Microsoft and healthcare - a terrible mix

[mpike]

None of us are strangers to the thousands of exploits that come out for Microsoft products.

It's a bad thing for every industry, but healthcare is the most critical. People's lives are at stake when your system is not reliable. When is this nightmare going to happen: 'Mrs. Jones, while we were performing the valve replacement for your son's sub-aortic stenosis, the data we use to determine which valve to use for replacement was corrupt, and we lost your son."

I have seen MANY EMR's - all of them windows based. I've yet to really find a physician (and I work with about 600 or so) that like the choices available, and almost all of them are reluctant to use Microsoft technology.

The cost of EMRs are also outrageous. We have so many vendors coming in trying to sell us stuff that doesn't do what we need it isn't even funny.

Physicians (most) are not programmers. They are the life line of society. Physicians know what they need in an EMR, but nobody to meet those needs, much less "cost effectively".

My question to the physicians is this, "If you had access to a programmer, and could guide the development of an EMR without the use of Microsoft infrastructure, basically creating the perfect EMR because you decide the direction the application takes - would you be interested?"

I'm a programmer, and have always been an open source advocate. I've done a lot of things, even made national recognition with a lot of them (CNN, Newsweek, and some others), and I'm 31.

I work in the healthcare industry, and I am so tired of seeing docs get the run around from IT that I've decided to make a difference.

I want to create (and have started) making the perfect EMR, designed to exact physician specifications.

I need physician input. Are there any docs out there who are interested in helping create the perfect EMR?

A consortium of physicians, coupled with a leading programmer, to create the perfect EMR, and do it for free.

I've already heard the "you can't do that", "it's not possible", etc. Don't bother with those comments.

The medical profession is one of the few areas that the people are passionate about what they do, and believe in what seems to be the impossible.

This forum (www.docsboard.com) is the perfect starting point, because you are all physicians, and already have a love of technology.

I've already got the patient demographic tracking complete. I now need the intimate experience of real physicians to make the medical portion work.

Mike

[DrWinn]

None of us are strangers to the thousands of exploits that come out for Microsoft products.

I want to create (and have started) making the perfect EMR, designed to exact physician specifications.

I need physician input. Are there any docs out there who are interested in helping create the perfect EMR?

A consortium of physicians, coupled with a leading programmer, to create the perfect EMR, and do it for free.

I've already heard the "you can't do that", "it's not possible", etc. Don't bother with those comments.
..........

I've already got the patient demographic tracking complete. I now need the intimate experience of real physicians to make the medical portion work.

Mike

Well..... don't know where to start with your post. Congratulate you for having the intestinal fortitude to take on such an ambitious project or ridicule you for being naive (no insult intended). I too was told that writing an EMR/ starting an EMR company was "not possible" and "crazy". Instead of listening, I took the early program that I wrote, brought in professional programmers (now numbering 15) and ploweed ahead. Although I am intimately acquainted with clinical medicine and technology, the road to our success has taken 6 years, going on 6 versions and still is not the "perfect" EMR. In fact, there is no such thing. The perfect EMR for me, or a cardiologist will be almost unusable by another specialty like oncology. We have spent 14 million getting here. It is not unusual in this industry for companies to have spent 50 million and not have a commercially viable product when the dust settles. As far as using Linux and Open Source, 'been there, done that'. The tools are lacking for performing many mandatory functions. Drivers for digicams, telephony, etc... are just not available. As much as I hate Microsoft (and I really do dislike their brand of corporate ethics), I cannot ignore them. Their .net architecture provides for functional capabilities that cannot be duplicated with Java and Linux and MySQL in a timely and cost effective manner. The TCO (total cost of ownership) actually becomes higher for EMR purchasers when you factor in these extra costs from development tool deficiencies.

AAFP already tried the Open Source EMR route. That initiative failed predictably. The EMR market is far too much of a niche market for Open Source to ever succeed. That is not to mean that some free and inexpensive products will not find a place, it is just that there is no financial justification for any of them to gain enough traction to become mainstream. By the way, when I started I only had to contend with one inexpensive product - SOAPware. Now you have Amazing Charts, AlBorg's home grown EMR and a slew of others. They perform the basics, but lack the bells and whistles that most sophisticated physician organization's demand. You are coming very late to a crowded game.

With all of the government push to create codified vocabularies, CCR and incorporate DOQ-IT and other clinical decision support tools, and the proposed EMR certification coming down the line, the requirements and costs to build and maintain a viable EMR are almost insurmountable.

If you do proceed, good luck... and get a testosterone (lithium?) level checked - your testicles must be giant. :D

[Kursk]

>>Dr. Winn: With all of the government push to create codified vocabularies, CCR and incorporate DOQ-IT and other clinical decision support tools, and the proposed EMR certification coming down the line, the requirements and costs to build and maintain a viable EMR are almost insurmountable.<<

Governmental interference and the ever changing landscape of standards are 2 obstacles that many docs find insurmountable. Most docs are afraid to commit to an EMR that can't guarantee operability with government requirements for billing and reporting for at least 5 years and I don't see any vendors making such a warranty to small practices.

I think for you to succeed you must be fast to market with moderate functionality that is self healing as most docs don't want to train or maintain software.

[DrWinn]

>>Dr. Winn: With all of the government push to create codified vocabularies, CCR and incorporate DOQ-IT and other clinical decision support tools, and the proposed EMR certification coming down the line, the requirements and costs to build and maintain a viable EMR are almost insurmountable.<<

Governmental interference and the ever changing landscape of standards are 2 obstacles that many docs find insurmountable. Most docs are afraid to commit to an EMR that can't guarantee operability with government requirements for billing and reporting for at least 5 years and I don't see any vendors making such a warranty to small practices.

I think for you to succeed you must be fast to market with moderate functionality that is self healing as most docs don't want to train or maintain software.

I can't argue with you. Until CCR is a reality and EMRs can freely share medical records, physicians will be (and should be) reluctant to commit to any one vendor. The only reason to jump on the band wagon now is to try and recognize operational efficiencies that will pay for the system (plus some) while the industry shakes out.

[Tim2]

Mike, FileMaker Pro can turn you into a cross platform, including handheld, programmer in minutes. It is mostly point and click programming and can take the number of hits a day required in a medical practice.

There is going to be much dissention about what I just said. There is the easy way and the hard way, the choice is yours.

FMP is not microsoft. It split from apple ~ 10 years ago.

[ozzie]

"There is going to be much dissention about what I just said. There is the easy way and the hard way, the choice is yours."
Yup and there is no way and thats the way I am going.. I aint even touchin' this thread . I got a web site or two to build LOL..
NT stickman

oz

[Kursk]

I am not sure there is an easy way unless you mean accepting a lot of limitations.

