SCREEN SIZE Be sure the screen size of your handheld computers is large enough to display the entire EMR screen.

I wish somebody had told me what I'm about to tell you about converting paper charts to electronic medical records, had sat me down and set me straight about the ABCs of EMRs.

Told me that adding an EMR will be a headache at first, no matter which system you choose. That there will be a growth curve for our nurses and doctors, steeper for some than for others. That it will be challenging for a multispecialty center like ours — from pain to plastic and most everything in between: GI, ortho, ENT and general — that does 650 cases per month, to make everyone happy. That there will be costly upgrades. That it will make certain things more efficient (government reporting and QI studies) and other things less so (it can take longer to chart a pain injection case than it does to perform one). That surgeons will want to access your EMR from their offices. And that screens will freeze while you're in the middle of charting a case.

But when we embarked on our EMR project nearly 3 years ago, I was in largely uncharted territory. I don't want you to go down the same dead ends and blind alleys as I did. Here, no punches pulled, is what awaits you as you make the move to EMRs.

It's a big (and ongoing) investment. Our startup costs were more than $160,000: about $100,000 for software, $30,000 for servers, wireless systems and IT consultant fees, and $36,000 for hardware (20 15-inch laptops that cost $1,800 apiece). Then there are ongoing costs. We pay our vendor a $7,000 quarterly service charge for upgrades and 24/7 customer support (the help desk will undoubtedly ask if you have the current hardware when you call to report an issue). Pay attention to the fine print. Will the support fees increase every year? Are upgrades included? Be sure to budget for IT projects associated with adding an EMR, such as building infrastructure, buying add-on modules, cloud storage and cycling out computers every 4 years.

FACE TIME Your nurses will spend more time looking at a computer screen than they will the patient.

Size matters when it comes to computers. We had a couple false starts with our computer procurement. We didn't buy enough and the ones we did buy didn't have big-enough screens. False start No. 1 was thinking that our nurses could share computers. We didn't put a computer in each bay, but we soon realized that each nurse needs her own — just as a paper chart travels with the patient from pre-op to PACU, so, too, must the EMR. False start No. 2: The screens of the 4 tablets we initially bought weren't big enough to display the full page, forcing you to scroll to get to the bottom of each page of the EMR. Very annoying. So we went with 15-inch Dell laptops that sit atop rolling stands that travel with the patient. We also have desktops in each of our 4 ORs. Hint: Buy computers that have fingerprint technology to avoid changing passwords every 30 days, forgetting passwords, or entering the wrong password and getting locked out.

Your nurses will be slaves to the screen. Instead of being up at the field paying attention and anticipating what the doctor or tech needs next, your circulators will be staring at a computer, tapping buttons and screens to keep up with their documentation. It's easy to forget about patient care and get caught up trying to find where to chart that the patient is in the supine position. EMRs can make simple things complex. Take the patient consent, for example. It will no longer be a simple pen to paper and sign here but a click here, accept button, hit next screen, check box, next screen, save, please wait while the computer thinks, oh, shoot, I double-clicked when I should have single-clicked.

It'll make your job so much easier. You can easily convert the data you've charted into helpful reports, such as compliance reports on quality measures. Want to know the ASA breakdown of your patients. Your average patient BMI? Your percentage of ontime starts? Instead of attaching a form to every patient's chart and spending hours on data collection, input and analysis, you're just a couple clicks away. Same goes for benchmarking and financial reports for board meetings.

The beauty of time-stamped records. EMRs time- and date-stamp your records, so you can easily show your accreditation surveyor that your doctors signed and dated everything. You can also show off the hard stop you activated that prevents charting in the OR without a signed patient consent.

Yes, there will be glitches. We call them "issues." And there'll be lots of them: issues with speed, upgrades, frozen applications and charting that doesn't save. We audit our EMR charts weekly, looking for glitches. Did the EMR save the patient consent signature? Are the medications properly programmed as mg instead of cc? Here's a good tip: Print out several packets of blank EMR charts so you can seamlessly transition in case your EMR goes down.

Your EMR can't outrun fast cases. For some pain injection cases, our nurses are still charting after the patient has left the building. By the time they power up the computer and move through the screens, the case is over. Some of our nurses prefer to chart these quick cases on paper and then input the data afterward in the EMR.

Surgeon compliance? Some surgeons, bless their hearts, will chart on-site. Others will want to access the EMR remotely to chart, bill or schedule (most physician offices still fax us a schedule request). We purchased a separate module to enable remote access for one of our groups, but HIPAA compliance is a concern. Expect a small pocket of resistance from old-school creatures of habit who'll insist on dictating and having a transcriptionist type out their op reports and H&Ps.

How much data capture? Do you want the EMR to capture data from monitors and anesthesia? That will likely cost a pretty penny for every monitor that gets hooked up. Although recording the BP and heart rate is efficiency at its best, it's also an added cost. If you want your scope towers to talk with your EMR system so you can wirelessly download pictures into the EMR, involve your vendor that maintains your scope towers.

Don't go it alone. Involve IT from the beginning, even as you start the assessment process. Bringing IT in after you have already contracted with an EMR vendor may put you behind. If you have a part-time IT consultant, as we do, you may want to increase the time he spends on-site. Finally, I highly recommend visiting a center similar to yours in terms of specialty and case volume that uses the EMR you're considering. OSM