Purchasing EMR software is a pressure-packed decision that you can't afford to get wrong. Electronic medical records systems come in all shapes and sizes, and sorting through all of the software claims is confusing and time-consuming. To clear the clutter, we've compiled tips so you can make the best possible choice when it comes time to go paperless.

1 Small, medium or large?
Are you looking for a major overhaul of all your facility's software, or an EMR component that you can add on to the practice management system you already have in place? It's helpful to think of EMRs coming in S, M and L sizes.

• Small: a purely clinical, standalone electronic medical record. This could be an ideal solution if you already have a practice management product in place and want to tag the EMR onto it, says Jan Kleinhesselink, RN, CPHQ, chief quality officer of Lincoln Surgical Hospital in Nebraska. Find out how well the EMR and your practice management software "talk" to each other to ensure a smooth flow of data and reduce data entry redundancies.
• Medium: an EMR with some additional capabilities like inventory management and billing features, but not a complete practice management component. Since 2-way interoperability between different systems can be difficult to achieve, this option can help smooth the flow of data between the most critical clinical and business functions.
• Large: a fully loaded practice management and EMR system that covers everything from scheduling and charting to billing and inventory management. If you're looking for a complete software upgrade, this soup-to-nuts solution might be best. But achieving the perfect balance between clinical and business functionality in a single product is hard to do, says Stephanie Diem, RN, BS, clinical director of Washington Square Endoscopy Center in Philadel--phia, Pa. "If you can't find 1 product that does it all, you may have to use 2 or more products to meet your needs." This modular approach can work well, says Ms. Diem, and in fact it's how many hospital systems work. The key is ensuring effective 2-way interoperability among the different components.

2 How much can you customize?
Most EMRs have some customizable components, such as materials and equipment databases. But to know if you can customize the EMR to fit your needs, ask your vendors these questions:

• What exactly does customizable mean? "Salesmen tend to throw around the word 'customizable' pretty freely and say things like, 'We can make it look any way you want,' but they won't. Not without a fee," says Ms. Kleinhesselink. One benefit of a flexible system that lets you make your own changes is that you can adapt quickly to changing regulatory, licensing and accreditation standards. If a surveyor finds something lacking in your documentation, it's nice to be able to go into the system and make the necessary changes quickly, says Ms. Diem.
• Can I use customized, add-on forms and documentation? "If you build new things into your forms, you want to make sure that it's actually measurable and mineable data," says Ms. Diem.
• Who's going to be doing the customization? Depending on the complexity of the software and how much of it you're going to customize, there could be a lot of data entry required and staff involvement in the process, says Ms. Kleinhesselink.

3 How are the charts built?
Make sure your EMR charting requirements meet recommended best practice guidelines for everything from patient identifiers to time spent in the OR to bedside medication verifications, says Ms. Kleinhesselink. Be sure to ask vendors which standards — AORN? Medicare? — they're using to build those charts, and how easy it is for you to adjust the system to make sure your facility's charting requirements match your individual state and local regulations and accreditation standards.

4 How easy is it to chart a case start to finish?
Going from paper to digital recordkeeping is going to be a major adjustment for your staff and physicians, so be sure to have some front-liners take prospective systems for a test drive to see how well they work. Many EMRs are set up to be as easy to navigate as surfing the Internet, says Ms. Diem, but don't take vendors at their word when they say the software is user-friendly. She recommends that when you get your hands on a demo system or visit other facilities using EMRs that you're considering, watch the staff chart a case from start to finish — and make sure it's a procedure that you frequently host at your facility. This will give you a feel for how well the system meets your charting needs.

5 The final (printed) product
Yes, "paperless" is the goal. But sometimes an outside source, be it Medicare, an accrediting body or an attorney, will need to see a printed copy of a patient's record or operative report. If you only see the system in its electronic format on the screen, you may be caught by surprise when that time comes, says Victoria Pearce, BSN, clinical director of Peninsula Eye Surgery Center in Mountain View, Calif. "What you see and work with on your computer screen is not necessarily what you're going to get in finished form," she says. Displeased with how her EMR reports originally read when printed, Ms. Pearce worked with her facility's EMR vendor to make them flow logically as a printed record so someone outside the facility would be able to read and interpret them correctly.

6 Pharmacy component and other "meaningful use" requirements
For hospitals vying for a piece of the federal stimulus money rewarding healthcare providers who make "meaningful use" of electronic health records, drug formularies, medication reconciliation and other pharmacy-related requirements are important to consider. That doesn't mean ASCs should overlook how their EMR systems handle things like medication verification, says Ms. Kleinhesselink. "Right now there's no financial incentive for ASCs to go with" a product that meets meaningful use requirements, "but down the pike there might be."

7 Flow of information
Another "meaningful use" component that you'll want to consider, whether you're in a hospital or ASC, is the interoperability of the system. Can it communicate with your surgeons' offices, labs, pharmacies and other facilities? How about your scheduling, billing and inventory management systems, if it's a standalone EMR? And if so, does this communication always go both ways? "Look at the ability of the information to flow in a logical manner and be available to people" in different departments and affiliated facilities, says Mary Kline, BSN, manager of hospital-based Park Nicollet Ambulatory Surgery in St. Louis Park, Minn. Be aware that in many EMR systems, data doesn't flow bi-directionally without some extra work on your part — or an added cost.

8 Anesthesia component
Anesthesia has been slow to join the digital revolution, but EMR solutions are gradually starting to add this component. Park Nicollet Ambulatory Surgery uses an EMR with a fully integrated anesthesia documentation component that includes vital signs and medications, which Ms. Kline cites as a big plus.

9 Upgrades and adjustments
You can see what the software looks like today, but what will it look like next year? How about 5 years from now? There are several known changes (ICD-10 being the biggie) and unknown but probable changes (quality reporting for ASCs) on the horizon for ambulatory surgery, most of which are going to have an impact on documentation. How easy will it be to alter your EMR software to reflect these changes?

10 Who will host your EMR?
Some EMR software systems are housed on internal servers, while others may be hosted on the web. Neither option is without risk of potential downtime, data loss or security breaches. Which is right for you?

• Internal hosting. Washington Square Endo Center controls and manages its own on-site server with its own IT support team. This requires internal infrastructure and labor, but also affords the facility more control. "When the Internet goes down, we're still working, because the system is supported by our own intranet," says Ms. Diem.
• Web-based systems. The Peninsula Eye Surgery Center in Mountain View, Calif., has been using a web-based system for 5 years now, and Ms. Pearce says the biggest advantage of web hosting is that all the information is backed up off site. "If your hard drive crashes, it's comforting knowing you can always get [the data] back." Instead of being responsible for backing up data and doing server maintenance and upgrades yourself, the vendor handles all of this on its own servers. As with any Internet-based system, "the worst nightmare is to walk in and find out that the web is down," says Ms. Pearce. Ms. Diem suggests that you make sure web-based solutions are protected through encryption and other data security measures, and that these measures are spelled out in your contracts.