RE: NO fee, NO hostage EMR/back-up

October 5, 2006

I have a powerbook G4 MAC like . Works great. Was about $1200 and it was my computer before I opened my office 18 months ago. I simply created my ownEMR for FREE, no hostages here and I love it, No monthly fees. No IT person. Nada.I backup on CDs which I keep one at home and one at my office and I backupmy entire computer on a carbon copy cloner (FREE off the internet) on to anexternal hard drive. I back up about once a week. I guess I could do it more if I wanted but I do not feel the need.Best part of all this. MACS are nearly flawless and have had no problems.I love the idea of docs controlling their own destiny and not gettingripped off by unscrupulous mean hi tech business people who donot necessarily have our best interests at heart. I am not sure why moredocs do not do open source or make their own EMRs. It is not hardespecially with a small patient panel.NO IT person needed (except my hubby and almost all my friends whorun their businesses on apple computers too)NO FEESNO HOSTAGE SITUATION.PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn Oct 4, 2006, at 4:50 PM, Seto wrote: I have a Mac Powerbook G4 (about $1200) that I use as my main computer (goes everywhere I go), plus about 6 months ago I took my 7 year old Blue & White G3 (upgraded to G4) from home and set it up as a server in the office. It runs the MacPractice practice management server ($4000), which I can also access as a client from the laptop. This is so my new part-time billing person can do billing while I'm doing my own thing on the laptop. I use the standalone version of SpringCharts, chosen mainly because it works on Macs plus it was dirt cheap (relatively speaking, that's $500 worth of dirt). I could get the networked version but since I am solo, see no need for it. SpringCharts has since raised its prices but I don't know the current price. Besides being cheap, I like the fact that the patient data stays in-house. No hostage taking here. Plus I figured if something better comes along, I won't feel as badly moving to another system as I would if I had spent $25,000 which I was quoted from Alteer 2-3 years ago.For backup, I run SuperDuper ($27.95) on the server every night which mirrors the main hard drive to a secondary internal drive. If the main drive ever goes out, I can keep working with no down time (assuming the secondary drive doesn't crash, too). I also run BackJack (about $20/month), which automatically backs up all my selected essential files to 2 offsite servers, on both the office server and my laptop. I also automatically backup essential laptop files to my .Mac account ($99/year). And finally, about once a week, I clone my laptop to an external 300 GB firewire drive ($150). I used to burn data onto CDs but didn't do it regularly. I think the best backup systems are those that happen without you having to lift a finger. I like being in control of my network, something I don't think I could ever do with a Windows system. Unlike LL, we can't all be computer super-geniuses. Everything runs wirelessly. All faxes are received by the server (no more wasted paper on "Last Minute Trips to Cancun!"). I even set up a VPN (Virtual Private Network), so that I can safely access my work server from home. I use the ScanSnap scanner to scan every scrap of paper into a PDF document (16 to 80 KB per page), even though I had to find a Japanese driver to make it work on a Mac. I cannot scan directly into SpringCharts but I can import images and documents. But I chose not to because it was easier just to keep all scanned documents in folders outside the EMR. I have it organized by patient name and I rename all the documents as "lastname.firstname.documentType.date.pdf" so that I can find things easily. And even though it isn't backup/server related, it's tech-related - I am in the process of converting the phone lines from AT & T (about $110/month for 2 lines) to Sunrocket VOIP ($199/year per line). It seems to be working fine so far and I like being able to fetch voicemail from my web browser at home. SetoSouth Pasadena, CA,I use e-mds and have a server. Actually, this was a very expensive part of the system as it is set up in a RAID 5 configuration with tape back-up and thus cost about $7500. Networking (setting it all up so that it talked to my other two computers) cost an additional $2000. I also have an IT guy on retainer so he can update all my stuff monthly (or whenever a Microsoft patch comes out). Ultimately, I would like to get an offsite server that serves as an immediate back-up if my current one dies. So far, however, I have not had to do anything to the server except change the tape every night before I leave.I like the idea of having the information on site, but if I had it to do over, I would find a cheaper way. My server is scalable to 15 docs (yet I only have one). It seems to me that my server is like a typical FP office with a burdensome amount of redundancy. In my streamlined system, I figure there has to be a better way. I also know little about the inner workings of “the box,” and so that is why I outsourced. Yes, the system works well and I have had no real problems in 3.5 years. I just still have some heartburn about the cost. Hope that’s helpful! -----Original Message-----From: [mailto: ] On Behalf Of LeeclanSent: Wednesday, October 04, 2006 3:34 PMTo: Subject: in house servers How many of you are using in House servers and doing your own backing up of data? Being on Alteer, it is all ASP so that your data is backed up offsite on their server. ECW gives you the option of doing either. With no experience of maintaining the server and doing my own back ups.... I am nervous about this. Do you have to hire a good IT person to help you maintain everything?( especially if you are like me and know little about computer hardware). Does the server ever crash and you can't get into your system? Lee