[ozzie]

"I think for you to succeed you must be fast to market with moderate functionality that is self healing as most docs don't want to train or maintain software."
Rather than look at self healing should not prevention be the idea ??
The idea of Docs or anyone untrained to maintain software is stupid to start with. Server based software should be difficullt to install for the same !@#$ing reason self open heart surgury is not a bright idea. Some folks think that all software is or will be click next , next , next , OK OK and no thanks I dont want to join MSN..
Server based software is complex due to many reasons and the environment plays a great part on how effective systems will be..
Bullet proof sytems are easy, bullet proof users are not.
Tis easy to make fool of an engineer, but you cannot make an engineer out of a fool.
I dont have time right now but with in the week I will show how powerful html can be and how you can have 20 different Gui's but in reality all the same..

Oz

[mpike]

Well..... don't know where to start with your post. Congratulate you for having the intestinal fortitude to take on such an ambitious project or ridicule you for being naive (no insult intended). I too was told that writing an EMR/ starting an EMR company was "not possible" and "crazy". Instead of listening, I took the early program that I wrote, brought in professional programmers (now numbering 15) and ploweed ahead. Although I am intimately acquainted with clinical medicine and technology, the road to our success has taken 6 years, going on 6 versions and still is not the "perfect" EMR. In fact, there is no such thing. The perfect EMR for me, or a cardiologist will be almost unusable by another specialty like oncology. We have spent 14 million getting here. It is not unusual in this industry for companies to have spent 50 million and not have a commercially viable product when the dust settles. As far as using Linux and Open Source, 'been there, done that'. The tools are lacking for performing many mandatory functions. Drivers for digicams, telephony, etc... are just not available. As much as I hate Microsoft (and I really do dislike their brand of corporate ethics), I cannot ignore them. Their .net architecture provides for functional capabilities that cannot be duplicated with Java and Linux and MySQL in a timely and cost effective manner.. :D

Thanks for your input... no insult taken, in fact, just motivates me more.

I am saddened to hear it has cost you so much to develop an EMR with so many resources. Either I am an exceptional programmer, or you did not get the best batch of developers.

Before I go on with my response, let me give you a little background on me. I am a programmer, maybe exceptional, maybe not. But, I've been on CNN, in Newsweek, Federal Computer Week magazine, and about 80 others. In fact, an application I wrote almost put WebMD in to bankruptcy. Not that I had anything against them, but, they had an inferior product (much like Microsoft and every EMR I have seen). And while WebMD had an army of programmers and hundreds of windows boxes, Redhat Linux and me took them down with an application that ultimately took me less than one day to develop (of course it grew from there). Everyone (including a WebMD sales rep who threatened to kick my ass after I debuted the application at the national health technology conference for HHS) laughed and said it wasn't possible. When people tell me something isn't possible, it’s that much more motivation to do it. I haven’t failed yet.

Don't take my word for it though... here is just one of the many stories on what I have written:

http://www.fcw.com/fcw/articles/2003/0505/tec-health-05-05-03.asp

Now on with the response :)

I'll pull out each thing you said and address it individually:


Well..... don't know where to start with your post. Congratulate you for having the intestinal fortitude to take on such an ambitious project or ridicule you for being naive (no insult intended).
I'll accept the congratulations, as I disagree with being naive. The project is ambitious, and I readily admit I cannot do it alone (the programming I can, but I need the physicians to help guide the functionality).


As far as using Linux and Open Source, 'been there, done that'. The tools are lacking for performing many mandatory functions. Drivers for digicams, telephony, etc... are just not available.

I didn't specifically mention Linux, although it is very viable. Please name a few of the mandatory functions that Linux cannot do that Windows can. I actually have a different approach, and that is implementing OS X technology (yes from Apple – OS X if you didn’t know is based on open source technologies FreeBSD/Unix). As you may have read above, Linux was what I used for E-Series. When I was introduced to OS X a little over a year ago, I haven't turned back. Let me take a real world application example. I wrote "X-Consult" - we are doing remote pharmacy consultations (with video and audio) across the country. With the new H.264 Codec, we can communicate at HD resolution with as little as a 256K DSL. We can do full telephony with as little as a dial up. This isn't something "we are thinking about" - we are doing it today, without a single windows server, and a shrinking number of Microsoft based workstations. The difference between open source programmers and "the rest of the world" is this: money doesn't mean anything, just creating the best product available. Obviously it is working, MySQL has over 6 million active installations, and PHP (for example) has over 15 million. Microsoft SQL has nowhere near that. MySQL continues to grow, as people migrate AWAY from Microsoft database technologies.


As much as I hate Microsoft (and I really do dislike their brand of corporate ethics), I cannot ignore them. Their .net architecture provides for functional capabilities that cannot be duplicated with Java and Linux and MySQL in a timely and cost effective manner..

I would never guess you dislike Microsoft, especially from your comment in another thread about Longhorn being the second coming. Longhorn is not going to be released until sometime in 2007. I also have a copy of it (albeit the beta versions). Mac OS X Tiger already has all of the technologies you mentioned, they are here now, and work now (official release 1H 2005). As far as .NET - MONO is an open source equivalent.


The TCO (total cost of ownership) actually becomes higher for EMR purchasers when you factor in these extra costs from development tool deficiencies.

Can you please give some examples of the development tool deficiencies? I cannot think of any, but there are 2000 some odd reasons to not trust Microsoft technology in healthcare (don't want to list them all, just check all of your windows exploits).


AFP already tried the Open Source EMR route. That initiative failed predictably. The EMR market is far too much of a niche market for Open Source to ever succeed.

If you are referring to OpenEMR.net - I would not call it a failure. I would also not say it is the best product. It is a great starting point, but lacks a few items which will surely be added. The fact I downloaded it and had it running in under 5 minutes is pretty good... It's not the direction I am going with my project, but I would not put down their efforts, because they have done pretty well considering the circumstances. My application is not opensource, but it is free - at this point it's too risky to release the source code to just anyone and have it end up with a commercial logo on it.


By the way, when I started I only had to contend with one inexpensive product - SOAPware. Now you have Amazing Charts, AlBorg's home grown EMR and a slew of others. They perform the basics, but lack the bells and whistles that most sophisticated physician organization's demand. You are coming very late to a crowded game.

It might be crowded, but as stated in the start of this thread, and as iterated by you, nothing has "everything" - yet.

I've already got full DICOM and standard image support, and I can capture and maintain full video including direct interfaces for echocardiograms, etc. And you do not have to have Windows to use it.


If you do proceed, good luck... and get a testosterone (lithium?) level checked - your testicles must be giant.

