At $213,000, the cost to convert from paper charts to electronic medical records was steep enough. Much of that went to one-time expenses: $120,000 for software and $72,000 for 24 hand-held tablets. The conversion will pay for itself in 5,000 procedures and 12 months, but that doesn't mean we'll be done paying. Here are 12 hidden and recurring expenses of going paperless.

More hardware for more users. When you envision how your environment will change with a paperless system, you'll see that more users will need access your network. Defining your users and where they'll need to access the system will tell you what hardware you'll have to buy. Create a spreadsheet of staff users by position in each clinical and business area. Note in the spreadsheet if the user already uses a workstation, where the workstation is located and the workstation's name in your network (useful for installation purposes). Next, identify the remaining users who'll need new hardware. Consider anesthesia and physicians if they'll be interacting with your system. A four-OR surgery center would need four additional pieces of hardware for physicians and five additional pieces of hardware for anesthesia (four for CRNAs and one for an anesthesiologist). In the end, you'll not only know how many more pieces of hardware you'll need, but also how many user licenses you'll need (if your EMR system is priced in that format).

Slave monitors. Consider adding one of these, an extra monitor connected to existing workstations in your business office, so users can review an operative report in the EMR on one screen and access billing software on another screen at the same time. For a few hundred dollars (and some upgraded PC video cards), you'll double productivity.

Server upgrade. A paperless system may require you to upgrade your server (a second server will run around $14,000, depending on the size and specifications) and purchase a direct inward dialing fax line or fax server. While a fax server is more expensive, a DID fax line means a recurring monthly charge; and, in some areas, the quality of this function may not be acceptable.

High-speed scanner. Look for a quality scanner that can scan insurance cards and driver's licenses. Ask the vendor to install a scanner at no cost so you can evaluate it for a few weeks. Once you decide on a scanner, plan on buying more than one to place in strategic areas in your center. Those areas will become clear once you're up and running and can assess true workflow patterns.

Wireless antenna system. If you plan to be wireless or are already wireless, have your IT person test for connectivity throughout the center where users will be. Poor connectivity will result in users experiencing issues similar to dropped-call syndrome when on a cell phone in a poorly covered area. You may need to install a wireless antenna system to ensure connectivity. Today, costs associated with going wireless are highly competitive compared to having a "wired system" and most vendors and paperless centers will recommend a wireless format. The square footage of your building will determine the cost of a wireless antenna system.

Built-in redundancy. Remember that there's no paper backup to your documents and CMS's security rules require you to have a disaster recovery and contingency plan for your documents. Consider housing the EMR on a separate server that backs up into the primary server. This way, you'll lose little data should disaster strike. While you may temporarily lose the ability to chart electronically, not all of your operations will be paralyzed. You'll still be able to access other critical functions such as billing, scheduling and financial processes. Both servers should have disaster recovery backup software that images the hard drive in the server every few hours. This way, if the hard drive crashes, your IT person will be able to rebuild it in a matter of hours, not weeks. Cost will run around a few thousand dollars or less (including installation). Finally, both servers should have off-site backup performed every 24 hours so that in the event your physical building is compromised, you'll at the very least only lose a day's worth of information. While this may seem like a lot, consider that with a paper system, years' worth of charts and data might be lost.

Laptops or tablets? Regardless of whether you choose laptops or tablets, add an additional gigabyte of memory so users will be less frustrated with their speed. Also, opt for embedded GPS tracking devices to locate missing-in-action laptops. Users will think twice about removing one if they know it has a GPS chip embedded. Compared to stationary workstations, mobile computers are priced competitively in today's market. Consider purchasing directly from the manufacturer and don't accept first-pass pricing. While you may not get pricing down, you can usually get extras thrown in, such as chargers and batteries. Make sure AC adaptors have a three-pronged, grounded plug. While this isn't standard for computer companies, healthcare accrediting bodies mandate that all electronic equipment within five feet of a patient must have plugs with a ground prong. (Besides, an electric shock to your nurses is terrible for employee morale.)

Carts. Consider purchasing carts for the clinical areas. Your nurses will thank you, and anesthesia will prefer having an "arm" attached to their machines. Cost can range from $150 to $4,000, depending on whether you need AC or battery capabilities in the cart. One way to save big: Buy battery mats at your local computer store and add them to an inexpensive cart.

Installation. The vendor will only include costs associated with installing the EMR, which is only about half of what you'll end up paying. Your IT person will be very much involved in upgrades, installing additional servers and wireless antenna systems, and uploading and configuring laptops. Talk with your IT person up front about his charges. Get a proposal for installation on identified hardware and then ask if you can cap the proposal to control costs. If not, a good rule of thumb is to double the vendor's installation quote to cover these hidden expenses. Most vendors will charge for travel associated with training. Try to cap the travel expenses by putting the vendor on a budget if you can.

Are you still HIPAA-compliant? Converting to paperless will mean that you have additional issues, policies, procedures and requirements. Once you've implemented the paperless system, you'll need to have an independent IT firm perform an audit for HIPAA compliance. Cost will depend on the size of your facility. CMS's security rules specifically require that you have an independent firm specializing in HIPAA to ensure you're placing proper security measures to remain compliant. Most independent firms will include the creation of customized policies and procedures required for CMS security documentation.

Scanning existing charts into system. Form a plan for getting rid of your paper charts. There are different choices here. You can hire a company to come and scan old charts, you can do it yourself with your newly purchased scanners, or you can rent commercial scanners and hire temporary staff to perform the tedious task. Regardless of which option you choose, start with the day before you went live and work backward.

Insurance. Your new hardware will come with a one-year warranty that won't include theft, damage and abuse, occurrences you should insure against for three years. The total cost of insurance should roughly equal the price of a few laptops.

Is it in the budget?
Most vendors will submit a proposal that only provides the cost of software, licenses, installation, training and support fees. That's a start, but there are many other things to consider. While it may seem that hardware costs quickly add up, a budget that doesn't accurately capture the reality of what you'll need will frustrate you even more. Planning your budget well will let you control your center's cash flow while providing the necessary tools to perform in a paperless environment.