October 5, 2006

I also think that it is much better to have your own data on your own server. It prevents you from being held hostage by the emr company. Backups can be easy but need to be done every day. When I was just trying out the software I was just backing up once a week and had a hard drive failure and lost a week of data. ( I was using a laptop for all of my information and tried to start it up after it had sat in my car in -20 degree temp.) I also have a mac emr that I think makes your IT costs much lower because of increased reliability. Spring charts is very nice. I have powermed which is more expensive but does more. I have spent no money on IT support for the last 2 years. I have gone over to the local apple store for some free support. Our network has been down only 20 minutes in the last 2 years.Larry LindemanI have a powerbook G4 MAC like . Works great. Was about $1200 and it was my computer before I opened my office 18 months ago. I simply created my ownEMR for FREE, no hostages here and I love it, No monthly fees. No IT person. Nada.I backup on CDs which I keep one at home and one at my office and I backupmy entire computer on a carbon copy cloner (FREE off the internet) on to anexternal hard drive. I back up about once a week. I guess I could do it more if I wanted but I do not feel the need.Best part of all this. MACS are nearly flawless and have had no problems.I love the idea of docs controlling their own destiny and not gettingripped off by unscrupulous mean hi tech business people who donot necessarily have our best interests at heart. I am not sure why moredocs do not do open source or make their own EMRs. It is not hardespecially with a small patient panel.NO IT person needed (except my hubby and almost all my friends whorun their businesses on apple computers too)NO FEESNO HOSTAGE SITUATION.PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywiblecomcast (DOT) netwww.idealmedicalpractice.orgOn Oct 4, 2006, at 4:50 PM, Seto wrote:I have a Mac Powerbook G4 (about $1200) that I use as my main computer (goes everywhere I go), plus about 6 months ago I took my 7 year old Blue & White G3 (upgraded to G4) from home and set it up as a server in the office. It runs the MacPractice practice management server ($4000), which I can also access as a client from the laptop. This is so my new part-time billing person can do billing while I'm doing my own thing on the laptop. I use the standalone version of SpringCharts, chosen mainly because it works on Macs plus it was dirt cheap (relatively speaking, that's $500 worth of dirt). I could get the networked version but since I am solo, see no need for it. SpringCharts has since raised its prices but I don't know the current price. Besides being cheap, I like the fact that the patient data stays in-house. No hostage taking here. Plus I figured if something better comes along, I won't feel as badly moving to another system as I would if I had spent $25,000 which I was quoted from Alteer 2-3 years ago.For backup, I run SuperDuper ($27.95) on the server every night which mirrors the main hard drive to a secondary internal drive. If the main drive ever goes out, I can keep working with no down time (assuming the secondary drive doesn't crash, too). I also run BackJack (about $20/month), which automatically backs up all my selected essential files to 2 offsite servers, on both the office server and my laptop. I also automatically backup essential laptop files to my .Mac account ($99/year). And finally, about once a week, I clone my laptop to an external 300 GB firewire drive ($150). I used to burn data onto CDs but didn't do it regularly. I think the best backup systems are those that happen without you having to lift a finger. I like being in control of my network, something I don't think I could ever do with a Windows system. Unlike LL, we can't all be computer super-geniuses. Everything runs wirelessly. All faxes are received by the server (no more wasted paper on "Last Minute Trips to Cancun!"). I even set up a VPN (Virtual Private Network), so that I can safely access my work server from home. I use the ScanSnap scanner to scan every scrap of paper into a PDF document (16 to 80 KB per page), even though I had to find a Japanese driver to make it work on a Mac. I cannot scan directly into SpringCharts but I can import images and documents. But I chose not to because it was easier just to keep all scanned documents in folders outside the EMR. I have it organized by patient name and I rename all the documents as "lastname.firstname.documentType.date.pdf" so that I can find things easily. And even though it isn't backup/server related, it's tech-related - I am in the process of converting the phone lines from AT & T (about $110/month for 2 lines) to Sunrocket VOIP ($199/year per line). It seems to be working fine so far and I like being able to fetch voicemail from my web browser at home. SetoSouth Pasadena, CA,I use e-mds and have a server. Actually, this was a very expensive part of the system as it is set up in a RAID 5 configuration with tape back-up and thus cost about $7500. Networking (setting it all up so that it talked to my other two computers) cost an additional $2000. I also have an IT guy on retainer so he can update all my stuff monthly (or whenever a Microsoft patch comes out). Ultimately, I would like to get an offsite server that serves as an immediate back-up if my current one dies. So far, however, I have not had to do anything to the server except change the tape every night before I leave.I like the idea of having the information on site, but if I had it to do over, I would find a cheaper way. My server is scalable to 15 docs (yet I only have one). It seems to me that my server is like a typical FP office with a burdensome amount of redundancy. In my streamlined system, I figure there has to be a better way. I also know little about the inner workings of “the box,” and so that is why I outsourced. Yes, the system works well and I have had no real problems in 3.5 years. I just still have some heartburn about the cost. Hope that’s helpful! -----Original Message-----From: [mailto: ] On Behalf Of LeeclanSent: Wednesday, October 04, 2006 3:34 PMTo: Subject: in house servers How many of you are using in House servers and doing your own backing up of data? Being on Alteer, it is all ASP so that your data is backed up offsite on their server. ECW gives you the option of doing either. With no experience of maintaining the server and doing my own back ups.... I am nervous about this. Do you have to hire a good IT person to help you maintain everything?( especially if you are like me and know little about computer hardware). Does the server ever crash and you can't get into your system? Lee