Thanks for the wish of luck, but I won't need it. I need physicians who want to invest nothing but knowledge. I've got a few right now (one of them being a cardiologist as a matter of fact, assisting with the echo interface guidelines).

Let me throw a little something back at you (with no insult intended). You're a physician, you've undoubtedly saved many lives, and for that in my eyes you are valuable to many people. You do however tend to shoot down any technology that you do not understand (open source), or you see as a conflict/threat to what you are developing.

I will be presenting this year at the MySQL conference. I would welcome any challenges for an "EMR Faceoff" with anything you may have, and my X-SYS Life Record.

I've been working on the EMR project since the first part of September, and it will be ready by Feb 2005. Again, I am only opening it for physicians who want to assist with functional guidance, but you are more than welcome to see what I am allowing the public to see at:

http://www.xsyshealth.com

Just remember in 1999, Bill Gates said "Linux is not a threat". Today, Microsoft has an entire division dedicated to the "engagement of Linux technologies". They have resorted to frivolous patent lawsuits (which have proved useless thus far, and will continue to do so in the future).

In closing, because of all the media coverage from my applications, Microsoft has offered me jobs on three different occasions, and I have met Bill Gates once (when he was trying to stop the government agency I work for from dumping Windows on the server platform, which he did NOT succeed on BTW).

I met Steve Jobs in June - a great person - and I believe OS X is going to be as powerful as Linux on the server platform, and (has already started) gaining significant market share on the desktop. Linux Tablet PCs are also already on the market.

I guess you could say I totally disagree with everything you have mentioned. Microsoft had a lot of help from the Bush administration, but open source continues to grow. With the new election, maybe a change will level the playing field even more, however, even if MS continues to incorporate their current method of strong arming the industry, they will continue to lose to innovation, in which they have never had any.

Mike

Disclaimer: Although I am a federal employee, all applications I develop are owned by me, and have no affiliation with the government what so ever (other than they may use them).

[ozzie]

When you have some time Mike I would like to talk we have many of the same ideas..

oz

[DrWinn]

Maybe our developers are not as sharp as you (although several graduated at or near the top of their class and are clearly geniuses). However, I have been proved wrong before.

I am a proponent of Open Source where and when it is feasible. We have donated our medication database and have offered up our ICD-9 database to the CCR committee. Our med database alone has some 35,000 meds with associated drug-drug interactions, etc. I would estimate that we have spent at least 2 million building it so far - and we will continue to expand it. You are welcome to download it at our website - and it is free as long as you do not "sell" your application for commercial gain.

Our CTO (another very bright guy) has recommended against the open source tools because of the added cost of writing drivers and apps that already exist in the MS space - so if you have knowledge to the contrary I would very much like to talk to you. Again, I applaud you for your efforts. I started before the space got so crowded. It just seems to me that you have a lot of catching up to do and you don't have a lot of time.

Also, we (I) believe that a stand alone EMR has limited utility (and viability), so the EMR makes up maybe 25% of our offerings. We also have scheduling, patient tracking, disease management, practice management and a host of other supporting apps that help tie everything together. We must have 2 million lines of code. I can't imagine how one programmer can catch up with that much development. I would love to talk to you. My direct # is 512-257-5209. Maybe we can each learn something from the other.

[DrWinn]

One last comment. I am most certainly not a fan of Microsoft. But I am not convinced that the emperor is dead either. Here is a recent post from elmr where I disparage MS.

------------------------------------------------------------------------
"This kind of poll lends itself to being abused. Certain vendors might run up their votes by contacting physician friends and having them vote for their company. I believe much of what is posted on internet threads and what is promulgated by certain consultants is fabricated. The fact that some companies win accolades and awards when their products have glaring deficiencies just seems to support this theory. Microsoft, for instance, used hype and deceit to eliminate a competitor that pioneered bringing the Windows concept to the desktop (does anyone remember the name of that company or their GUI?). A well known saying in business is that "superior marketing wins out over superior products". Perhaps big business is really saying 'unethical marketing wins out over superior products'. Sigh.
Joel (HTAdvocate) is continually frustrated by examples of unethical business practices that we see every day, but that we refuse to participate in. Hopefully more and more companies will rely on pearls of truth and wisdom to paint a clearer landscape.

Might I suggest a rating of companies by their integrity and ethics (of course, this too is subject to flagrant abuse!!). Besides e-MDs, (for the lurking saboteurs, yeah, I think we are pretty durn ethical), I would cast a vote for Soapware, PowerMed and PMSI. Hmmmm, all these companies were founded by and still run by physicians.... fancy that."

[ozzie]

yeah sure

sleeping with the emperor and paying the emperor's taxes makes you not a fan but worse a supporter...LOL

snip
"Our CTO (another very bright guy) has recommended against the open source tools because of the added cost of writing drivers and apps that already exist in the MS space"

More FUD

snip
"AFP already tried the Open Source EMR route. That initiative failed predictably. The EMR market is far too much of a niche market for Open Source to ever succeed."

Now you have to be kidding right ? Open source takes up that space along with freeware and shareware..

You are making a basic Microsoft mistake here.. Open source is not application specific, its not a server, its more like a way of life, its a an attitude if you will.,its about people caring about results not profits.. Kinda like how HMO doctors should be... sigh

I was like you too until I started working hard with open source and now my only regret is I should have done it much sooner.

[alborg]

My my... this discussion truely rocks! Beats the 1st Bush/Kerry debate by a long shot. Take the line:

"Either I am an exceptional programmer, or you did not get the best batch of developers." :eek:

Yipes! I'm impressed...

The only complaint that I have is the phrase that states:

"... AlBorg's home grown EMR and a slew of others. They perform the basics, but lack the bells and whistles that most sophisticated physician organization's demand... " :mad:

But I know- Dr. Winn has a product to sell, and I must represent the competition, so I'll read that in the light that it was offered. :rolleyes: The EMR database that I designed from MS Access which I use at my office is way past the "basics", and at least for me does more than any expen$ive EMR (like e-MDs) can do. If it's currently "missing" a non-basic item, it's because of design, not lack of my skills which go back to the DOS days 15 years ago. I started the MS Word EMR Project this past summer mainly to demonstrate that it could be done on any platform- even in the seemingly "simple" and inexpensive MS Word. Although my bug-laden version 3 (just to wet appetites- there is a Bug.doc file that explains exactly the known bugs being fixed) is downloadable now, last night I successfully compiled it on my laptop, so in the next few hours/days the final template- including scheduler, prescriptions, a toolbox wizard for multiuser setups (yup, still in Word) will be uploaded to my Yahoo Briefcase. Version 4 may even have an ODBC connection with Medisoft for electronic billing. I may even eventually port my oncology chemotherapy applets from Access in future versions. All for free... :cool:

Mike, I applaud you for your efforts, and I'm sure that many of us true reasonable/free/even "open source" diehards that have already chimed in will be there for you to help out in areas where we can.

