Home Forums Discussions Feedback and Recommendations SQL DATABASE OH PLEASE!

This was once a frontline project for AC or so I was told. Will we ever move off Access or at least have the option to do so?

Hopefully!

I've got MS SQL on my current PM program and it has been working ok. Just be sure to develop it for Vista and 64 bit operating systmes. I had to move the PM program off my main server because it wouldn't work with the combination of Windows XP 64x with RAID and a quad core processor for reasons that are as yet unknown and would cost too much to debug.

I need to buy a few more computers and notice that DELL is only offering VISTA operating system with its Dimension product. Do you think VISTA is inevitable like death and taxes? Also, we have choices between 32bits and 64 bits. Given I have a network with 10 terminals (I'll need to buy more CALS), should I be purchasing the 64 bits, or am I asking for trouble?

Appreciate your answer on these hard hardware issues.

i have talked with jon about moving to sql, and he tells me (recently) that he plans to use sql express for the database, and that is planned to be completed by the end of 2007.

regarding vista, i think the most stable operating system from microsoft is xp pro. i have a network with sbs 2003, and four workstations with xp pro. although i am having some issues with sbs, xp pro is very stable. don't mess with success.
if new dell machines are only coming with vista, consider building your own (not hard), and installing xp pro oem, from newegg for about $135.

If I remember correctly in a SQL Express enviornment one can still use a P2P set-up? Just want to be prepared for what is coming down the pike.... Thanks.

Roy, I went to the Dell's ultra confusing website, and I was able to configure PCs with Windows XP Pro. In fact, I was not able to find Vista Ultimate, which is the only Vista which comes with either 32 bit or 64 bit. One can make any of the other versions 64 bit by buying an upgrade disk from Microsoft for $10.00. This makes you wonder why these didn’t come with that feature anyway. Probably, because most home users don't need or know what to do with 64 bit OS. Plus, there is only so much room on a DVD.

I would be wary of going with 64 bit especially on multiple PCs since there are certain requirements to run 64 bit. Your mobo has to support it for certain things, and your processor must by 64 bit. Your programs do not have to be 64 bit, but they have to be 64 bit compatible and you may have major problems with hardware such as printers and scanners that will require 64 bit drivers.

The advantages of a 64 bit OS is not that noticeable as you would need at least 4GBs of RAM to see an improvement there. 32 bit programs can only utilize roughly 2.7 to 3.1 GBs of RAM even if the computer has 4GBs of RAM. You will see some slight improvement in performance overall but not nearly enough to be worth it. XP Pro's 64 bit OS has too many issues.

More on memory loss from 32 bit OS:

http://mistywindow.net/?p=6
http://mistywindow.net/?p=8

Software compatibility list:

http://www.iexbeta.com/wiki/index.php/Windows_Vista_Software_Compatibility_List

Hardware compatibility list:

http://www.microsoft.com/technet/windowsvista/evaluate/hardware/default.mspx

I think you would be asking for trouble. As Microsoft moves further toward 64 bit OS and all Vista versions come out with 64 bit (doubtful), the OS themselves will support many more programs and hardware devices especially since the OS will supply many more 64 bit drivers. As well as, HP and Dell and Okidata, etc. will come with 64 bit drivers.

If you can find the right machine at Dell (it appeared that Dimensions are now Inspirons), then HP has XP and you can customer build them at xTechnology.com with XP Pro as well.

Hope this helps.

Moving to SQL Express in essence is also a move to SQL Server. SQL Express is simply a lightweight version of SQLServer. It can be run in a client-server environment. The limitation is that the database cannot exceed 4GB. The upside is speed and scalability.

Ah.. be careful what you wish for...

Microsoft's SQL when configured in a client-server environment requires that ALL network connections be ROCK SOLID. Even a good wireless network does not meet this criteria, as frequently the wireless connections are renegotiated "behind the scenes", dropping the connections to the SQL database. Lytec uses this, and it's maddening, as their program does not recover from lost connections to the SQL server, requiring that the program be stopped from the task manager and restarted, loosing any work that was on the screen when the connection went down.

I do not know if MySQL has this problem. Given a choice, I prefer MySQL for other reasons.. but that's just me.

I'm hoping before committing TOO many resources to the conversion off of Microsoft Jet, that they test for this and plan on being fault-tolerant of it.

Regards,

V.

Vinney this is one of the reasons why MS developed ADO.NET: it does not require a constant connection to the database. The application connects to the database, gets the data it wants and disconnects. The data is manipulated, the connection to the database is opened, and the database is updated. All kinds of data concurrency rules can be implemented.

By the way this, is exactly how your online banking and services work. You do not maintain a permanent connection to the database.

Additionally, the Jet engine is not a client server database engine. When you develop SQL client-server applications there is a tremendous amount of inherent power in the database engine itself, that will take a lot of load from presentation layer.

If the application is architected as an n-tier(data tier, business logic, presentation layer) it will make for more efficient development paths.

Lytec and the other Medical software are still using Visual Basic 6. This technology is EIGHT YEARS OLD, and was developed before applications had to work in a disconnected environment.

George K. Fahnbulleh
Solutions Architech
Lake Piso Software

Hi George!

You are EXACTLY right, and if Jon implements some kind of ADO solution, I'm fine with that, but I don't think their SQL light does.