October 5, 2006

I also think that it is much better to have your own data on your own server. It prevents you from being held hostage by the emr company. Backups can be easy but need to be done every day. When I was just trying out the software I was just backing up once a week and had a hard drive failure and lost a week of data. ( I was using a laptop for all of my information and tried to start it up after it had sat in my car in -20 degree temp.) I also have a mac emr that I think makes your IT costs much lower because of increased reliability. Spring charts is very nice. I have powermed which is more expensive but does more. I have spent no money on IT support for the last 2 years. I have gone over to the local apple store for some free support. Our network has been down only 20 minutes in the last 2 years.Larry LindemanI have a powerbook G4 MAC like . Works great. Was about $1200 and it was my computer before I opened my office 18 months ago. I simply created my ownEMR for FREE, no hostages here and I love it, No monthly fees. No IT person. Nada.I backup on CDs which I keep one at home and one at my office and I backupmy entire computer on a carbon copy cloner (FREE off the internet) on to anexternal hard drive. I back up about once a week. I guess I could do it more if I wanted but I do not feel the need.Best part of all this. MACS are nearly flawless and have had no problems.I love the idea of docs controlling their own destiny and not gettingripped off by unscrupulous mean hi tech business people who donot necessarily have our best interests at heart. I am not sure why moredocs do not do open source or make their own EMRs. It is not hardespecially with a small patient panel.NO IT person needed (except my hubby and almost all my friends whorun their businesses on apple computers too)NO FEESNO HOSTAGE SITUATION.PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywiblecomcast (DOT) netwww.idealmedicalpractice.orgOn Oct 4, 2006, at 4:50 PM, Seto wrote:I have a Mac Powerbook G4 (about $1200) that I use as my main computer (goes everywhere I go), plus about 6 months ago I took my 7 year old Blue & White G3 (upgraded to G4) from home and set it up as a server in the office. It runs the MacPractice practice management server ($4000), which I can also access as a client from the laptop. This is so my new part-time billing person can do billing while I'm doing my own thing on the laptop. I use the standalone version of SpringCharts, chosen mainly because it works on Macs plus it was dirt cheap (relatively speaking, that's $500 worth of dirt). I could get the networked version but since I am solo, see no need for it. SpringCharts has since raised its prices but I don't know the current price. Besides being cheap, I like the fact that the patient data stays in-house. No hostage taking here. Plus I figured if something better comes along, I won't feel as badly moving to another system as I would if I had spent $25,000 which I was quoted from Alteer 2-3 years ago.For backup, I run SuperDuper ($27.95) on the server every night which mirrors the main hard drive to a secondary internal drive. If the main drive ever goes out, I can keep working with no down time (assuming the secondary drive doesn't crash, too). I also run BackJack (about $20/month), which automatically backs up all my selected essential files to 2 offsite servers, on both the office server and my laptop. I also automatically backup essential laptop files to my .Mac account ($99/year). And finally, about once a week, I clone my laptop to an external 300 GB firewire drive ($150). I used to burn data onto CDs but didn't do it regularly. I think the best backup systems are those that happen without you having to lift a finger. I like being in control of my network, something I don't think I could ever do with a Windows system. Unlike LL, we can't all be computer super-geniuses. Everything runs wirelessly. All faxes are received by the server (no more wasted paper on "Last Minute Trips to Cancun!"). I even set up a VPN (Virtual Private Network), so that I can safely access my work server from home. I use the ScanSnap scanner to scan every scrap of paper into a PDF document (16 to 80 KB per page), even though I had to find a Japanese driver to make it work on a Mac. I cannot scan directly into SpringCharts but I can import images and documents. But I chose not to because it was easier just to keep all scanned documents in folders outside the EMR. I have it organized by patient name and I rename all the documents as "lastname.firstname.documentType.date.pdf" so that I can find things easily. And even though it isn't backup/server related, it's tech-related - I am in the process of converting the phone lines from AT & T (about $110/month for 2 lines) to Sunrocket VOIP ($199/year per line). It seems to be working fine so far and I like being able to fetch voicemail from my web browser at home. SetoSouth Pasadena, CA,I use e-mds and have a server. Actually, this was a very expensive part of the system as it is set up in a RAID 5 configuration with tape back-up and thus cost about $7500. Networking (setting it all up so that it talked to my other two computers) cost an additional $2000. I also have an IT guy on retainer so he can update all my stuff monthly (or whenever a Microsoft patch comes out). Ultimately, I would like to get an offsite server that serves as an immediate back-up if my current one dies. So far, however, I have not had to do anything to the server except change the tape every night before I leave.I like the idea of having the information on site, but if I had it to do over, I would find a cheaper way. My server is scalable to 15 docs (yet I only have one). It seems to me that my server is like a typical FP office with a burdensome amount of redundancy. In my streamlined system, I figure there has to be a better way. I also know little about the inner workings of “the box,” and so that is why I outsourced. Yes, the system works well and I have had no real problems in 3.5 years. I just still have some heartburn about the cost. Hope that’s helpful! -----Original Message-----From: [mailto: ] On Behalf Of LeeclanSent: Wednesday, October 04, 2006 3:34 PMTo: Subject: in house servers How many of you are using in House servers and doing your own backing up of data? Being on Alteer, it is all ASP so that your data is backed up offsite on their server. ECW gives you the option of doing either. With no experience of maintaining the server and doing my own back ups.... I am nervous about this. Do you have to hire a good IT person to help you maintain everything?( especially if you are like me and know little about computer hardware). Does the server ever crash and you can't get into your system? Lee