One last note- although I may bash Microsoft and their business practices/ethics on occasion, I generally feel that their softwares are some of the best out there and few competitors offer the ease of use, the interoperability, and overall redundancy that is seen in their applications.

Regards,
Al

[DrWinn]

With all of the government push to create codified vocabularies, CCR and incorporate DOQ-IT and other clinical decision support tools, and the proposed EMR certification coming down the line, the requirements and costs to build and maintain a viable EMR are almost insurmountable.

But Al, will your EMR be able to be "certified"? The government requirements for certification (and subsequent payment for use thereof) are likely to be quite stout (and changing). Do you have the time and energy to keep up with these changing standards and requirements? What happens to all of the docs using your EMR if you die? There are other things to consider than just lowest cost. Finally, my comment was that sophisticated physician organizatons demand more than what the inexpensive EMRs can offer. Do you really not agree with that? I'm not talking about one doc shops which could probably get by with Word macros (at least until cetification becomes required).

[ozzie]

Will all due respect Dr Winn is the retail boys that have created all the the bells and whistles that most sophisticated physician organization's demand. But meanwhile much basic funcionaltiy gets lost in the translation.
To this day no one has a simple EMR forget all the bells and whistles.. Just something that a doc can use on any platform.
And no not for a large practice with a cap of say 5 drs.

This is right out of a GE play book..
"Do you have the time and energy to keep up with these changing standards and requirements? What happens to all of the docs using your EMR if you die? There are other things to consider than just lowest cost"

which "proposed EMR certification" ???????????????/

oz

[alborg]

Hi guys:

>>> which "proposed EMR certification" ???????????????/

Ozzie- I think he's referring to any one of the various "initiatives" to make up the futuristic "health information framework", s.a. that envisioned by the NCQA since 1996. (URL: http://jama.ama-assn.org/cgi/content/abstract/282/12/1184?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=electronic+medical+record&searchid=1098496038567_6972&stored_search=&FIRSTINDEX=0&journalcode=jama). It hasn't gone anywhere in the past 8 years...

As I've understood the various initiatives ("standards") that I've come across is that they are currently and most likely remain -> optional. Alternatively, simple tweaks and calling yourself "standardized" is the eventual route for most EMR vendors, s.a. what has occurred with HIPAA.

The general activity today is to promote patient privacy and to decrease medication errors. Others (think "HMO") want to add the "data mining" concept and attach that information to bonuses (or decreased payments).

Dr. Winn >>> But Al, will your EMR be able to be "certified"? The government requirements for certification (and subsequent payment for use thereof) are likely to be quite stout (and changing).

These aren't "requirements" but optional initiatives. With the low penetration of EMRs at the current time, I doubt very much that there will be a mandatory government intrusion into this arena in this manner, further escalating the overall EMR costs for the physicians beyond HIPAA, and jeapordizing further growth into the current escalating use of EMRs in the medical world. Of course, we'll hear about worse case scenarios by you and other EMR vendors trying to frighten/intimidate physicians from writing their own cost-efficient systems or using free/inexpensive systems and towards purchasing high-priced EMR programs ("HPEMRP") that they can little afford in today's budget cutting medical environment... The push will more likely be to focus on interoperability and easing electronic interchange, not bankrupting physicians by forcing them to purchase high-priced EMRs (or go back to paper and pencil).

On the other hand, if the government does require such an onerous situation, I'd rather be using a cheap EMR now, then later purchase a reasonable EMR based on the final "standard" rather than purchase a HPEMRP now and have to change in the future to another, even more expensive HPEMRP.

>>> Do you have the time and energy to keep up with these changing standards and requirements?

I might- and if I decide not to redevelop into one "standard", I'll simply write an XML or ODBC bridge connection to keep my EMR up-to-date. Case in point: after conforming my software to the Medicare "National Standard Format", when that standard became dated, I later tried but didn't have the time to reinvent an HIPAA compliant electronic billing module (based on the Medicare ANSI ASC X12N 837 format). I then chose to use Medisoft, bridging that software to my EMR via ODBC (for free since I use MS Office that comes with its own ODBC drivers). :D

>>> What happens to all of the docs using your EMR if you die?

My software is written using standard off-the-shelf Microsoft Office software. The formats are ubiquitous throughout the civilized world. Porting the table data to another platform would be easy... and unlike the situation of what has been seen with high-priced softwares that have gone belly-up, free.

Other than that, I guess that there won't be any further upgrades, huh? <g> ;) Numerous HPEMRs have gone under in the past, and many more will go with the wind in the future... This scenario isn't just limited to inexpensive/free EMRs.

>>> There are other things to consider than just lowest cost.

I've never said "lowest cost"... just "low cost". My cutoff for what I consider to be a decently priced software is $1000.00. The main reason for this is that over the years, most user needs will change. Read the following article just published about a doc that changed his EMR 5 times in the past 25 years:

"Tips from an EMR pioneer" Medical Economics Magazine (Oct 8, 2004)
URL: http://www.memag.com/memag/article/articleDetail.jsp?id=127159

Throwing away more cash in one outlay is really- foolish. :o

>>> Finally, my comment was that sophisticated physician organizatons demand more than what the inexpensive EMRs can offer. Do you really not agree with that?

If by "sophisticated" you mean any organization that wants to throw good money away, well... then let them "demand" what they wish. A MS Access frontend can be used (and has been used) very successfully with an SQL backend by many a fortune 500 companies. Just checkout the Microsoft website for "case studies" examples:

URL: http://www.microsoft.com/resources/casestudies/FindCaseStudy.aspx

>>> I'm not talking about one doc shops which could probably get by with Word macros (at least until cetification becomes required).

Again, you seem to be the only one talking about "required" certification... seems like you want that to occur so as to shove those HPEMRP down our throats. It ain't going to happen...

In summary, let me quote Charles Safran, MD from his JAMA article from 2001:

"While the electronic patient record seems to be the holy grail of clinical computing, the idea is straightforward: take the physician's paper chart and make it electronic. Of course, since paper records are not standardized neither are electronic records. An informal count finds more than 400 companies that claim to have such programs for physicians..." :eek:

URL: http://jama.ama-assn.org/cgi/content/full/285/13/1766

Regards,
AL

[ozzie]

Thanks Al
As I thought just more marketing FUD..
This is just more reasons why we should get a co -op going ..