Lytec is still using VB6, that's true, but the migrated 2 years ago from Pervasive's database engine (in other words, relabeled B-trieve, if I remember correctly) to MS SQL. When they did, database reliability went out the window. While the dropped connections do not corrupt the database (at least they got THAT part right), when the connection drops the program does not recover gracefully. I would hate to see Amazing Charts wind up in that situation, as we LIVE in Amazing Charts.

Amazing Charts is written in VB6, and quite frankly while MS Jet is ancient technology, it gets the job done and has been solid as a rock, even if it's slower than sin. While I'd love to see a migration to a newer database engine, I don't want it to be move that causes instability on systems like mine which use wireless connections.

Regards,

V.

Vinny,

The difference is in the programming tool. VB6 is 8 years old. VB 2008 was released in Nov2007. Any program looking to migrate from an Access Database w/VB6 to SQL Server w/VB6 is asking for trouble!!!

With the .Net Framework 2.0+ you get a fully object-oriented version of VB. This allows the development of much more robust applications. The slowness you describe is specifically because of the Jet Engine. I have a client who has 4 providers...and a needs to be able to access the system externally. An IP addressable db would do the trick.

Yes, maybe you do, but unfortunately it's not just a recompile and relink under new tools, and the Amazing Charts codebase is NOT small and is NOT simple. VB6 may indeed be 8 years old, but a migration to .Net is NOT trivial. A number of programming tools and 3rd party modules that Amazing Charts uses are not available in the .Net framework, and coding around this issue would also be major. This is not a trivial hack, unfortunately.

There are SQL databases available that don't have the issues that Lytec and other MS based SQL's have, which would be excellent for migrating AC to. There are also NON-SQL databases that would also be excellent.

While I agree that migrating to SQL server under VB6 is "asking for trouble", my experience has been migrating to SQL server without VB6 can also be asking for trouble.

Heck, if it were up to me, I'd pick MySQL. :-) Still, ask any 5 software design engineers a technical question, get 20 answers. My only criteria for whatever Jon decides is that it has to be ROCK SOLID. My PREFERENCE would be that it not break too much of the existing code base getting there.

An IP addressable database would indeed to the trick - I'd love to be in a secure, client-server environment with secure transaction processing on both our in-house network and externally though our gateway. Still, the thought of being locked in to Microsoft's database makes me nervous, based on experience with other products which use it.

BTW - where in AZ are you? My brother and sister live in Tucson, and I have been known to drift out there every couple of years or so.

Regards,

V.

Vinny,

It would be best to re-architect the entire thing FROM THE GROUND UP! I am not a believer in dragging along COM based systems in to the .NET world.

The number of programming tools/components available for .NET far exceed anything that was available for VB6. Anything. The reason is simple. A .NET component can be written in ANY .Net language and used in .Net application in any language. So a C# component can be used in a VB.Net application and vice versa.

YES! AC really needs to be re-architectured from the ground up in an n-tiered paradigm. It wouldn't be an easy task but the future benefits and maintainence out weighs the pain of re-design and refactoring. Current advances in .Net 2.0 and 3.0 are significant and future LINQ to Entities may even address the issues with database lock-in.

Um.. gang? let me tell you a little story...

A long time ago in a galaxy far, far away, there was an accounting package called "Flexware". It was originally written in UCSD Pascal, ported in Pascal to the Mac, and it did quite well for itself. Someone decided that it really needed to be re-engineered from the ground up - in C. It took over a year, and it almost put them out of business, in order to convert to C. They gained no functionality, it cost them a fortune, and it almost put them out of business.

Believe it or not, there are a lot of people running code written in the 1970's in COBOL because the cost of re-writing this with more modern tools far exceeds the cost of maintaining the existing code base.

I think it would be foolish for Jon to convert Amazing Charts - which currently works under VB6 JUST FINE, to .NET **JUST** for the sake of converting to .NET. I agree that VB6 is a platform that borders on brain-dead in a lot of ways - no argument there. Even so, it's possible to use a perfectly good modern database under VB6 just fine, and conversion to .NET isn't a trivial hack. The decision to go to a different database engine should be totally separate from any decision to change development tools or platforms, and each decision weighed carefully for cost and benefit.

Regards,

V.

Vinny,

I have been joined by another expert in my opinion. The suggestion that VB6, a language that is more than 10 years old, with hardly any support, not object-oriented should somehow remain the platform for Amazing Charts simply does not hold water.

We are advocating converting to the .NET platform because there are multiple benefits of doing so. The number one benefit is vb.net and the .net framework is OBJECT-ORIENTED. A properly architected .NET application saves time and money by utilizing re-usable code. The second advantage in the n-tier architecture is the ability to separate the various layers of the application into distinct subsets.

For example, the data layer would hold the data and stored procedures, the business rules layer would hold the application logic. The presentation layer (user interface) could be written for windows, the web or even a smart client. Because presentation layer only presents the data to the user, and holds little code, the application can be "ported" to new devices quite easily.

Additionally, Vinny, SQL Server 2005 is tightly integrated with the .Net Framework. While TSQL is a clunky language, using VB.Net a developer can write CLR Stored Procedures.

But here is the largest benefit. As the practitioners who use AC become more and more successful and their practices expand, AC will have to expand to accomodate their growth. I currently work with a client who delivers their entire application as a SERVICE: there is no infrastructure cost to the end user, they sign up and they are up and running. The software provider provides the database, the application and everything via the web.