October 5, 2006

The

problem with that type of free “bare bones” system though is that

it is just basically an electronic version of a paper SOAP note, right?

EMR is not synonymous with practice management system. Alteer, eCW, etc

do much, much more than just create an electronic note. The work flow,

the coding, the scheduling, the billing, etc are all integrated & this

could never be duplicated by a do-it-yourself free EMR. Your system beats

storing paper charts for sure, but what else does it do to help your office efficiency?

I think it goes back to the volume thing: if you are super low volume then just

about anything you do/any system you implement will seem to work, but once you

bump things up to the next level (say, over 10 – 12 pt’s/day), then

you need a more integrated system.

in house servers

How many of you are using in House servers and doing your own

backing up of data? Being on Alteer, it is all ASP so that your data is

backed up offsite on their server. ECW gives you the option of

doing either.

With no experience of maintaining the server and doing my own back

ups.... I am nervous about this. Do you have to hire a good IT person to

help you maintain everything?( especially if you are like me and know little

about computer hardware). Does the server ever crash and you can't get

into your system?

Lee

October 5, 2006

You are correct. Low flow and volume allows a bare bones system to work. I have not found that I need any bells and whistles beyond what I have now.My practice is just a big experiment in creating my own destiny so in keepingwith the experiment I have created an EMR that works well for me.Pamela The problem with that type of free “bare bones” system though is that it is just basically an electronic version of a paper SOAP note, right? EMR is not synonymous with practice management system. Alteer, eCW, etc do much, much more than just create an electronic note. The work flow, the coding, the scheduling, the billing, etc are all integrated & this could never be duplicated by a do-it-yourself free EMR. Your system beats storing paper charts for sure, but what else does it do to help your office efficiency? I think it goes back to the volume thing: if you are super low volume then just about anything you do/any system you implement will seem to work, but once you bump things up to the next level (say, over 10 – 12 pt’s/day), then you need a more integrated system. in house servers How many of you are using in House servers and doing your own backing up of data? Being on Alteer, it is all ASP so that your data is backed up offsite on their server. ECW gives you the option of doing either. With no experience of maintaining the server and doing my own back ups.... I am nervous about this. Do you have to hire a good IT person to help you maintain everything?( especially if you are like me and know little about computer hardware). Does the server ever crash and you can't get into your system? Lee

October 5, 2006

The

simplicity of your practice is admirable. Sometimes that’s all we do need.

in

house servers

How many of you are using in House servers and doing your own

backing up of data? Being on Alteer, it is all ASP so that your data is

backed up offsite on their server. ECW gives you the option of

doing either.

With no experience of maintaining the server and doing my own back

ups.... I am nervous about this. Do you have to hire a good IT person to

help you maintain everything?( especially if you are like me and know little

about computer hardware). Does the server ever crash and you can't get

into your system?

