve the $39/month seat fee.

The time is drawing near to move forward...additional comments are greatly appreciated!


Much thanks to everyone,

DRM

Hi DRM,

I been reluctant to post in this thread, my views are somewhere between dinosaur and lunatic fringe. I am a solo family physician, with one physician's assistant, in rural Western Maryland, basically Appalachia. We have a shortage of primary care physicians, which is worsening as busy solo physicians retire. Reimbursements are not very good, patients are older, sicker, with multiple problems, and lots and lots of psychosocial issues. Given all of this, I've tried to keep costs as low as possible. I started this practice in 2005, at that time it was with Amazing Charts, version 2.

We started with a peer to peer network, with myself, the physicians assistant, and the medical assistant using laptops in the exam rooms. We have had very good experience with wireless laptops, speed is about the same as wired, basically no issues here. I like the flexibility of the laptop, I can literally have it on my lap, facing the patient, as I take the history, or I can turn it 180? and show the patient the screen. Plus, if the patient is a real talker, I can go through other messages, refill requests, and so forth while they are talking.

The technical gurus, such as Sandeep and Bert, will give you many good reasons that they prefer a server, as opposed to peer to peer. You can search for many of these threads. They are right, but I'm not sure that the advantages are overwhelming. Peer to peer works. JBS also uses peer to peer.

We actually have eight hardwired computers, as well as the three laptops. Each laptop connects to AC independently, we don't use them to mirror the desktop. So, in my office, I can have two charts open, one on the desktop and one on the laptop. In the patient room, I can only have one open.

Backup is done using ACs backup program. I have a second hard drive in the main computer, and an external hard drive on the main computer, the backup writes to each of these, as well as to AC off-site backup.

This has worked, and worked well. If I were just starting, and had the money, I would let someone good set up a server and run this (you may want to talk to Sandeep about this.) I am staying away from the cloud, with the number of computers we have, the monthly fee would be quite high.

Another cloud option is offered by Indy, who posts on this board. He actually has servers which can host your practice on the cloud. I'm not sure how this compares, financially, to AC. I can say that he is extremely knowledgeable and helpful.

Good luck!

Gene

Hi DRM,

I been reluctant to post in this thread, my views are somewhere between dinosaur and lunatic fringe. I am a solo family physician, with one physician's assistant, in rural Western Maryland, basically Appalachia. We have a shortage of primary care physicians, which is worsening as busy solo physicians retire. Reimbursements are not very good, patients are older, sicker, with multiple problems, and lots and lots of psychosocial issues. Given all of this, I've tried to keep costs as low as possible. I started this practice in 2005, at that time it was with Amazing Charts, version 2.

Can't post!

We started with a peer to peer network, with myself, the physicians assistant, and the medical assistant using laptops in the exam rooms. We have had very good experience with wireless laptops, speed is about the same as wired, basically no issues here. I like the flexibility of the laptop, I can literally have it on my lap, facing the patient, as I take the history, or I can turn it 180? and show the patient the screen. Plus, if the patient is a real talker, I can go through other messages, refill request, and so forth while they are talking.

Gene,

I feel your pain... Speak to us brother!

"Bump"

I tried to post a long message last Sunday, but due to problems with the board, I was unable to do so.

Since the board is now fixed, I went back to find the thread to try to re-create the message, and magically, the full post from last week is there!

Post 61066 above.

Gene

Hi all:
I'm a solo Family Medicine physician in N.J. I've been using AC for 2-3 years and moved from version 5 to 6.1 to 6.3.3. I went to the ACUG in Boston and got to know a bit better AC. I recently signed in for UPDOX and being very busy I cannot check all the faxes that come in. Any advise in how to improve this?
How do you use AC to improve patient flow? Does anyone have used UPDOX to schedule appointments?
I'll appreciate your input

Gene,

Thanks for the "bump." Your comments are very much appreciated.

As much as I like the idea of being in the cloud, the cost is prohibitive and we will go with the in house server option. Right now I plan on having desktops in the exam rooms for the nurse. I will try those out with large screens and the toy with the idea of a Lenovo tablet for mobility sake. I do like to move around the room and would be nice to have that flexibilty.

Thanks again for your comments!

DRM

LOL, the advantages are overwhelming. Before I start a P2P vs Server war, I think if all we did was use AC, then maybe they would be fairly equal. But, we don't. We have a full network (we being all of us) with billing and maybe Exchange and maybe SharePoint and other software programs that people use. Don't want to use Exchange and SharePoint as good examples. But, it's the same when users only back up AC with a flash drive and call it good with no full server backup. Then they get the Crypto Locker and that one backup isn't going to save you.