Everyone understands quite clearly that it is not a trivial hack. No one suggested it ever was. I said re-architected. I never suggested a "trivial hack."

I have over 15 years software engineering expertise, including the last 8 with VB.Net. No matter what your devotion to VB6 is it is without foundation. I would no more recommend using VB6 to develop an application today, than I would recommend travel from AZ to CA by stagecoach!

Guys,

I have no great love of VB6. BELIEVE ME I have no great love of VB6 !!!! Bear in mind, though, it's not MY decision, it's JON'S. I'm just another bozo on this bus - not my product, not my decision. I am NOT devoted to this platform, other than asking the very legitimate question, is the conversion to another platform worth the cost and time to make the change.

It's fun to debate with other software professionals. I respect your experience, but you need to bear in mind that I, too, am not exactly lacking in experience here - I've been cranking code since 1974, with my first machine being a DEC PDP-8e with real core memory! I wrote a runtime environment for a multi-user accounting platform which paid my living expenses through medical school, for an consulting client that was with me 19 1/2 years (until I retired from the software industry). In order to troubleshoot the infamous AC "can't print on HP printers" bug, I was running Amazing Charts under linux, and sniffing postscript errors through postfix. This is one of the reasons that Jon has given me access to Amazing Charts source code. I had to LEARN VB-6 in order to work with Amazing Charts, and have no great love of it. (ok, so we've proven we can pee farther than everybody else.. now lets get back to the technical debate :-) )

Amazing Charts is not a small simple program.. it has a pretty large code base. It is FAR FROM vanilla VB6 code internally in many places. Database access is, however, packaged in only a few areas of the code that would need to be massaged to work with another database - it would not require a total re-write. The conversion to VB.net would NOT be trivial, and the conversion of the existing codebase to an object oriented programming approach would require an almost TOTAL re-write. (We can debate the pros and cons of object-oriented design another time) Unless you've seen the source code for Amazing Charts, you really have no idea the size or scope of what you are suggesting.

Let me ask you these two simple questions (the first is a 3-parter) 1) What are YOUR personal estimates as to what it would cost in terms of a)man-hours, b)dollars and c)time to redesign, recode, and test your proposed conversion? and 2) If all of this work results in a program that looks, and other than database issues works exactly the same as the existing program, how can you justify the expense?

Regards,

V.

Guys,
I have been reading and watching this for quite some time now and it seems that you are talking at each other rather than with each other. "G" makes the good points of switching to a better, cleaner and more modern foundation for AC which in and of itself is probably a decent idea.

But the point that Vinny makes can not be denied. At what cost? AC is probably the least expensive EMR on the market and this is Jon's nitch. I shudder with deep understanding of what Vinny speaks of that such a conversion could "shoot the goose that is laying our golden eggs".

I have had this "expense" limitation conversation with Jon more than once and not always under the best of circumstances. Jon and AC have limited resources and not bottomless pockets and so cost and cost benefit is always in play with AC. To spend countless hours and dollars just to get back to what we already have seems pointless to me under such tight financial constraints.

Jon has made it clear that he only has so much budget even for such things as tech support for his users, and so I doubt he is going to or should attempt to find goodness knows how many extra dollars just fix what is unseen to most of us average end users. Most of us just want a modern fuel injected car... We put the key in, in the morning and the think easily wakes up, runs and idles smooth and gets us from point A to point B without a hitch. Exactly how it does this, so some extent I really couldn't care, as long as the darn thing work and works reliably each day my doctor and my office need it to. End of story.

Personally, I would much rather he use his limited resources continuing with his increase and improvements in support, tweak and refine the product we already have, and continue to develop the new features that we will need to get our day to day jobs done in our offices or that we need to compete and comply in this crazy business. Do I really care if the fuel injection system is throttle body or multi-point??? Not really if they are both going to be basically the same to me from the seat of my pants. And not at the risk of "Shoot our golden goose". That is a price too steep to pay....

Have a great night ya'll
Paul

I am enjoying listening in on this IT discussion, which is a little over my head. I have heard these kinds of discussions about AC repeated in other forums as well.

I am wondering how this upgrade to SQL will affect the users who have to "live in this program," as Vinny says?

I worry that this database conversion is diverting resources away from bug-fixing and new feature development.

Does Amazing Charts, being an "economy model" EMR, have the resources to successfully pull off an arduous re-architecture?

At this moment, Jon is diverting resources to convert to SQL. Meanwhile, there are issues of basic functionality which have been deferred in favor of this development. That's Jon's decision to make, but it is a reality.

(I do have to say that I appreciate Jon taking time out recently from the big tasks to address a number of annoying bugs, and add some welome features).

I also worry that the conversion might actually rob AC of some of its advantages in the market.

Right now, AC may not be the most elegant EMR on the market, but it has some unique qualities which set it apart. I would characterize these as follows:

• Low cost.
• Ease of installation.
• Simple networking.
• Approachable interface (GUI).

I am worried that #1, #2 and #3 may all suffer with this upgrade.

Amazing Charts has to keep making its established market happy, which is solo physicians and small groups, who have mild to moderate computer expertise. To me, this means AC needs more of what is already working for it:

• The program needs to stay simple and intuitive, to reduce strain on the users, and AC's support staff.
• The program needs to run fast on older, slower computers.
• The price needs to stay as low as possible.

p.s. - Could some of you experts explain the difference between MySQL and Microsoft SQL Express edition?