Lee

October 5, 2006

Thanks ,I am really just doing something my dad told me to do a long time ago. KISS = Keep It Simple StupidIt goes with my LOVE practice.By the way, both my parents are physicians and they both counseled meNOT TO GO INTO MEDICINE.I am so glad I did. I really love what I do.Have a great day to you all (and congrats Moitri)Pamela The simplicity of your practice is admirable. Sometimes that’s all we do need. in house servers How many of you are using in House servers and doing your own backing up of data? Being on Alteer, it is all ASP so that your data is backed up offsite on their server. ECW gives you the option of doing either. With no experience of maintaining the server and doing my own back ups.... I am nervous about this. Do you have to hire a good IT person to help you maintain everything?( especially if you are like me and know little about computer hardware). Does the server ever crash and you can't get into your system? Lee

October 5, 2006

Just got back from dropping off a letter at the post office across the

parking lot from the mall I'm in, and I stopped in the supermarket to pick

up thermometer covers/lemon-scented hand sanitizer, and I dropped off some

old diplomas to get new frames at the framer in the mall....

I don't mean to bore you with my mundane midday errands, but the question

of complexity reminds me of my errands and what I spoke to a student about

last week. That is ...

IF we are designing the " running of an office " , we would not want the

doctor's time to be used for these errands,

BUT, IF we are designing the " living of a life " , the doctor may want to do

these errands him/herself - I do.

When I get back to the office from doing " little things " I tend to feel

well and my spirit is lighter. I think that is a good thing for my life.

This issue of complexity to run a busier office balancing with simplicity

to not bog down our lives may also tie back to the income question

discussed recently as we each need to work for an income. But we need to

remind ourselves that we can't live just to work. Little things do count.

I'm pretty sure this sentiment rings true for many of us as it may be part

of what lead us to this list in the first place.

So whether we are seeking better incomes, more efficient EMR, better

quality medical care or a better life in general, each of us has lots of

choices. And this group demonstrating the great variety of options we can

implement in the office (and in life) is simply great!

I'll get back to work now...

Hope everyone else's weather is a pleasant as here in Rochester.

Tim

> Thanks ,

>

> I am really just doing something my dad told me to do a long time ago.

>

> KISS = Keep It Simple Stupid

>

> It goes with my LOVE practice.

>

> By the way, both my parents are physicians and they both counseled me

> NOT TO GO INTO MEDICINE.

>

> I am so glad I did. I really love what I do.

>

> Have a great day to you all (and congrats Moitri)

>

> Pamela

>

>>

>> The simplicity of your practice is admirable. Sometimes that’s all

>> we do need.

>>

>> in house servers

>>

>> How many of you are using in House servers and doing your own

>> backing up of data? Being on Alteer, it is all ASP so that your

>> data is backed up offsite on their server. ECW gives you the

>> option of doing either.

>>

>> With no experience of maintaining the server and doing my own back

>> ups.... I am nervous about this. Do you have to hire a good IT

>> person to help you maintain everything?( especially if you are like

>> me and know little about computer hardware). Does the server ever

>> crash and you can't get into your system?

>>

>> Lee

>>

October 6, 2006

I applaud what Pamela has done. I think a lot of us who have come into

computers after the invention of the GUI and have never worked from a

keyboard based terminal era have over estimated the amount of " value

added " by the EMR developers to what can be done yourself using just

the basic power of the system you get when you buy your computer.

I have not seen her EMR working, but I suspect she set up a sytem of

" Folders " for patients with subfolders for various parts of their

medical records, and then she files things there, probably using some

type of organized way of naming the files so that they get sorted

automatically by date and/or type of file by the file browsing

software built into her computer .

I did something similar with Linux when I first started using it. I

started with a folder for each patient's prescriptions and wrote a

simple program to connect their prescription list to a fax program so

I could fax back refills requested by the local pharmacies from my

computer. I had the program read in the drug name, dose, quantity, no.

of refills and the name of the drugstore they had used on the last

refill. I then had the program write up a simple message with the

answer and then look up the fax no. for me and fax it back, adding a

new entry into the patient's prescription file as a record of the

transaction.

The type of programming I did is really rather simple for those who

started with computers in the Apple II, Commodore 64 or DOS days. In

those days you typed commands from a " green screen " text based console

from the keyboard to activate other programs or to rename or copy,

delete or move files around or to read info. inside files. There was

no GUI. The upside of this is that once you learned some of those

simple but powerful commands, you could write " programs " that were

nothing more than simple files containing multiple lines of these

keyboard commands. When you ran the program, it merely activated these

commands sequentially. But this allowed you to automate repetitive

tasks. Later you could add " branching " which allowed you to take

different actions based on " if then " tests of certain conditions. Add

" looping " which is just repeating something over and over again until

some other condition you set is met, and you have about all you need

to do a lot of stuff automatically.

