Home Forums Discussions General Discussion Cost and Effectiveness of U.S. Medicine vs Other Countries

what is generally regarded as most stable platform for AC v10.x?

server/workstation?
2012 r2, 2016, 2019? windows 7,8.1, 10 which win10 release?

A server will always be the most stable although I have found AC will run well on any PC if you have enough RAM.

Windows 7 is reach EOL and will be a HIPAA violation on first day. We don't even use it, but I have a father in my practice who saw a computer running Win 7. Happens to audit for the hospital, and he pointed it out right away. So, a HIPAA fine could be around the corner, i.e. don't use Windows 7.

If you are going to use 8, then use 10. Eight is basically bye-bye. Just use the latest release. So far, it appears they just update them. I am hoping they don't come out with a whole new OS.

When Win 10 first came out, it was a nightmare. But, they changed it to make it more like 7, and it is actually very good.

So, either Windows Server 2019 Standard on a server computer or Windows 10.

My answer would be it depends on the office/situation.

If you're going to use Windows 10, best to use Windows 10 Pro. Windows 10 Home users are basically beta testers for Windows Updates now.
https://www.howtogeek.com/fyi/bug-i...be-deleting-files-back-up-your-data-now/

To minimize your need for upgrades/maximize your investment, it's always best to go with the latest available operating system that is compatible with your software. Server 2019 or Win 10 Pro/LTSB as Bert recommended. (If AC is all you use.)

Windows 8/Server 2012 have an EOL date of 2023.
Windows 10 (earlier builds)/Server 2016 have an EOL date of 2026.
Windows 10 (later builds)/Server 2019 have an EOL date of 2029.

However, it can still make sense to use Server 2012 if you have something like Medisoft/Lytec. Upgrades for that are in the $5000+ range. We are still putting that in for practices this year. By using 2012, they have another 4-5 years with their current version of Medisoft.

Sandeep's reply above leads me to wonder about the current state of EMR's

I have been using AmazingCharts for about 8 years now -- and still find it frustrating in many ways, but I have workarounds, and I get my notes done and my bills sent.
I never heard of Medisoft or Lytec -- but in searching for information about them I see that there are still about 150 or more systems available for small practices.

I don't know how one could evaluate them -- the reviews are not very helpful, and almost none of them will tell you what the actual price is or how much it costs to switch from one to another, or what the learning curve might be -- so I just stick with tried and true AC. Hard to imagine how I could recoup the investment in money and time if I were to change -- even if some of my current annoyances were fixed. After all these years, and having struggled with one hospital system, then watched them switch to Cerner (which is horrible) and being on the receiving end of at least 3 hospital implementations of EPIC -- I can say that I don't think that any of them really are very helpful in terms of improving practice efficiency or inter-professional communication.

What surprised me most was that eClinicalWorks says it has the biggest market share with >850,000 users -- and I have never heard anything positive about it.

Where are we going with this technology??

Also, does anyone have any report about AC 10.2? I'm sill on 10.0.1 -- am I missing anything

I think that most of us were hoping that eventually all small EMR's were going to be "gobbled up" by larger EMR's ( and I believe a lot of EMRs were developed with the hope that they would be acquired) and eventually you would only have a few left, so the choices would be small. Then everyone would have to choose one and live with its quirks and problems and workarounds. Does not look that this will happen anytime soon.

Agree.
Life is way too short to spend a lot of time evaluating and switching between EMR's.
The EMR seems like an evolutionary dead end, or at least quagmire.

But medicine isn't much fun anymore--I miss the old days where I could just call up a specialist on the telephone and talk about a patient--now it's layers of electronic and bureaucratic sludge to wade through before you can even hope to talk to another human being

Medisoft/Lytec both have EHR sides but most practices use the Practice Management side for billing. Part of problem is that there isn't much feedback going to AC as to what to do next. A lot of tech companies are chasing industry buzzwords.

What I hear from most docs is that they want to improve efficiency and streamline features. (not add a ton of new ones) I really wish they would've chose a company that uses a similar design language to their EHR for billing. Most practices I've worked with were not huge fans of ACPM/MedFx. Most offices that do in-house billing seem to be running Medisoft. External billers with AC seem to prefer EdgeMed. Might be good for AC to research that and build tighter integration.

This is tech as a whole right now. Most products have reached maturity which is why everyone is switching to subscription models or building out their ecosystem. Apple has always been on OS X. Windows stopped at 10. EHR's are in the same boat. They lose as many as they gain. Now that their market is locked down. They have to sell more services to that customer base or just keep increasing the price for existing customers.

Apple's case: People are holding onto iPhones longer than ever. Have to make iPhones more expensive, start offering additional services and devices (watches, airpods, apple music).

Amazing Charts is doing the same. AC Reminders/Pop Health Add-ons, Enhanced Training, etc.