I doubt it would affect 2, 3 or 4 but certainly #1.

MySQL vs SQL Express:

http://tinyurl.com/cyalf (scroll down all the way under SQL Server to find link for the free version)

I have learned a lot from this thread and appreciated the debate. But, in the end, I leave it in Jon's capable hands.

Yes, but Jon does seem to "listen" to the banter here from time to time and so all opinions are important. I think it is important to remind Jon and ourselves as well, why we are here, what it is that we love and value about this different product and how would we feel if AC stopped being AC.

If I have to send my staff to one of those exensive conferences just so we can all understand how to use the darn thing??? Will AC work the way we work or will we have to work the way it wants to make us? And there are many of us that the networking is really important in that we don't own servers and we are in no hurry to get one. After the killer tower I just bought we really have no need for a server in our little office probably for years as long as AC doesn't start to require one just to function properly if at all.

So easy to learn, easy to use, easy to set-up, run, live with and take care of. And to drain AC's limited resources just for some moderate or modest gains, which many of us may not even really feel or notice, seems real silly and off target to me.

Instead, debug her, tweak her and improve her and keep her current where it must stay current to be used in a practical sense, like State specific Rx's and better databases. I don't know what the program or database behind QuickBooks is and I really couldn't give a darn, it simply does what I need it to do day in and day out as our financial database. Isn't that what we all really need out of AC???

My only experience here is that it seemed when SoapWare converted to SQL, things changed for the worse. It was shortly thereafter that my system crashed, my data was corrupt and the support team was calling my server a "dinosauer". I was forced to upgrade my operating system, buy a new server and inevitably ditched SoapWare for AC (perhaps the only thing good to come out of it). As I have said on numerous occasions...be careful what you wish for. There is nothing wrong with the mundane if it works well and suits ones needs.

Leslie

Right, Leslie. If we have to upgrade our equipment, this represents a hidden cost or complication of the upgrade.

And, how will we discover that we have to upgrade? When things don't work properly anymore.

Bert, I hope you are right and installation and networking are not significantly more difficult. Right now, AC is so easy to install and network. I would hate to lose that.

"Every conquest brings a newer quest" ~ Eleanor Roosevelt

This is the essence of the software development lifecycle. With every iteration, the uses want/demand more features, thus the development cycle never ends.

In the history of software development version 5 is always substantially different from version 1, both architecturally and in capability. It is understandable that the users love the USABILITY features in Amazing Charts. That usability can be maintained, as the product as re-architected.

This of it this way. The 1980 TransAM was a wonderful car. The 2008 TransAM is also a wonderful car, with substantial technology improvements that increase "useability" ie, safety, fuel efficiency, and drivability. While we love the 1980 TransAM, in order to continue to maintain it and drive it daily we have to spend a lot of time foraging for parts.

Vinny, I don't know anything about the AC Code base, so I cannot give you estimates; just as you cannot provide a full diagnosis and treatment plan for a someone you pass on the street.

With regards to the question of what changes need to be made, eventually a zero footprint version of AC would be spectacular. Just sign up and go, nothing to install, run everthing over the net!

G,
There are many of us who will leave the moment any program, including AC goes to a "Zero Footprint" as you so put it. Why don't you call it what it really is, a program that we have created our data in, our intellectual property in, and yet we can never own it, hold it in our hands, it is a permenant taxi-meter for the software developer to hold the user hostage because simply to get to their data they must "pay" a monthly, yearly, quarterly fee just to access some server that has the program their data was created in....

We here on this board have hashed this one out and this dog can't hunt. Keep going brother and dig yourself a deeper hole as you turn off everybody reading here. This is our intellectual property and we care to own an actually working copy of the program that is will be created in so we can always access our data. I won't even bother to re-type all the points I and other good users like our dear friend Roy have already spoken of in these pages, you can do a search and find them. But believe me when I tell you either we own the program or we walk.... Period, short the end.

We here call these programs ASP model prgrams as they are hosted on someone else's server. These vendors brag about a 97% retention rate of customers and on the surface it sounds great until you stop and think of why they are able to retain so many more customers than other vendors..... WHY, really use that supposedly big brain of yours and think why... Because it is a proprietarty written program that the data only really works correctly in it's original native program. So what are all these suckers going to do to be able to access their charts, their intellectual property, their data??? That's right continue to pay the "ransome" to the ASP vendor just so they can open up a document they already paid to create in this program a year ago. Forever stuck on the vendor's taximeter.

In the reverse I buy a copy of MS office and all the spreadsheets and word docs I create in it are mine and as long as I have a decent machine with a proper version OS on it, I can access and continue to create more data and more of "MY INTELLECTUAL PROPERTY" in those programs until the end of time. That is my right as they legal owner of the program that I purchased and nobody can every take that away from me or make me stop.

Yes, people who fall for this ASP "three card monty" (now you see 'em, now you don't) vendors are suckers and if you want us here to be your next group of suckers, you better watch out, because I'm really starting to get PO'ed here, hands off the one last decent and friendly for the small and solo practice program left our there. We don't shut off people's accounts here for free speech even if we don't agree with however crazy or offensive their speech may be, but believe me when I tell you, we here at this board are of a somewhat different mindset and we are quite proud of that. "Hands off my AC" OK? If you don't care to actually understand the users and the community then, the nitch or anything else about it, then you maybe technically smart as all hell, but you are very ignorant in terms of marketing and sales, business and basic good old human interactions and Psych.