Later I learned about a simple programming language called Tcl/Tk that

does the above type of programming, but also allows you to build your

own GUI's and connect them to the type of program I described above.

That way, instead of typing the command to start a program from the

keyboard, you could start it by clicking a button with the mouse. You

could also have pop up menus, listboxes and all the familiar things we

see in GUI based programs, and you could link those to other simple

actions.

Gradually I built on the original prescription stuff and now have

accounting, demogaphics/insurance, drug database drug interactions,

insurance claims all using the same relatively simple programming and

file based data structure. It is network based with a server/client

set up, so multiple users can access the system at multiple stations

in an office or from home. The external programs I needed for faxing,

scanning, converting images from one format to another were all

available for free off the internet.

You can see a " Flash movie " of what my program does at

http://alcald.homelinux.org/TkfpDemo.html

I have not gotten much response from this group when I've posted about

it before, but you never know, maybe it would be of interest to somebody.

Caldwell M.D.

Tulare, CA

>

> ,

>

> I use e-mds and have a server. Actually, this was a very expensive

part of

> the system as it is set up in a RAID 5 configuration with tape

back-up and

> thus cost about $7500. Networking (setting it all up so that it

talked to my

> other two computers) cost an additional $2000. I also have an IT guy on

> retainer so he can update all my stuff monthly (or whenever a Microsoft

> patch comes out). Ultimately, I would like to get an offsite server that

> serves as an immediate back-up if my current one dies. So far,

however, I

> have not had to do anything to the server except change the tape

every night

> before I leave.

>

> I like the idea of having the information on site, but if I had it to do

> over, I would find a cheaper way. My server is scalable to 15 docs

(yet I

> only have one). It seems to me that my server is like a typical FP

office

> with a burdensome amount of redundancy. In my streamlined system, I

figure

> there has to be a better way. I also know little about the inner

workings of

> " the box, " and so that is why I outsourced. Yes, the system works

well and I

> have had no real problems in 3.5 years. I just still have some heartburn

> about the cost. Hope that's helpful!

>

> in house servers

>

> How many of you are using in House servers and doing your own

backing up of

> data? Being on Alteer, it is all ASP so that your data is backed up

offsite

> on their server. ECW gives you the option of doing either.

>

> With no experience of maintaining the server and doing my own back

ups.... I

> am nervous about this. Do you have to hire a good IT person to help you

> maintain everything?( especially if you are like me and know little

about

> computer hardware). Does the server ever crash and you can't get

into your

> system?

>

> Lee

>

October 6, 2006

I watched the flash demo. WOW thats amazing. Your program does everything that mine does(alteer) and then some. I am one of those that entered the computer world never knowing what was under the hood. I don't think that I could do what you have done but it is encouraging to see that it is possible. The idea of being able to customize the program to your needs is wonderful. No more being held up or blackmailed into following the way the company thinks it should go. The costs to your system is time and direct investment. I got out of a large group because I believe that medicine can be done in different ways and that not eveyone has to buy in to everything that a group may choose to do( whether it be for the " profit " or the views of one strong leader despite their beliefs) Unfortunately I did not apply that theory to my computer system and now I am paying money to have someone else decide what I should and should not do with the patient record. Because this is so integral to the issue of Ideal practice, this has begun to concern me more and more. The overhead increases from an owned offsite systern are one concern that is counter to the ability to control cost and avoid the " patient treadmill " syndrome. More important however is the ability to do quality care and to adapt as necessary for the good of the patient. Recently I have thought of the ideal medical practice concept as much like gorilla warfare. (Don't take that the wrong way.) I don't think we are at war, just the concept of being able to move and adapt to the changing climate is easier in the small practice. Of course if we get to isolated there is a risk of wrong vision. This is what really charged me at the aafp meeting. Listening to speakers there and their focus made me realize We can really do this and we can aim at quality like never before.

A quick aside may be in order. I come from Canada and the treatment of asthma in the early nineties changed to incorporate more use of oral steroids, the necessity of pfts and peak flows and asthma action plans. The change in the average action of doctors both young and old was almost overnight. I attribute that to the small amount of doctors in the country. On coming down here the literature was the same and many doctors were acting on the reccomendations but many were still not aware some years later. All this is to say that small groups networked together can probably move faster than the same number of physicians in one large group. If the focus is strong, the movement will be strong. In general I think that anyone in this day and age that goes out on their own has a true commitment to a dream and I suspect that that dream is purified and focussed by the practice set up process.

My recommendation to anyone starting out in this would be to apply the same principle to the electronic medical record as we do to the concept of small nuclear practices. Own as much of the vision and work as possible and hire/contract with people to do what you cannot do. I would much rather have paid my money to somone to build me a system similar to yours and then pay the fees I pay currently to someone who works for me, rather than to someone who is following their own vision.