Let me jump in. I started AC at pre-version one. Downloaded it on a Friday. Trained staff on Monday morning. No "go live" crap. I looked at a ton of EMRs. Just like anything else it would have been good in the government had seen this coming. Total integration.

Hospital and EDs use the fancy Cerners and EPICs and Centricity, not because they document well, but because for CPT coding and HIPAA. They documented everything, you know that a two-year-old isn't smoking. I can't even read them. They are longer than
H & Ps. There are so formatted, they take around six pages for an ear infection. It is rather easy to document an ear infection in AC, although I wish the note formatted better. But, due to reconciliation of meds, they list them three times. And, where they are going, and who is picking them up and the color of the pill. And, not only that the patient understood, the patient must read back now.

The same mistake I made with template physicals was sending a kid to cardiology for a murmur only to have COR: RRR, no S1 and S2, no murmurs. They do the same. Eleven physical categories for a splinter. Now they also put the HPI at the bottom with MDM at top. Kinda like someone telling you the ending of a movie. It is twice as long as the HPI at the bottom.

The best ED notes I used to read were dictated. SOAP note style. Not APSO. I have received the CXR report from radiology, so I know it is there, but I have to look everywhere.

AC is great. There are some workflow issues that could be better. But, if you notice, the same people talk about AC on here all the time. It is far less used now I think partly because the network debates of servers, etc. died off especially with the cloud.

Do you know how many of my suggestions have made it into AC. 0. Yes zero. Do you know how many have gone into NewCrop. Five. LOL.

It's my fault. But, every time I talk about something and complain about a feature, I don't take the time to enter it correctly. I guess I can't expect AC to sift through the board.

One thing I think they miss (and development has improved tremendously), but going by how many people want a feature that is good but not necessarily game-changing, it gets done. But, if three people recommend something that would make a HUGE difference, it is not looked at. You know, like using first initial, last name; first name, last name; last name, first initial; last name first name all one one screen is just silly. Searching on first names. Where else in the world is that done? And, my favorite are messages with Re Re Re Fw Re Re: message. But, that will never, ever change. Ever.

If you are using Dish network and you want to switch to Direct TV, you call Direct TV, and you are done in two days. EMRs sort of have you trapped. Difficulty changing data over.

All true Bert.
Yes, Sandeep -- "tech" is sort of mature, in that it hasn't really done anything new in quite a while. Just more of the same, but faster, and in higher resolution.

Sort of like the automobile industry -- also "mature" and also having trouble finding a business model that maintains growth of profits, even as more people worldwide have the "benefits" of automobile transportation.

I disagree that "Part of problem is that there isn't much feedback going to AC as to what to do next." I think many people have tried to communicate their needs, and to a limited extent, AC has been willing and able to cooperate with them -- certainly more so than EPIC or Cerner-- but it isn't enough.

What we need is either one universal EMR (like thay have in Sweden, according to my Swedish cardiology friend) or at least a uniform set of file formats so that data from one EMR can be imported directly to another without going through cumbersome PDF files and an intermediate service like Updox. My "imported items" folder now is at 37GB -- in in some of the charts indexing is a nightmare.

Still, I think the problem with EMR started long before EMR -- with the development of the E&M coding process that requires extensive documentation to demonstrate that a particular code is justified.

I don't think there is any way out of this except to put doctors on salary, eliminate the redundant and obsessive documentation and develop a universal EMR -- we could all go to work for the VA perhaps.

I know that the current system is unsustainable -- I can't imagine wanting to go to medical school in this environment, at least, not with the intention of being a family doctor. I'm looking for an out myself -- but that isn't so easy, either.

Agreed. I think looking for one EMR is not doable. The cat is out of the bag. In fact, I tried the VA EMR years ago, and it was terrible. The CPT coding process is a joke and just provides for having to hire billers and coders or worry about typing in frivilous lines to make it meet the process. In the more expensive systems, you have it bill for you. If it doesn't meet CPT, ask it why. Needs one more ROS. OK. Done. Or pick a code and see if it is accepted. But, that means it has to be a drill down process that allows the EMR to parse the data.

AC had/has what few EMRs had/have. Many, many physicians from all specialties using their product and spending countless hours writing what could be done better. And, these were improved with each comment. Yes, it is sending in an idea through the "system" (which I get), but so much info on the board. And, the most info was the displeasure with the support, which never seemed to be heeded.

Remember the Big81. What came out of that? Tens of people telling me how stupid I was because I am not a statistician. And, a group of ideas born out of many, many hours that weren't taken seriously, because the highest request (being able to close folders in imports) had only five votes. FYI: It did pass later. Another criteria for a suggestion was it could not in any way be supported by me.

Maybe I am the only one who thinks this, but open up a chart from the patient list to have it default to today's date is the single most questionable thing I have. But, developers don't agree, so OK.