And by the way, sure I love my new multi-point fuel injected, 5.2 magnun Jeep Grand Cherokee, but there are things I can do with and more importantly for, repair and take care of myself, on my old analog, carburated, electronic ignition Dodge Dart that has the older brother of the same exact motor, the 318 cid, that I just can't for my newer Jeep. I need new tools and new tech just to be able to read a trouble code or read the data coming off the various sensors, just to be able to begin figuring out why she is throwing a code at me. Many times the simplicity factor way out weighs the tech improvment factors. As a Sunday driver, I'll take my beautiful old Dodge Dart any day. And when I was truely poor and had to maintain my car by my own brain or throw it out, that is what I would always buy as a daily driver, because I could fix and care for whatever it threw back at me. Even today I have this issue once in awhile with my newer Jeeps. Sure their MFI is reliable, smooth, and gets slightly better MPG's while returning a little better output in HP and torque, but I can fix my Dart myself and the tech is simple and any reasonable smart person can take care of it, themselves. And that is what we have with AC. If you start messing with that, you will have a rebellion on your hands, so back off, OK???

I suggest that you go do some searches and some informative reading here for a while, then and only then, start chimming in about suggesting such offensive ideas like ASP models with totally re-designed architecture. You may be big on tech smarts but..... You still have a whole heck of a lot left to learn my friend..... Catch ya on the other side....

HockeyRef,

Please do not try to "poison the well" by attempting to cast the ASP Model as any different from the current licensing model in terms of the ownership of YOUR INTELLECTUAL PROPERTY. The ONLY DIFFERENCE between the ASP Model and the installed software model is the POINT OF DELIVERY. Everything else is the same.

While AC has a wonderful licensing model, like any other EHR program it is still a charge per provider. Yes the charge is low; however, it is still "metered!"

You do not OWN AMAZING CHARTS, you license it from the software developer. YOU OWN THE DATA YOU CAN CREATE WITH IT.

The same is true of Word, Excel or any other software program you use. Your argument about ASP vendor retention rates that it is simply due to the fact that "they own your data" is a canard. Because the same holds true for ANY EHR program you buy. You remain loyal to that program, WARTS and all, because you simply cannot TRANSFER YOUR DATA into another system without prohibitive costs.

That you find a discussion of architecture, usability and delivery OFFENSIVE and insulting is something for you to ponder. I, on the other hand, am sufficiently curious, that no exposure to knowledge offends me.

You wrote: "If you start messing with that, you will have a rebellion on your hands, so back off, OK???" I am a potential user of AC, I do not know the owner, the programmers or anyone in the company. I do not have the capacity to alter the direction of the development in any way, so how does simply DISCUSSING what I see as potential for change lead to in your words "a rebellion?"

This much I do know, "When the sun comes up the lion it knows it must outrun the fastest gazelle or it will starve; when the gazelle wakes up it knows it must outrun the fastest lion, or it will be eaten. It does not matter if you are a lion or a gazelle, when the sun comes up, you better be running."

I use that metaphor to point out that software development NEVER STANDS STILL. AC has competitors who will constantly look at what they are doing and try to do it better. One cannot be in the software business and be averse to change...just ask WordPerfect, which was once the largest software company in the world!

Forget about owning vs. renting - my ISP is not that dependable. I actually use a fiber optic line which is the best available in our area, but there was a few days in the last few months where it did not work at all. I think it is imperative that the software be on my machine in my office.

BCMD,

You wrote: "At this moment, Jon is diverting resources to convert to SQL. Meanwhile, there are issues of basic functionality which have been deferred in favor of this development. That's Jon's decision to make, but it is a reality."

It is highly likely that the "basic issues of functionality" you desire is not mutually exclusive with the SQL development. I am willing to believe that some of those "basic issues of functionality" and other enhancements are easier to deliver in the SQL platform than in the current platform.

This is what I will hang my hat on: The person who came up with AC was smart enough to come up with it; I trust he is smart enough to improve it in a manner that will increase its ability to continue to deliver rapid new features.

SFHill No doubt that is a legitimate concern!!!

Wrong,
I have access to the program and even if I move to another program I can still open the old encounters with this copy of a program all I want and need. Are you really so blinded by your own side of the table here, or are really trying this hard to sell us all a package of goods???

Tell me there is no difference between the disks I own and hold in my hand for QuickBooks or Office, verses an ASP rent it or loose it model and I can see your nose growing even thru the fiber and coax my friend. You are entitled to your own slanted perspective, but please don't blatantly lie to all of us, we have seen this all before and we know just how one sided it is. If I own a valid copy of XP and then a copy of any of these programs that run on it, I can use that program for another fifty years or until I can't find working hardware that they can run on.

Matter of fact we are doing this right now. We have an old laptop with XP on it and a valid copy of the old charting program we used to use. Every now and again we have to boot the sucker up to access data from some old encounter or to copy a record for a patient or doctor. We can do this practical forever. Now why on earth would I want to change this paid up front and never paid for again relationship to one that I need to pay a small ransome for that same forever time, just to be able to comply with state and federal law, not less do the right thing and protect access to these old encounters for doctor and patient? I can never leave you because you literally have us by the b@ll$. Where as in our case we have already moved on, live and let live. We now longer purchase support but the program is ours to keep, to have and to hold and legally do with as we please.... No future costs unless we need to purchase some support at prevailing rates. Done, period short the end.