I don't blame alteer for doing what they are doing. That is their business. I kind of wish I had seen the light sooner. I know what I would have done then but I am not sure how that translates now that I am fully invested into the system.

Rene Milner

I applaud what Pamela has done. I think a lot of us who have come intocomputers after the invention of the GUI and have never worked from akeyboard based terminal era have over estimated the amount of " value

added " by the EMR developers to what can be done yourself using justthe basic power of the system you get when you buy your computer. I have not seen her EMR working, but I suspect she set up a sytem of

" Folders " for patients with subfolders for various parts of theirmedical records, and then she files things there, probably using sometype of organized way of naming the files so that they get sorted

automatically by date and/or type of file by the file browsingsoftware built into her computer . I did something similar with Linux when I first started using it. Istarted with a folder for each patient's prescriptions and wrote a

simple program to connect their prescription list to a fax program soI could fax back refills requested by the local pharmacies from mycomputer. I had the program read in the drug name, dose, quantity, no.

of refills and the name of the drugstore they had used on the lastrefill. I then had the program write up a simple message with theanswer and then look up the fax no. for me and fax it back, adding anew entry into the patient's prescription file as a record of the

transaction. The type of programming I did is really rather simple for those whostarted with computers in the Apple II, Commodore 64 or DOS days. Inthose days you typed commands from a " green screen " text based console

from the keyboard to activate other programs or to rename or copy,delete or move files around or to read info. inside files. There wasno GUI. The upside of this is that once you learned some of thosesimple but powerful commands, you could write " programs " that were

nothing more than simple files containing multiple lines of thesekeyboard commands. When you ran the program, it merely activated thesecommands sequentially. But this allowed you to automate repetitivetasks. Later you could add " branching " which allowed you to take

different actions based on " if then " tests of certain conditions. Add " looping " which is just repeating something over and over again untilsome other condition you set is met, and you have about all you need

to do a lot of stuff automatically. Later I learned about a simple programming language called Tcl/Tk thatdoes the above type of programming, but also allows you to build yourown GUI's and connect them to the type of program I described above.

That way, instead of typing the command to start a program from thekeyboard, you could start it by clicking a button with the mouse. Youcould also have pop up menus, listboxes and all the familiar things we

see in GUI based programs, and you could link those to other simpleactions. Gradually I built on the original prescription stuff and now haveaccounting, demogaphics/insurance, drug database drug interactions,

insurance claims all using the same relatively simple programming andfile based data structure. It is network based with a server/clientset up, so multiple users can access the system at multiple stationsin an office or from home. The external programs I needed for faxing,

scanning, converting images from one format to another were allavailable for free off the internet.You can see a " Flash movie " of what my program does at

http://alcald.homelinux.org/TkfpDemo.htmlI have not gotten much response from this group when I've posted aboutit before, but you never know, maybe it would be of interest to somebody. Caldwell M.D.Tulare, CA > > > > > > > > ,

> > I use e-mds and have a server. Actually, this was a very expensivepart of> the system as it is set up in a RAID 5 configuration with tapeback-up and> thus cost about $7500. Networking (setting it all up so that it

talked to my> other two computers) cost an additional $2000. I also have an IT guy on> retainer so he can update all my stuff monthly (or whenever a Microsoft> patch comes out). Ultimately, I would like to get an offsite server that

> serves as an immediate back-up if my current one dies. So far,however, I> have not had to do anything to the server except change the tapeevery night> before I leave.> > I like the idea of having the information on site, but if I had it to do

> over, I would find a cheaper way. My server is scalable to 15 docs(yet I> only have one). It seems to me that my server is like a typical FPoffice> with a burdensome amount of redundancy. In my streamlined system, I

figure> there has to be a better way. I also know little about the innerworkings of> " the box, " and so that is why I outsourced. Yes, the system workswell and I> have had no real problems in 3.5 years. I just still have some heartburn> about the cost. Hope that's helpful!> > > > > > in house servers> > > > How many of you are using in House servers and doing your ownbacking up of> data? Being on Alteer, it is all ASP so that your data is backed up

offsite> on their server. ECW gives you the option of doing either.> > > > With no experience of maintaining the server and doing my own backups.... I> am nervous about this. Do you have to hire a good IT person to help you

> maintain everything?( especially if you are like me and know littleabout> computer hardware). Does the server ever crash and you can't getinto your> system?> > > > > > Lee>

October 7, 2006

Rene,

Thanks for the nice reply! I agree with your philosophy.

You're right, there has been a big investment of time in this thing.