[DrWinn]

I've never said "lowest cost"... just "low cost". My cutoff for what I consider to be a decently priced software is $1000.00. The main reason for this is that over the years, most user needs will change. Read the following article just published about a doc that changed his EMR 5 times in the past 25 years:

"Tips from an EMR pioneer" Medical Economics Magazine (Oct 8, 2004)
URL: http://www.memag.com/memag/article/articleDetail.jsp?id=127159



By the way, this article substantiates what I have been saying for some time - that modern EMRs create returns on investment of $50,000+ (in some cases much more). The ROI is dependent on many factors (like optimal physician use and innate capabilities of the EMR). Al, I admire your obvious intelligence and altruism. I just think that you suffer from tunnel vision - purchasing software (or anything for that matter) at some arbitrary maximum price. By the way, I shop ebay all the time and save bundles - but I am buying some high ticket items - just at a big discount over retail.

There is more to the equation than "low price". Would you agree that buying something for $1,000 that returns $10,000 is great, but buying something for $10,000 that returns $50,000 is better? (about $31,000 better). The ROI for the expen$ive EMRs is actually higher - want some reference offices to prove it? It isn't just charting, but the whole gamut of internal messaging, prescriptions, fax and lab management, integrated PM, and the patient portal for secure email/disease management. Add patient filled out health history and the efficiencies that are created go way beyond simple charting applications.

Dr. Brailer has stated if the EHR vendors do not get together and create an interoperability standard, the government will get involved and force it. The EHR vendors are working together now with HIMSS and CCR to build an interoperability standard. I am involved in this process. You will be reading much more about this in coming weeks.

I tend to think of myself as a fellow physician in the front lines fighting for what is best for physicians and our patients. Sure, I started a software company, but my soul goal is not just to drive shareholder value. Yes soul. Where it has been reasonably fiscally responsible, I have donated components to Open Source (like a huge medication database that competes with the likes of First DataBank) I am balancing a degree of altruism with my corporate responsibility. I know cynicism abounds, but believe me, we are all on the same side, trying to push the limits of technology to improve patient care and make medicine fun and profitable again for doctors.

[EMRhelp.org]

The idea of Micro$oft in Healthcare brings NEW meaning to the saying

Blue Screen Of Death. :eek:

[alborg]

Hi David:

>>> I just think that you suffer from tunnel vision - purchasing software (or anything for that matter) at some arbitrary maximum price.

I kind of AGREE with this... except that the price is not "arbitrary". The problem that I see in the pricing models for EMRs is that price is settled outside of the usual business/economic manner- in the medical world the vendors feel that their softwares are worth $xxx based on their OWN, sometimes delusional perceived value, rather than the true value as should be set by the buyers. Since the buyers are relatively wealthy, dumb (concerning software), and naive they tend to succomb to this perceived notion of elusive "ROI" and thus competitive decreases in pricing is stifled.

I do believe that ROI provided by EMRs is there- but by much less than that stated by the vendor crowd. If a software is overpriced, then the true ROI falls. If there is no ROI, s.a. the case where an elderly physician fails to understand/acquaint himself with the use of his recently purchased EMR, then that physician loses money. Less expensive EMRs usually have 100% of the real features needed to run an office, sport a simpler interface, and if not used, the losses are less.

This doesn't represent the use of "blinders" but of use of numerous softwares over the years. On the other hand, your "blinders" comment has some reality, though. When purchasing high priced EMR software (HPEMRS), you need to go about it like you're purchasing a new car, or going grocery shopping- list the features that you truely need and the price that you can afford. With today's HMO/PPO/Medicare belt-tightening, we really need to focus on those softwares that are reasonably priced and feature "rich" (at least "rich enough"). Most users will only use at most about 80% of the features that a HPEMRS will offer... why pay for what you will not use?

>>> Dr. Brailer has stated if the EHR vendors do not get together and create an interoperability standard, the government will get involved and force it. The EHR vendors are working together now with HIMSS and CCR to build an interoperability standard.

This is supposed to help out the physician community? I see this as HPEMRS vendor collusion- an effort to drive out competitors s.a. inexpensive EMRs and EMRs developed and used by niche groups of techies. What will eventually determine the success of such an effort will be raw competition by those EMRs that are either free or that cost less than $1000.00. If enough angry docs get together- a final implementation of "open source" and/or a deluge of market free EMR softwares will occur in response. I for one would be the first to take this matter before my elected representatives and just like we physicians have clamored for malpractice relief, we'll ask for anti-trust relief from the collusion brought on by select groups of HPEMRS vendors forcing their costly softwares onto the masses. Heck, I would prefer a government takeover to the implementation of such an arbitrary standard by a select few EMRs that would otherwise have difficulty bringing in more business due to a perceived price gouging.

BTW, most of the inexpensive/free/"home made" systems already comform to ODBC and XML standards as set by Microsoft in their developmental platforms- and the interfaces are either inexpensive or free.

The Microsoft Biztalk initiative is interesting in that it has also brought HIPAA/HL7 interoperability to the medical world, but unfortunately it is a bit pricier... it suffers from that syndrome that if it's associated to "medical" then it has to command a hefty price. Hopefully, it'll come down in price or better yet, a competitor will offer similar features that will sell for less.

>>> I tend to think of myself as a fellow physician in the front lines fighting for what is best for physicians and our patients... (snip)

Yeah, yeah... but really, deep down inside from our many discussions I've felt a warm soul in there. ;) You now have to come down to that place where the large physician masses are huddled, crying out for the perfect below-$1000.00 EMR, led by what those in the HPEMRS retail side consider the "EMR anti-Christs" (yup, I've been called that :rolleyes: ). There's money to be made, and this is where the action in the upcoming years will be...

Regards,
Al

[Kursk]

What's the problem with CCR? This appears to be essentially an XML document. Any EMR regardless of price should be able to create such a simple XML compliant document at no great expense. The hassle will be agreeing to the standard, not implementing it - or am I missing the big picture here?

[alborg]

What's the problem with CCR? This appears to be essentially an XML document. Any EMR regardless of price should be able to create such a simple XML compliant document at no great expense. The hassle will be agreeing to the standard, not implementing it - or am I missing the big picture here?

Yeah, you're right... although I did mention XML, I was having my John Belushi/Animal House moment with my last letter. I was on a rant...

But what I don't understand is why not permit an independent government agency to set the standards. If these standards are set by the very folks that have everything to gain by destroying their competition the "standards" can be used in a neferious manner. What, are we going to have a committee composed of Praxis, eCW, and e-MDs folks doing on site reviews and/or in charge of certifying their competition? That would suck...