We on this side of the business of medicine are used to many people from all sorts of sides in this industry coming at us, to use us as a conduit to what they believe is their money. Sell us goods and services that are obviously and firmly not in our own best interest no less those of our patients. Personally I have developed a pretty good sniffer and BullCCHIT meter, and these ASP models, stink to high heaven and back again.

But I must admit if I was some selfish, greedy vendor I might want to pull this one over on folks like us too. Your model certainly puts the vendor in a most enviable position; so I guess we all know where your morals lay.... Nice to know you too. Now at least I know never to turn my back on you...

Good Night and Good Luck,
Paul

If I had one wish for this board, it would be that we don't attack the character of other members. I hope in the future we can disagree with a position without going after people on their morals or imply that others are offended by exposure to knowledge.

HockeyRef,

People can disagree without being disagreeable. I have a different view on the future of software delivery. You have a different view. We can disagree without the invectives, and personal attacks. We need to dispense with the ad homemins, and argue our points with civility and respect.

When I worked in VB6 our biggest support concern was what the end-user installed on his/her machine. Did he/she install a dll that broke our installation? I grudginly moved over to the webdevelopment side with .Net. What I found there for all of it's complications the delivery of the software is not dependent on the end user's machine configuration. There is something for that, expecially from small development outfits.

I am interested in how software is used in the medical profession because my wife of 25 years is a physician. However, I can use my capabilities to make her more efficient is a good thing. To immediately ascribe my difference with you to greed is outrageous. Remember, as a man thinketh, so is he!

Eric you make a very excellent point. I have a lot of experience on a motorcycle forum that experienced some pain over the issue of censorship and etiquette. The current forum is 90% self policed by the members effective use of peer pressure and a sort of group etiquette that evolves over time.

Paul, your rhetoric may be appropriate within your own office for arguing a point when selecting a vendor or a software. And you are welcome to talk to me any way you feel you should, after all I used to abuse my Jeep Cherokee pretty badly! But I think as a rule for a forum like this it doesn't all work so well. You have no control over your audience. Some may know you, like you and respect you, and accept a strident tone as intended, but others may be new to the forum, not have any idea how to take you and be unduly offended by the framework of your arguments. The whole thing with the little emoticons that are on some forums are an attempt to make up for what communication we lose in this format. Take a breath, chill, soften up a bit, then tell us how you really feel.

gkfannbulleh, hang in there with us. Paul has a 'style' that is not entirely Socratic, but he makes good points, and seems, (in my brief presence here) to contribute a lot to the forum. I am interested in your thoughts about where we are headed with software, licenses and management of the medical record. I also believe the record creates a database that has intrinsic, marketable value which we have probably already lost the intellectual rights to and which we will face continued, increasing pressure to give up. I suspect that as the 80% using paper charts slowly come on board, and do so with the vendor offering the best deal, this will increasingly put us in a position with no control of the market. An opportunity, too slow to be realized, now sure to be lost. At this time I would count me "in" as one who wants no part of a system that is internet based. That model has no appeal to me for the two reasons Paul has discussed. I want the data on my server, not someone elses, and I want to keep seeing patient even if the Net is down. We just came back from a NINE DAY ABSENCE from internet service courtesy of some problem that I still do not fully understand with Verizon. Verizon will soon be our former ISP, but the model I am considering now will include TWO ISP's so that we have a quick fix before this ever happens again.

Do you think we will reach a point where the individual Dr. may use a software of his or her preference, access data from a common database maintained by a third party (Insurance or government)? And all other providers with a legitimate excuse for access will see the WHOLE chart, my notes, your notes, the lab and hospital record all in this 'repository'?

Sorry if I got way too out there, but when I hear about the taximeter crowd I go balistic. There is no way to compare the two lease, and less on someone else's server no less verses own the disks in your hands as anywhere near the same. They are lightyears apart. Instead of you and I butting heads here, two guys who both care for their wives and their repective practices, please really search this site for all our CCHIT, ASP type posts for the last year at least and then lets talk again.

There is no way in hell unless we are the legal owners of a working copy of the EMR will you ever get me and my wife to buy into the lie that is ASP style programs. If I can't run it on my own if and when we want to part ways, then it is a hostage situation and how anyone can not see that is beyond me.

And don't forget, AC is the low budget side of town. We just can't have it all and we have accepted that. Matter of fact we don't even want it for the most part. The road to hell is paved with good intentions. CCHIT was probably conceived by a few folks who thought they were doing people a favor, a good thing, and then the greedy enterprise software vendors along with the insurance carriers got their grimmy little paws on it, and now it has little to do with medical outcomes, quality of care or the better handling of medical data, and everything to do with sleaze, power and greed. All while violating every citizen's once respected rights of medical privacy while at the same time spying full time on doctors like both of our loved ones.

Have a good night and try to remember it is not what people or vendors say to you in the honeymoon phase as they are trying to get you to buy into their horseCCHIT, it is what legal rights in a contract or by the rights of posession and ownership do you have if and when you get divorced. No relationship like this lasts forever, ya need something concrete that you can hold onto. Not a taximeter to be held over your head like some tightening noose for 7 years after your last visit with your last patient. Don't just react, stop and think about your wife, without her knowledgeable tech husband, and every patient and their family who depends on her and how these two situations are obviously lightyears apart.

be well.....