I started it in 1996 with the prescriptions. So it's been going for

almost 11 years now. We started doing progress notes in 1998. The

electronic claims were added about 3 years ago.

Each little button or little task that it does might represent

anywhere from one evening's work to several weeks of work get

functioning properly. For the amount of time I invested, I could have

just seen more patients and paid for a system and had a lot left over,

maybe even been retired by now, but I enjoy doing it as a sort of

combination hobby/obsession/cumpulsion.

It really wouldn't have been worth the investment of time in an

economic sense if I just did it only for myself. However, now that it

works reasonably well, if others wanted to use it (it is available

free because it's " open source " ), they would have the advantage of

getting to use it without the time investment.

Kathy Broman and Becky are using it and have contributed many

of the ideas as to what it now does. You can check out a page we set

up that tells about how they got into it at

http://tkfp.sourceforge.net They have also spent a lot of their time

thinking about how to make it better and putting up with some of it's

quirks. However, the next person who decides to use it would not have

to go through that pain again, at least not as MUCH pain.

The idea we had was to create a group of users on the Internet that

would support each other with the installation, training, trouble

shooting etc. rather than having to hire as much help. Basically

between Kathy and Becky and myself, as well as Dr. Arnold Welden and

Dr. Jerry Park, who are also using it, we do have a small group

working like that already. But we probably don't have the critical

mass needed so that if something were to happen to me and I were to

meet with an untimely demise (shudder!), the project might die out,

although I think Jerry Park and hopefully Kathy and Becky would be

able to carry on without me. I think we are on the cusp of such a

sustainable group.

You don't really have to go too much deeper under the hood of your

computer to make it into a customizable machine that you can adapt to

your own work flow without having to spend tons of money on software

or consultants. But you do have to invest some time. It's a trade

off, I guess. If you really enjoy seeing 20-40 patients a day and

would rather hire somebody to do all the computer support, that's

fine. But this does give you the option of spending more time learning

about the computer and spending less money on outside help. I think

there are many " layers " of knowlege regarding computing all the way

from the fundamental interface between the physics and electronics up

to the ordinary Mom and Pop user who just knows how to turn it on and

get their e-mail. To install and run this stuff, you do have to go

about one layer deeper than a lot of people are willing to do, but you

by no means need to be a programmer or an electrical engineer. As the

programmer, I am maybe one layer deeper than that, but I'm still only

on the surface as far as actually knowing how it all works, but as

long as I can make it do what I want, that's all I need to know.

The question would be whether a group like that would have enough

members who would be willing to share their expertise with newbies

coming along. As busy physicians, it could be a big commitment. But

the idea has worked in other areas of software development such as the

Linux operating sytem. If you think about it, the Internet itself,

probably the most wildly successful software project of all time, is

an open source collaboratively developed project done mostly by

volunteers. I think it could work for EMR development, I hope so

anyway. There are a number of other open source EMR projects going in

various states of development. I have some links to some off the URL I

mentioned above.

> > >

> > > ,

> > >

> > > I use e-mds and have a server. Actually, this was a very expensive

> > part of

> > > the system as it is set up in a RAID 5 configuration with tape

> > back-up and

> > > thus cost about $7500. Networking (setting it all up so that it

> > talked to my

> > > other two computers) cost an additional $2000. I also have an IT

guy on

> > > retainer so he can update all my stuff monthly (or whenever a

Microsoft

> > > patch comes out). Ultimately, I would like to get an offsite

server that

> > > serves as an immediate back-up if my current one dies. So far,

> > however, I

> > > have not had to do anything to the server except change the tape

> > every night

> > > before I leave.

> > >

> > > I like the idea of having the information on site, but if I had

it to do

> > > over, I would find a cheaper way. My server is scalable to 15 docs

> > (yet I

> > > only have one). It seems to me that my server is like a typical FP

> > office

> > > with a burdensome amount of redundancy. In my streamlined system, I

> > figure

> > > there has to be a better way. I also know little about the inner

> > workings of

> > > " the box, " and so that is why I outsourced. Yes, the system works

> > well and I

> > > have had no real problems in 3.5 years. I just still have some

heartburn

> > > about the cost. Hope that's helpful!

> > >

> > > in house servers

> > >

> > > How many of you are using in House servers and doing your own

> > backing up of

> > > data? Being on Alteer, it is all ASP so that your data is backed up

> > offsite

> > > on their server. ECW gives you the option of doing either.

> > >

> > > With no experience of maintaining the server and doing my own back

> > ups.... I

> > > am nervous about this. Do you have to hire a good IT person to

help you

> > > maintain everything?( especially if you are like me and know little

> > about

> > > computer hardware). Does the server ever crash and you can't get

> > into your

> > > system?

> > >

> > > Lee

> > >

> >

>

October 7, 2006