AL

[mpike]

Maybe our developers are not as sharp as you (although several graduated at or near the top of their class and are clearly geniuses). However, I have been proved wrong before.

When it comes to medical science, law, accounting - I think "official education" is important. When it comes to IT though, it's totally different, especially with programmers. I've seen MANY "top graduates" and "MCSE" folks know nothing but what they were taught. Many times, no make that every time I see someone who is 18-20 years old who has been using computers their entire life (out of love), they are 50 times more knowledgeable than someone who went to school and "learned" it as a job. I do a lot of things people make consider "strange" when I am selecting programmers (I won't go in to all of them here) but probably the most notable is completely ignoring their grades. Case in point, if you are interviewing two people, one comes in with a suit and tie, the other comes in casually dressed. The well dressed one is at the top of his class at ITT or some other college. The "not so professional one" has no college, and his high school grades really sucked, with the exception of science and computer related courses. Throw both of them a curve ball and ask them how to write an application that will do some related task (maybe sort lab accession numbers or something). EVERY time, the "not so professional" one has prevailed. They think not in patterns, but in creative thought, with no "taught boundaries". The "I went to college to get in to computers" person will have a set pattern, and will not be able to do it in a fast, efficient manner. These are just my experiences, but they've been consistent for me.


We have donated our medication database and have offered up our ICD-9 database to the CCR committee. Our med database alone has some 35,000 meds with associated drug-drug interactions, etc. I would estimate that we have spent at least 2 million building it so far - and we will continue to expand it. You are welcome to download it at our website - and it is free as long as you do not "sell" your application for commercial gain.

Thank you very much for the offer; I may take you up on it. I've got ICD9 data already built, but the drug interaction stuff is something that would really come in handy, especially for one of the other applications I have written (X-FORM), which is a formulary management system. What is your website address?


Our CTO (another very bright guy) has recommended against the open source tools because of the added cost of writing drivers and apps that already exist in the MS space - so if you have knowledge to the contrary I would very much like to talk to you.

To put it bluntly, you might want to reconsider your CTO. The beauty about open source is the resources available. You had mentioned you have 14 or so programmers, the open source community has *millions*. Most likely, there is an open source driver for whatever hardware you may want to run. Take it a step further, and go with superior OS technology coupled with superior hardware, and you won't need the drivers. Tablet PCs are pretty touchy for drivers - and they already have a linux tablet pc. Linux is not the only option either. I personally believe you are limiting yourself by listening to a CTO that says "Microsoft is the only way." It is (currently) the most popular way, but is not the best, and may not be number one forever. Especially when you deal with healthcare. Physicians are not tied in to the same standards as everyone else - they in essence can create their own “environment”. They are a great deal more intelligent than the average "user". Joe Blow uses windows because that’s what someone told him to use. Physicians will use whatever the best technology is for them, and when X-SYS Life Record goes public, it will definitely not be limited to windows technology.


Again, I applaud you for your efforts. I started before the space got so crowded. It just seems to me that you have a lot of catching up to do and you don't have a lot of time.

If I were working 9-5, time might be an issue. Generally I do not get to bed until about 3 or 4 am... I am back up at 7 for my "professional job", and when I am done there, start back at it. So far, I've got a pretty strong "battery" - I'm 31, so hopefully it won't give out any time soon.


Also, we (I) believe that a stand alone EMR has limited utility (and viability), so the EMR makes up maybe 25% of our offerings. We also have scheduling, patient tracking, disease management, practice management and a host of other supporting apps that help tie everything together. We must have 2 million lines of code. I can't imagine how one programmer can catch up with that much development. I would love to talk to you.

You are totally correct there; many different components must be utilized. I've got the patient demographics covered, practice management, and "life record" details I've seen no other application even come close to - the scheduling is being worked on now. I can't really explain how I write this stuff so fast. I generally get a simple module done in a night or two, and a more complex one (like the echocardiogram interface) takes me about a week (of course this is all working in the middle of the night as well). The E-Verify application I wrote (the one at the top of the thread) took me about 6 hours from a Motel 6 motel room. That single application did more than WebMD was able to pull off in a year. Maybe it’s because I "think different" than any of the other developers I’ve seen. Another case in point - HIPAA (yeah I hate it for the most part, too). 270/271 transactions took me a day to complete, there are still companies that can't get it right... then there is the 837 - took me one evening to write a parser and make a web based error reporting mechanism for 837 transactions with their associated error and resolution - other companies are still trying to sell an unfinished product.


My direct # is 512-257-5209. Maybe we can each learn something from the other

I've added it to my address book.


Mike

[mpike]

Microsoft, for instance, used hype and deceit to eliminate a competitor that pioneered bringing the Windows concept to the desktop (does anyone remember the name of that company or their GUI?).[/I]

You probably are referring to Apple. I wouldn't write them off, they have adopted open source for their operating system, and are gaining major market share, especially in government. I won't go in to it now, but Apple's Tiger operating system is going to revolutionize IT. It's the first "true 64 bit" OS, and they already had the first true 64 bit hardware architecture. Microsoft is still very far away from a stable true 64 bit OS (by their own admission). I could make a whole new thread on Apple and healthcare (and I might in the near future), but not right now.

Mike

[mpike]

You are making a basic Microsoft mistake here.. Open source is not application specific, its not a server, its more like a way of life, its a an attitude if you will.,its about people caring about results not profits...

That is a PERFECT analogy! With your permission, I would like to use it the next time i try to explain why open source people do what they do :)
Mike

[mpike]

Mike, I applaud you for your efforts, and I'm sure that many of us true reasonable/free/even "open source" diehards that have already chimed in will be there for you to help out in areas where we can.


Thank you very much! :) I would like to see what you have done - you seem very passionate and definitely know what you need :)

I'm getting ready to co-locate a server so people can log on and actually use what I've written (to test it out, and give feedback)... still waiting for the price quote from the place though.

In order for this to work, I need everyone's opinion - even if it's "Mike, it sux!"

I've done lots of research and worked with many docs to get where it's at now. One of the number one complaints I've gotten from docs on "other" EMR apps is, "It takes me 20 minutes to get the data in to this thing, then I lose time and cannot see a patient, so healthcare and potential revenue go down."

I've worked, reworked, and reworked again the entire process flow on XLR - docs can have patient data entered and complete in under 2 minutes - also complete with voice integration. I need some docs that are serious about implementing an EHR.

I can give the software, but they need to buy the hardware (and everyone needs a computer anyway)... so - volunteers are welcome :) I've got some local offices here, but I would also like some "techy type docs" (like on here) that can give feedback from both perspectives.