Martin, there are two major initiatives regarding the portability of health records. check out www.healthvault.com, that is Microsoft's iteration. Google announced it's initiative here: http://googleblog.blogspot.com/2008/02/google-health-first-look.html.

Additionally the two initiatives mentioned above will force software vendors to produce and consume (export and import) a patient's entire medical record in a more or less standard format. This also means any EHR worth it's salt will have the capability to import a patient's record from one of these two vaults. Let's extend that thought a little further. There is no reason why as a doc who wants to switch EHR systems you would not be able to EXPORT ALL YOUR PATIENT RECORDS FROM ONE SYSTEM and IMPORT IT INTO THE NEW ONE!

The standardization that portability will bring will also be a boon for providers, freeing them from unproductive systems.

While I understand the desire to HAVE YOUR SERVER, I believe in the next 10 to 20 years will see a major increase in the use of "managed" systems. Reliability of connectivity is a major issue with that model. Many new docs, perhaps may not have the capital to invest in an entire office system. For the younger docs who grew up on YouTube, IPOD, having their data "managed" will not be such a psychological barrier. The notion of INSTANT OFFICE with no hardware to manage will go a long way.

This is just how I see the future.

HockeyRef, I understand the privacy concerns. But take a look around you. YouTube, FaceBook, MySpace, free email, free online storage. Unfortunately the kids today, do not share the same concerns regarding privacy, the they have no disdain for plastering their information anywhere on the internet. Some of these same kids are the docs of tomorrow...think about it.

So rather and complain about what has happened, I prefer to try to shape what will happen, in whatever small way I can!

I definitely agree with DocMartin and Eric on this one. There is no reason to get upset and ballistic simply because a very knowledgeable person happens to present ideas that may not be ones we would accept. G has not done anything to offend anyone and, in fact his statement about "that no exposure to knowledge offends him," did not, in my mind offend anyone else.

I was taught a long time when in a debate about with another person on a very touchy subject such as Republican vs Democrat or abortion that you gain little by trying to persuade the other person to your side, because it isn't going to happen. Rather you gain so much more by listening to his or her argument as you can keep your own view, but you will be smarter for it.

I first started with the ASP model called Logician Internet which became Medscape Encounter. It was a thing of beauty. To this day, no EMR has ever produced a prettier progress note. It was far better than it's bigger and more bloated not-ASP model, Logician, now Centricity. And, a few of my friends used it, and we could share information. I still see the day where a patient could be referred to a consultant and the patient could use their health card or USB key to give access for one day or a hundred days. This could be write or read/write. The consultant could bring up the data and then simply dictate or type a note right into the ASP.

Now when Medscape Encounter folded a lot of people lost their data. And, that is what scares a lot of people. But, that doesn't mean the ASP model can't improve. My programmer and I are already experimenting with an ASP model coupled with a server model that is constantly in sync. That is very doable.

I think if we hold our heads in the sand, we will miss a lot of chances to keep up with the Joneses. Certainly, AC got to where it is by not adding expensive bells and whistles but that doesn't mean that another vendor is going to make a smaller version of their big version and take over the market share. While we debate this, I am certain Jon is all over this.

Thanks G for bringing this information to the table. I agree with many things you are saying. On the other hand, it is only fair to say that while theoretically, the licensing may be the same, try telling those physicians who lost all their data when Medscape Encounter went under that the "ownership" of AC is not better. Sure, we may be paying to license it, but my guess is having it on our PCs is still a hell of a lot different than licensing it in Cyberspace. The key phrase here whether true or not is, "Possession is nine tenths of the law."

G, it is ironic that your links above are proving your opponents ideas valid. Both links are broken; although maybe I am missing something on the Blog one.

GK,
I agree that the kids today "don't get it" but you'd be suprised. My nine year old daughter gets the idea that what is in her medical chart is nobody's business but hers and her doctors (and mommy and daddy for the moment). She and I share a common minor Dx and she doesn't want anyone to know who shouldn't know.

The majority arguement is a weak one at best. So these kids don't get it. Time for all of us to demand that our school districts require Orwell and 1984 in the Junior HS then. As you said we should "shape the discussion".... Well we are. Teach and spread the word thru your daily interactions with your patients. There is another way, but we all must stand up and say; "I'm mad as hell and I'm not gonna take it anymore" (1000 points for any new member who can properly tell us who this is a quote of and from where, NOT YOU BERT!)Instead of just going along, fight my man, fight. Stand up for your rights as an American no less to defend your poor over worked unpaid, under apperciated wife and all her fellow docs.

And we practive what we preach. We are no longer giving out Vaccinations not because Nancy is doesn't want to or care to, but because the state wants to mandate that we violate our patients' civil rights and liberties and put each and everyone of them under the age of 19 in their stupid and invassive vaccine registry. We don't want own kids in there no less anybody else's. ZIG HEIL! No less the fact that as always the didn't put a dime in the budget to pay us a darn cent for all the extra paperwork and data entry, right Vinny??? You get a brand new 16 year old patient and give her one flu vaccine, if her previous provider hadn't entered her data because he saw her before the law took effect, guess who has to BY LAW and Penalty enter and compile all of that patient's shots for the brave new order??? That's right us who just saw her for the first time because her mom felt is was time for her to have a "real doctor".