Bert -- when the doctors allowed the insurance execs and hospital administrators to control the profession (instead of professional societies) -- and that happened about 1985 with the Clinton "reforms", NOT "Obamacare" -- we lost our way and lost our profession.
I don't have a clue how we can get it back.

The administrative takeover is complete.

I've been to a few of the AC conferences. Very few attendees at the big conferences with the major decision makers. I think the last AC/Harris conference had maybe 4-5 AC users present. Inlight, ACPM, etc. weren't exactly big hits. AC Reminders can be pretty big for some practices. It's the little things here and there.


That was the original goal but insurance and pharma execs jumped in and turned the whole EHR thing into mass data collection. That data is extremely valuable for them but does nothing to make practicing easier.

I admit I have never been to an AC conference -- it's always too far away from me and too expensive to take time off work plus the travel expenses (when we also have to go to mandatory CME conferences). But lots of good suggestions have come up in these forums.
I've always assumed that the "meaningful use" and MIPS/MACRA hijacked the development of EMR so it really didn't make any difference what us lowly end users thought.

It seems to me like there is plenty of IT and coding talent out there -- the problem of the EMR is not a TECHNICAL problem. The problem now is that the medical system isn't for patients and doctors and nurses -- it is for executives and shareholders of the corporations.

When I started in medicine, the doctors hired the administrators.
Now the administrators hire the doctors.
Who pays the piper calls the tune.

Hey but we can't have Medicare For All, because "too many people love their employee health insurance." It's great when policy is dependent on poor premises.

I definitely don't want to give up my employee paid automobile insurance and homeowner's.

As to the conferences, your point is valid. But, they didn't always used to be about giving and getting ideas. The annual ones were about AC users coming together excited about the product.

I don't know. The can give a lot of feedback, but I don't feel it gets listened to. Again, I understand it is just random so probably not AC's fault.

I wouldn't mind insurance if they paid the friggin' claims. And, pay at the time. So many doctors hate Medicaid. Maybe in Maine we just get reimbursed well. But, no copays to worry about. They pay on time. They deny very few claims. And, patients with Medicaid come in once a week. And, you get the three-for-one deal when they want the other's ears checked. It is the best kept secret from Congress. They seem to have little notion of the ER abuse and the PCP abuse of Medicaid patients. They think there aren't enough providers so they open FQHCs. There is the fraud.

The FQHC in Bangor. Breaking new ground.

This has to be illegal if not unethical. A Federally Qualified Health Center making twice or more of what the solo provider makes straight from the Federal Government. And, they want the patients to pay for the facilities. Right on their website.

https://www.pchckids.com/ways-to-give/

Unfortunately, the voice of a few directed the development of products that most users didn't want. AC made a substantial investment into InLight for DPC practioners. ACPM was more of an integration but still a big project. These two projects took the bulk of AC's resources but didn't really pan out. I'll let you think about the timelines of when those were developed and when AC changed hands.

I enjoyed the early conferences from the Bertman and Pri-Med era. I think the staff got a lot out of them from my discussions with them. I know there were changes made based on input from those conferences. I've only been to the local Harris conferences and they seemed more to push the add one and not as much teaching. Seems to be a lost opportunity
Conferences are expensive to host and to attend but you hopefully get what you pay for if they are properly planned.
It appears Harris is satisfied to babysit the product without a lot of development. That's too bad.

Health care is evolving into a data driven field and would be best suited to one player with one set of rules. There are too many self interests to allow it to aggregate into a single entity. We could provide much more reliable care with a consistent system and it would be more efficient and effective.

"healthcare" is not medicine. Insurance companies made up that word.
It is a brand of snake oil, and they have us all saying it. Like "provider". No doctors any more?

The medical profession is moribund -- has given in to technocrats and financiers.
It's a shame, but it is evolution in action. Proves that evolution is not directed toward perfection, but only toward survival in an ever-changing environment.

At this moment in time individual greed has replaced social cohesion. That won't be sustainable in the coming decades when a changing environment will result in loss of the ability to imagine oneself a rugged individual. Money won't buy safety or happiness when the sea level has risen 3 feet -- let alone the promised 300 feet when all the Antarctic ice melts.

While healthcare is not medicine, medicine is a subset of health care.
There were gains in health from healthcare with cleaner air water and such before medicine made major advances. Can you imagine practicing in the pre penicillin earn?

Major money began to pump into medicine with the government programs (Medicare and Medicaid) and the start of insurance companies for medicine. I'm old enough to remember open wards with 12 beds that's not even close to being allowed anymore. What started as a tiny fraction of the GNP has grown to almost 18% (for HEALTHcare).

So yes, financiers need to be involved especially given our for profit mentality. We spend twice the GNP vs Great Britain (9%) and don't have any better statistics nor complete coverage. Medical care is the leading cause of bankruptcy in the US. It's a financial racquet and we are but cogs in the wheel.