Anyway, DRM, just wanted to make one comment, and you can take it for what it's worth. Tablets. First, are you going to have desktops in the room and then use a tablet on top of that? I hear you about moving around the room, but does having a tablet really give you an advantage when moving around logistically? Just a question. Not a judgment.

One of the advantages of AC is that you get to try it out first.

You need to play with wired vs wireless. Wireless is very dependent on both equipment and building structure. Maybe it will work well, perhaps not. You do need to take a few extra steps to secure it but you should check it out. It doesn't require hard wiring.

Desktop vs laptop vs tablet: Again, a preference issue. For my eyes, bigger is better. That will be desktop (although my home laptop is 17 inches.) Tablets can work, especially if you have an external keyboard, but they are smaller. Try it out, see what you like.

Then there is hosted vs server vs peer to peer. This is a bit more difficult because it's more difficult to switch back and forth between these three. Cloud based is dependent on consistent and fast internet. If you don't have it, then it really isn't an option (how fast? ask AC, I actually don't know.)

Peer to peer vs server? As Bert says above there are volumes on the board about it and strong sentiments in both camps. I'm in both having one of each in 2 offices. Servers require more of an outlay. If you REALLLLLLLLY have the time, download a trial version of Windows Server and compare it with a peer to peer. Impractical but possible. Truly not as crucial as the other factors, you can always go from P2P to Server based.

Windows vs Mac: Keep it Simple, Windows will win. Yes you can add a node with a Mac, but it's way more difficult to set up a system without Windows unless you are doing cloud based. OR you could go Linux.....

I have used all three. The tablets were fun, but useless. You need a keyboard. Computer in the room seems best, hard wired, real keyboard and mouse, big screen the patient can see across the room....
I keep coming back to the laptop and that is all I use in the room. I can set it down, or out of the room during a procedure to minimize it's function as a fomite, and I can close a chart and cue up the next patient as I walk to the next room. For me laptops are the only way to go in the room.

I like my Surface Pro 2, yes I have a keyboard and a mini-mouse to make it fully functional but comparing it to my ThinkPad I like the smaller footprint and easier to carry from room to room and do not loose any speed in connecting, printing, checking websites, logging into AC etc.
Yes it is twice the price of a laptop.
If AC developers weren't so busy with MU and other mandates and would write it to be touch screen/gesture compatible it would be a near no-brainer.

Which is why I use the X2xxT Lenovos. There is no touch capability in AC, but when you get adept with the stylus, it's almost like touch, and in addition you have portability, adequate screen space, a built-in keyboard, handwriting recognition, and if you plug in a USB microphone, Dragon Dictate (works just fine on those machines) if you want it.

I can't imagine being tied to a desktop, and even my old eyes don't have any problem with the laptop screen size.

Wireless is only marginally slower than wired in my setup -- maybe if you have lots of users? I don't know why some people have an issue with it.

@DRM1-- why do I have three tablets?

Well, I use one at home, which also goes with me on the road. I log into the office with RDP.

I have three at the office -- one for me, one for my partner, and one is a spare, because now and then something doesn't work somewhere.

The nurses use X200 (not tablet) for portability -- we have several of those. I get them on E-bay, and I have never had a problem with them not working. They seem bullet proof.

I bought the x220T new, and I have 3 x200T's. I actually prefer the older machines, but it's pretty much of a toss-up. The X220T has a faster processor, and works marginally better with Dragon.

Tamastoria,

How do you utilize Dragon into AC? Da you have to click into each window individually?
Do you utilize a template?

I just use the regular Dragon, not the Medical version. It won't, of course, work directly with AC on the same machine. I rarely need to dictate on the same machine as I have AC -- just my documentation style, I handwrite or type the short notes and only dictate ones that require some effort and consideration, well after the visit -- so I don't waste the money on the Medical version.

However, if you have it on your laptop that you carry from room to room, or at home or on the road, you can remote (RDP works best) to another computer (like in my office)where you have a copy of AC and the Dragon doesn't recognize the AC as an EMR -- it treats the remote window as an unknown window and will accept the dictation.

At that point, you can either dictate directly into the individual AC fields -- there is some funny behavior, but it works pretty well -- or you can dictate into the "dictation box" that allows full text and correction control, and then transfer it to the AC field.

Yes, I use templates, too. I use many different ways to enter data, depending on the situation. Templates can be easily written to allow correction and completion with Dragon.

Reading that last post may seem a little confusing. You can have AC open on a laptop you carry around, and another instance of AC on another machine (e.g. a desktop in your office). You can "remote" to the desktop from your laptop -- if both machines are on the same network it is very fast -- almost like being on the host machine. That way you can dictate with Dragon onto charts that are open on the desktop. But of course, you can't have the same chart open simultaneously in both places.