Mike

[mpike]

But Al, will your EMR be able to be "certified"? The government requirements for certification (and subsequent payment for use thereof) are likely to be quite stout (and changing)

I can comment here, I'm a federal employee. There are no standards in the works for EMR software - that alone gives you many years. HIPAA still isn't fully implemented (although required). And even what is implemented, there are so many "ways" to do it, there still is no standard (from an IT perspective). Do you know how many versions of the "standard 837" file there are? About 500, and a new one emerges almost every day.

I do not believe any "standard" will be forced at the development level - the standards that may materialize over time will most likely be "data must be encrypted", or high level in nature and not application specific. Think about this - if a "standard" was made that you had to use Microsoft SQL - the first time that thing crashes and kills someone, millions of lawsuits will be filed - the docs will say "they made us, talk to EMD" - you will say "hey the govt made us use the technology!"

But let me conclude with this - any standard the government creates they must also adhere to in the VHA, HHS, etc. The Va ViSTA application still cannot do live online HIPAA mandated 270/271 transcations.

Forget about making a regulation for something "standardized" - it uses Cache/Mumps for crying out loud - how can you standardize that, especially throwing in Fileman...

Mike

[mpike]

Will all due respect Dr Winn is the retail boys that have created all the the bells and whistles that most sophisticated physician organization's demand. But meanwhile much basic funcionaltiy gets lost in the translation.
To this day no one has a simple EMR forget all the bells and whistles.. Just something that a doc can use on any platform.

It's coming Ozzie :) By Feb 2005 - if not sooner. You are totally right on your comments above - one doctor I talked to said this:

"***** EHR takes 15 steps to do what I can write in less than 10 seconds, I'll stick to doing it by hand."

Mike

[mpike]

he Microsoft Biztalk initiative is interesting in that it has also brought HIPAA/HL7 interoperability to the medical world, but unfortunately it is a bit pricier... it suffers from that syndrome that if it's associated to "medical" then it has to command a hefty price. Hopefully, it'll come down in price or better yet, a competitor will offer similar features that will sell for less.

Cloverleaf is another one... but don't believe everything you read on Biztalk. We have it, many, many, MANY problems.

Microsoft has always been great at lying - oops sorry, I mean marketing. Talk to real world users - call some hospitals using it - ask the customers (and not the MS business partners).

Microsoft Exchange is another example... they hype it up, but the reliability rating is only 70% up time - pretty bad if you ask me.

Mike

[BigDoc]

What's the problem with CCR? This appears to be essentially an XML document. Any EMR regardless of price should be able to create such a simple XML compliant document at no great expense. The hassle will be agreeing to the standard, not implementing it - or am I missing the big picture here?
You are correct, it is easy to generate an XML document from many programs, the CCR components (http://www.docsboard.com/forums/faq.php?faq=ccr#faq_ccr1) have already been decided

[pprescot]

"***** EHR takes 15 steps to do what I can write in less than 10 seconds, I'll stick to doing it by hand."Mike



RIGHT ON!

My feeling exactly over 30 years of using various EMRs. Yes, a lot of standards will have to be met, but the KISS principle should still apply as much as possible.

[Kursk]

On the other hand, EMR get blamed for 'slowing' the doctor down, when in fact it is making the doctor do what he is supposed to be doing in terms of legibility, accurate and complete documentation/prescribing, reminding them to give shots, complete a full ROS, check feet, pulses etc. Most doctors try to compare just the time in documenting an encounter - which is not accurate when you credit the time EMR saves you later reviewing dicatation, refills, interoffice communication etc - all time savings AFTER the office visit but enabled due to the EMR usage DURING the visit.

So yeah, it might 'slow' you down, but at the same time you are actually doing a lot more!

[Kursk]

You know what? I am just not that comfortable with these guys:

C. Martin Harris, MD, Chief Information Officer, Cleveland Clinic Foundation
Douglas E. Henley, MD, Executive Vice-President and Chief Executive Officer, American Academy of Family Physicians
John Hummel, Senior Vice President, Information Systems, and Corporate Chief Information Officer, Sutter Health
Charles Kennedy, MD, Vice-President of Clinical Informatics, WellPoint Health Networks Inc.
Graham O. King, Strategic Advisor, McKesson Corporation
Mark Leavitt, MD, PhD, Commission Chair and Medical Director, Healthcare Information and Management Systems Society
Jane B. Metzger, Vice President, First Consulting Group
Susan N. Postal, Vice President, Health Information Management Services, Hospital Corporation of America
Wes Rishel, Research Director, Gartner, Inc.
John Tooker, MD, Executive Vice President and Chief Executive Officer, American College of Physicians
Reed Tuckson, MD, Senior Vice President, Consumer Health and Medical Care Advancement, United Health Group
Andy Ury, MD, Chief Executive officer, Physician Micro Systems, Inc.

Doesn't seem to be a practicing MD amongst the bunch. But they are all gonna decide what we need.

Cause my office is really pretty much a carbon copy of the Cleveland clinic.

Certification Comission for Healthcare Information Technology (http://www.ahima.org/press/press_releases/04.0901.cfm)

http://www.ihealthbeat.org/index.cfm?Action=dspItem&itemID=105700

"The commission includes 12 industry leaders from hospitals, payers, vendors, medical organizations and health care analyst firms, in addition to two non-voting members from the government. The group this week decided that its mission would be to:
Increase provider confidence about investments in IT;

Ensure interoperability of health IT product with emerging local and national health information networks; and

Increase the availability of incentives to health IT adoption.
As part of these objectives, Leavitt said the group agreed to develop both a short- and long-term roadmap for certification, which has yet to be created. For example, the group could begin to certify EHR products based on their functionality and the following year could certify products that meet certain standards for interoperability with other systems.

The commission also agreed that the initial certification process should be in step with market reality and that the majority of the marketplace should be able to pass the certification process in the first year. Leavitt said the commission thought it would be difficult to get vendor cooperation if it was too difficult to pass but left open the possibility that the bar for certification could be raised in subsequent years. The group also agreed that it would oversee product certification, rather than accrediting organizations' whose products meet certain requirements. It also decided that the test for certification would be based on a pass/fail basis, rather than on a numeric rating system. The commission has not decided which organization would conduct tests to certify these products.

In the coming months, the commission plans to form working groups on various aspects of certification. Before these groups form, the commission plans to conduct a full assessment of industry efforts to create standards for EHRs, Leavitt said."

[mel]

Why don't they use docs who are out there in the trenches? :confused:

[CountryDoc]

First, Wow!

This really is a wonderful thread. There are lots of golden nuggets in the babble of all our voices. I'd be a card-carrying member of your in-the-trenches open-source damn the "Authorities" camp and party if you'd have me...