To it's benefit medicine has become more outcome driven. More science less art, but there will always be an art to medicine and not an insignificant portion.

We as a country have a significant streak of laisse fare belief. Do it on your own! But give me clean roads, water and support my favorite pork barrel project.

In the past the cost of medical care was such that it was affordable to anyone with a job. It was not a significant expense for employers to provide it. That's no longer the case and we now have less coverage and more cost and uncontrolled ancillary costs.

When was the last time the insurance plans increased YOUR fees? You ARE controlled.

Until we the people have legislatures that decide it's in the best interests for universal medical care we are not going to see improvement. It's the only way to contain costs and expand coverage.

I understand that not everyone agrees with me (including a majority of congress ) but I felt it needed to be said. Other than that I totally agree with Tom above

Agree Wendell.
And it got that way because of social evolution -- probably pretty much the same dynamic as Darwinian physical evolution -- not because any one or group specifically willed it to be this way.
And it will continue to change -- maybe for the better, maybe not. That's evolution in action.
I wish that AC had continued to evolve the way it was going when it got started.
I wish that we had universal health care.

If wishes were horses
Then beggars would ride.
If watches were turnips
I would have one by my side.

I agree with most of what Wendell said above, but I think even we docs have begun to believe the much repeated mantra of "US medicine being more expensive than the rest of the world and not more effective". The latter is not completely true.

The most dramatic superiority is in cancer survival rates. American women with breast cancer have the highest survival in the world, over 90%. Your chance of dying of lung, breast, colon or prostate cancer in the UK is 1/3rd higher than in the US. A study comparing colon cancer cure rates in US & Europe in 2013 concluded "The wide differences in colorectal cancer survival between Europe and the USA ... are probably attributable to earlier stage and more extensive use of surgery and adjuvant treatment in the USA." America has among the best cancer survival statistics because of an abundance of high technology equipment and drugs, more extensive screening, and more aggressive treatment. Physicians in other countries can't or don't make them available to their citizens, because a 1-2% higher survival rate at a much higher cost is not considered necessary. Notwithstanding the ethical issue, this would not be acceptable to me if I was in that group. And it is certainly not acceptable in America that cancer outcomes are less optimal in some racial & ethnic groups.

The US has higher mortality rates for diabetes & heart disease, which has been attributed to a population that is becoming more obese & sedentary. Is this a medical care issue? I wish I had a way of changing lifestyle behaviors. Maybe better education to prevent children becoming obese may help.

I saw an interesting statistic during discussions of our recent US measles outbreak. While we in America are fretting over 1200 cases of measles this year, The EU counties have over 60,000 cases, with only a slightly higher population.

Just something to think about when the talking heads start up the healthcare rant again this election cycle.

Taken as a whole, American medicine provides far less value per dollar than other comparable countries. I don't think you can marshal any statistics to disprove that statement.

It may be true that there are small differences in cancer survival between countries -- but the differences appear to be within the range of statistical error if you look closely. On the other hand, no other comparable country bankrupts its citizens because of cancer or autoimmune disease, and employer-paid health insurance is good only as long as you are employed, and as long as the employer provides insurance. If you get really sick you will lose your job -- and your insurance. Self-employed people pay ruinous sums for very bare-bones coverage.

I personally don't think these social disruptions are mitigated by the possible few extra months of life for SOME cancer patients.

The USA has chosen to spend vast sums of money on "defense" -- but we could easily provide housing and health care to most of our citizens if we were to re-order our priorities. I don't think we need to debate health care vs. defense -- but it is clear there is a lot of money sloshing around in both areas, much of which could be spent more wisely than it is at present.

There are, indeed, many things the US does better than other countries in the medical field. Much of the true difference in cost is the ancillary field.
We pay more for hospital care because if tighter regulation and higher costs.

We probably train far more physicians than other countries but I have no data to back that up. Despite federal subsidies and low pay, resident care is done at a loss.

We pay far more for drugs because we subsidize the pharmaceutical research to the benefit of the rest of the world.

We have a lot of duplicate administrative services between all the various insurance companies.

We have WAYYY more MRI, CT PET and other machines than other countries because we have a fee for service based system. So yes, you can get MRIs much more quickly and efficiently. When they are under integrated managed care (say Kaiser) I suspect they have much lower access to imaging than the rest of the US population.

We have led the world in medicine research and codification of outcomes improvement. This has benefited the entire world. We have paid the price.

My point in bringing up the disparities in medical spending are to show that you can reach a medium where we provide perhaps 30-40% more care (universal coverage and complete coverage for those not completely covered now) without it being more expensive to the population as a whole. There will have to be sacrifices but they should not have to come from the medical community as it is more controlled than other sectors of the health care cost. We can show the world that better care is possible under constrained budgets.