Yes portability is a lofty goal and if implimented in a non-spy on the doctor and patient way it just might be worth considering. But why the manditory back-door spy portal for the carriers and there for the government, the largest and probably to be larger still provider of healthcare. What is in mine or your medical chart is nobody's business even if they are picking up the freight. Why are Americans always so willing to throw out the bill of rights?

I came from a different industry, one with lots of standards. Theater and TV as an audio and lighting tech, stagehand. 525 lines of interlaced resolution, 29.97 frames per second (drop-frame), no questions asked. Great idea, now all TV's, tapes and discs can work and play anywhere in the country. Who is this brave new world is gonna pick and choose how much data is enough and what style of charting will be approved. Trust me and everybody else here, their idea of a CCHIT system won't look and work on a day to day basic ANYTHING like this lovely little program we all have here.... It will be some NextGen enterprise monster that only you, Bert and Vinny will be able to run and take care of without half an IT team. And just like the vaccine regisitry, they won't pay us nearly enough to make it worth while...

What does protablity got to do with interconnected servers run and accessed by law by the courts, the carriers and the government? Picture this, if patients can't trust the privacy of their health records, how long until your wife or mine mistreats any number of them because they don't tell part or the whole truth? Who's butt is on the line when that patient crashes? I just posted something to another guy who was stalking Vinny here, about what we in Psych refer to as the Bogus Pipeline. It was a body of experiments and research to try and finally get people to more accurately self-report. It is tough enough to get patients to finally trust a doc, now we have to add them being concerned that their health insurance company and the government is watching them and that at any time the courts could access their stuff as well.... Please. The line in the sand must be drawn here. (Jean Luke Piccard)

I have a totally different idea. Instead of medical records stored in centeralized servers with a few million healthcare professionals and their related staff, having total log on access to, why not have "E" medic alert tags and braclets much like the pay at the pump or a usb zip drive. You could have en entire families health records on a single little drive. And now if I loose my drive it is only me and mine that has had a security breach, not half the east coast. We already have assumed consent laws on the books, so the lie that we need a national system so just in case you have a car accident 500 miles from home is bogus. We could cover ER docs and EMT's and the like with the same assumed consent we have right now. It is assumed that if you were so bad off that you couldn't speak for yourself, that you would like someone to attempt to save your life, so they would be covered for accessing your little drive to get at your health record in a true emergency... No more national health record needed. Just flushed away in one swoop.

But if you are a greedy carrier who cares not about healthcare or outcomes and simply wants to find a way to deny care or take back payments, or attack a decent hard working doc, then yes a national health record sure makes sense. So too if you are part of the majority of the morons on both sides of the isle who want to destroy the bill of rights with warrentless searches and kangaroo courts. If you are a good man of integrity, all of us, I'm not just call you out, you actually seem sincere here, but you really need to think this thru some more, then question and fight and come up with viable alternatives to these people's invassive and self serve horseCCHIT.

I mean honestly imagine the security nightmare alone. Billing clerks, front desk people, nurses and MA's, mid-levels and docs, managers and all the folks at each and every insurance carrier in the country! It is just insane. Can we really lock this thing down that tight in such a pervassive and over populated system? Hell no, and everyone with half a brain knows that, and you are smart enought too, I know you are, you know it too.

I posted a while back about these vaccine registries and the possible coming of a nation centeralized health record. Recently we were all up in arms because a few folks, contractors at the State dept, yes the State Dept, acessed all three of the remaining Presidental candidates passport records, and goodness knows what they did with the information or who they shared it with no less. Well imagine in 20 years from now, instead of it being just where they went, in and out of any given country and the basic demographic like data that is in such a file... Instead we will be talking about Senator "X's" abortion she had when she was a scared teen of 16 years old, or Congressman "Y's" previous history of treatment for moderate depression and mild substance abuse in college... To me that is a place I never want to ever let this country get to, we have already gotten way to close to it already and it is time for all people of good conscience to push back and say a firm "NO". The great RIT needs to be returned to its rightful place of honor. To be defended at all costs.

I would rather see an EMR that is contained within the walls of the practice and unless the patient or their legal guardian says otherwise, it never leaves that place, just like a paper record does today... Who is this record for, the carriers, the gov't, NO, it's for the continued good care of the patient and for that doc who is trying to provide such, nothing more, and nothing less.

Sorry I got so over the top... I lost myself and forgot you were on our side and not just some software developer like that other guy who was stalking Vinny here just the other day. My mistake and I am embaressed. But if you really are your wife's defender and assistant in this insane business, then please for both your sakes, put on your paraniod practice manager's thinking cap (even if you are just tech support) and question what these idiots send down the shute at us. It is never what is apppears and they always have a well dsigned cover story. Never, please, never take what these A-holes say at face value or you and your wife will be had for sure... Watch both your backs.

And now I will: "you have to go sit in zah little box, you can not do zat, it is bery bery bad, you go to box, everyone stare at you, it is bery bad" (Slap Shot, Opening Interveiw with the Chief's Goaltender) I must under the rules of fair play give myself a 2 minute minor and a 10 misconduct for Unsportsman Like Conduct, how embaressing is that??? So I will go sit in the corner now getting our new tower ready to take over the main data folder duty for our little P2P network for being a rude, bad boy.....

Have a great night,
Paul