When I left residency 5 years ago there was nuttin' - NOTHING - that a young idealistic (and poor) country doctor could find to use and now, well, now the selection of free and open-source alternatives just warms my heart incredibly. It's like a whole different world, and I have no idea what 5 more years may bring. Your discussion forum, in networking excited committed individuals, has created another sort of mini-community. It inspires me and probably others who continue to care for people, write emr's, innovate and explore how to practice.

CottageMed is my donation to helping others enjoy medicine more and care for patients better. There are slews of links on our website to the other open-source projects (which reminds me, i'll have to add AlBorg's internet address to our site too - which address should I use?).

I, like most doctors, have to juggle a lot. We have 2 young children at home to feed and clean and put to bed - I envy programmers who have day and night to plug away at wonderful EMR projects. I only get to write upgrades in insomniac bursts on call or my vacations. It's a fun hobby for many of us.

We have a fast growing non-profit cooperative practice that I have to maintain ('in the trenches') and keep from getting out of hand, policies to develop and workflow to analyze... not to mention the paintings i still haven't hung and shelves we haven't found to finish outfitting our exam rooms after using them for 6 months now.

There are academic growth and CME to attent to, home repairs still hovering over every shoulder after 3 years, and the many things my physician wife and i haven't even remembered to get to yet. Still, we plug away on our EMR projects because they are fun to write and fun to share and, doggone it, even our simple ones make a clear fundamental difference in people's lives.

I want to thank the poster who pointed us to the Medical Economics article about an EMR veteran who spoke from a great fount of experience. EMR's are hired, not married, and everything else he wrote combined great wisdom and common sense in the very tight package of a single page.

Like all home-grown EMR's, CottageMed could be so much more if it was all that I did. But Keeping It Simple, (Stupid), has meant that any feature or change we make is one we (and hopefully other physicians) truly need. A very demanding cost-benefit analysis drives every improvement. We do not soil ourselves in modern marketing. The question, conscious and subconscious, is as follows: does the time to program a new feature save me or our coop team more time, frustration, or less errors that it costs to write in the immediate future?

Of course, if others chose to help design or write improvements any open-source project could explode and quickly run past any private effort, but none of our projects has that momentum yet. I began programming in 1983, i enjoy it a lot, but I'm not particularly gifted at all as a programmer. That is one of the beauties of Filemaker (and MS Access to a lesser degree). We've done what little hard work really needs to be done. You can design and program it more without knowing any real programming skill, a user can customize cottagemed just by cutting and pasting in what they'd like to use, and I find that just amazing.

It's a long way from a Tandy TRS-80 model 1 to this wonderful wacky future we're living in now... and next week 'they're' comingto do a free install of Zix 'scrip services with free pocket pc's and router for our little office. So let's keep plowing ahead, and let the fun begin !

Stefan Topolski MD
Shelburne Falls, Ma
drred(AT)mtdata.com
CottageMed v1.9 update due soon in mid-December
http://mtdata.com/~drred/webpage.html

[fran403]

Great discussion.....as a practicing cardiologist in a solo practice, I have been quite interested in initiating an emr system...however, the prices are ludricrous at the present time...and the purveyors want to sell you hardware, cables, networking etc.

[ozzie]

Great discussion.....as a practicing cardiologist in a solo practice, I have been quite interested in initiating an emr system...however, the prices are ludricrous at the present time...and the purveyors want to sell you hardware, cables, networking etc.
Would that be just like many physicians want you to take a gadziilions tests ??

Main reason for new cables etc is because that old cat 3 crap just dont cut it anymore and as soon as the local network slows down because its cat3, who does all the howling ??
Just as a patient start treatment within a set of guidelines so should networked systems..
The best systems in the world cannot stand a crappy infrastructure.. I have seen it all and it's the first place to start looking..
I have dealt with more rats nests than the Orkin man.
One I recall was an attorney telling me how stable the network was, and how I did not need to do a site survey everything was good to go. Kinda funny considering the network had no cables.. All data transfer was done via floppies or they would email each other via dialup.

[mpike]

Would that be just like many physicians want you to take a gadziilions tests ??

Main reason for new cables etc is because that old cat 3 crap just dont cut it anymore and as soon as the local network slows down because its cat3, who does all the howling ??
Just as a patient start treatment within a set of guidelines so should networked systems..
The best systems in the world cannot stand a crappy infrastructure.. I have seen it all and it's the first place to start looking..
I have dealt with more rats nests than the Orkin man.
One I recall was an attorney telling me how stable the network was, and how I did not need to do a site survey everything was good to go. Kinda funny considering the network had no cables.. All data transfer was done via floppies or they would email each other via dialup.

Ozzie, I don't think Fran meant just networking... I see a lot of IT people trying to take advantage of physicians because everything "thinks" they are rich (the docs) (hell, it comes with up brining.. be a doctor or marry one).

Call some of these EMR companies and see the load of crap they try to throw on you... I agree with you, that you need a good infrastructure, but a lot of these EMR companies are taking advantage of the situation (a CAT5 cable should be 5-6 bux, not $75).

mike

[ozzie]

true maybe, but that was learned behavior from hospitals selling tylenol for $20 LOL

I am sure there are extremes out there and its easy to pick the eyes out of any proposal too.. Its important to note thats regardless of the system there will be costs in infrastructure. Also many prices mean nothing until you do a complete site survey . Thats why it not a good idea to quote over the phone because folks love to hold your feet to the fire under duress when its come to pricing. Me personally I give the client a list to go shopping with. I give them specs to buy and warn them that should they go cheap on the specs that they will suffer and dont bother calling me about it ..
For me if I cannot buy for $3 and sell for $10 I am not interested. I am in the labor sales game not the retail hardware game.
Also what ever someone charges is their deal . its not up to me to judge other pricing. Working part time whilst having full time job is one thing..
Not having a full time job and being totally dependant on client's is another . So there is an overhead to have me available 24 and 7. So in the end that $70 cable maybe just a rebilled 1.5 hours labor.. as it took an hour and half on a sunday to go and fix that cable . so the cable may have well been free..
I prefer to help folks here more on the strategy and good practice than debate costs. Also a part of me says dont kill the messenger and defend your brothers in the trade until your KNOW all the facts.. <--- maybe thats the greater lesson here

oz

[thhall]

Dear mpike,
Absolutely I am interested! In fact, I am so interested that I have spent the last 6 years working with a privately paid programmer to do just what you wish to do. I have been using my home grown Microsoft Access based application to track allergies, medications, allergy to drug interactions, manage prescriptions, keep track of patient medical histories, and electronically generate admission and discharge orders. Please contact me at mz3thhall@aol.com if you wish to discuss any of my specifics. Thank you for your consideration.