Common EMR Implementation Issues – Unexpected EHR Expenses

This is the start of a new series of posts that I plan to do over the next week or two. I’ll probably try and space them out so that they don’t overwhelm anyone. However, it’s going to be a series of common EMR implementation issues that I hear over and over again.

This series was prompted by a post on HIStalk by Inga where she talked about her visit to the doctor and his complaints about his EHR implementation. As I read through the list of complaints, I realized that they were all complaints that I’d heard before. If I’ve heard them all before, then they must be pretty common and worth talking about more.

Ideally the discussions in this EMR implementation series will help practices and doctors that are implementing an EMR to avoid these issues. I also know that I don’t necessarily know all the answers to avoiding these problems. So, I welcome others feedback on ways to avoid these problems in the comments as well.

Today’s Common EMR Implementation Problem: Many Unexpected Expenses

I can’t tell you how many times I’ve heard a doctor or medical practice talk about all the hidden expenses that they incurred during their EHR implementation that they didn’t plan for. Here are 3 tips to help you avoid this situation.

Unexpected EHR Expense Tip #1 – Plan for hidden expenses. Add $5000+ to your budget for hidden expenses. Hopefully you won’t have to use it, but if (and likely when) you need to use it you’ll already have it in your budget.

Unexpected EHR Expense Tip #2 – Get your EHR vendor to outline everything and anything they could charge you for. Once they’ve done that, consider putting the list of expenses in your EMR contract so that new expenses from your EHR vendor won’t appear. Here’s just a few EHR expenses that you might incur (and may not expect):
-Up front fee (almost everyone just focuses on this)
-Maintenance Fees (monthly, annually, etc)
-Upgrade Fees (to update your software…these are sometimes called Hot Fixes)
-Interface Fees (both sides of the lab and EMR company)
-Device Integration
-Training Fees
-Support Fees
-Licensing Fees (to license their various databases and/or clinical content)
-Install Fees
-Other non-standard modules – You mean you didn’t realize that the patient portal was an extra $150/month?
-EHR or PMS data migration Fees
-Template Creation Fees
I’m sure there are others that I’ve missed. I look forward to seeing the comments on this. I’ll update the post with other suggestions as they come in. As you can see, EHR vendors can charge you in lots of interesting ways.

Unexpected EHR Expense Tip #3
While EHR vendors can often throw unexpected fees at you, it’s probably even more likely that the other outside purchases you have to make during your EMR implementation will be a surprise. Here’s a list for you to consider the other EMR implementation related fees that might come unexpectedly:
-Server cost (almost everyone focuses on this)
-Software cost (including the operating system or third party software your EHR vendor might require)
-New Desktop/Laptop Costs
-Upgrading Desktop/Laptop Costs – You might find that your existing computers aren’t powerful enough to run the EHR you chose. This is particularly true if you’re using something like voice recognition with your EHR.
-Fax Server
-Fax Server Software
-Scanners – Yes, that is plural and people often start with one scanner and then have the unexpected cost of another scanner because they could really use 2+ scanners. Other times people use a cheap all in one scanner which quickly dies after they start scanning in bulk and they realize they need to buy a $1000+ scanner that can handle the required scanning
-Printers – You’ll likely need a few of these to print our prescriptions, patient education, etc etc etc. Plus, you’ll often need a better printer than the one you have.
-Dragon Medical Voice Recognition – The software, the mic (spend extra for a great one), etc. Some don’t realize all of this costs and doesn’t usually come with the EHR software.
-New Network Ports – You could go wireless, but many like the reliability of a wired connection. This costs to run the lines and cut out new internet connections
-Bigger Internet Connection – This is particularly true with a SaaS EHR setup. You think your current internet connection is enough and then you realize you need to pay for a bigger pipe (internet connection) or possibly even a second “backup” internet connection
-Backup Software
-Backup Hardware
-Off site Backup Service
-Cables – Lots and lots of cables required. Sometimes you even have the cable, but then realize you want a longer one. Unexpected expense!
-Power strips and other peripherals – $10 here and $10 there. This stuff starts to add up. Plus, get ready for things like your mouse to start breaking now that you’re using it a lot more.
-UPS (uninterruptible power supply)
Chip Hart added the following suggestions (Thanks!):
-Practices should purchase 25-50% more laptops/tablets (and/or batteries) than they expect.
-All those laptops and tablets will need a SECURE storage and recharge barn.
-You may be paying a carpenter and electrician.
-Integration fees? Data conversion fees?
-Will you need hands-free headsets for your staff, now?
-Maybe it’s time to get bigger monitors.

Hopefully the above lists will help you plan for all of the various fees that are associated with an EHR implementation. Many of these EMR costs are necessary, but end up being really annoying when you didn’t know they were coming. Check through this list to see if you’ve planned for all the EHR costs.

In a future post, I’ll see if I can’t take the above list and give you some ideas on how you can save on some of the costs above.

About the author

John Lynn

John Lynn

John Lynn is the Founder of, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Great Post!!! In addition to all the above lets not forget ALL the hotfix and upgrade cost you’ll incur during the years. Which also means, more servers needed… 🙂 More so now with all the meaningful use requirements. All the EHR vendors are banking on this…

  • I just wrote a piece about this for the SOAPM section at the AAP. I’ll toss some additional comments here:

    – Practices should purchase 25-50% more laptops/tablets (and/or batteries) than they expect.
    – All those laptops and tablets will need a SECURE storage and recharge barn.
    – You may be paying a carpenter and electrician.
    – Integration fees? Data conversion fees?
    – Will you need hands-free headsets for your staff, now? Maybe it’s time to get bigger monitors.

    Many more to consider, too.

  • Melissa,
    You’re definitely right about that. Particularly important for the one time purchase EHR software. However, even the monthly subscription EHR software can come out with a new feature that wasn’t part of the subscription.

    Great additions. I updated the post and gave you credit. Secure storage is such a pain and can be really expensive. Particularly if you want the laptops to charge while they’re being stored.

  • This is a great post. As we get into MU 2, and 3, I am sure there will be even more costs that arise. It may be time to look at a different model around this. What if the up front fee, training fee, licensing fees, upgrade fees, support fees, and template creation fees were all Zero. ARRA money could then be applied against some of the other costs and the rest retained for those hidden costs, still to be revealed! Looking for a new way of looking at things then check out Dan Pinks new book “Drive”. It has a focus on how we are now doing things VERY differently.

  • The bigger picture here is: the EHR salesperson is not going to tell you all of this…why would they?

    One of their selling points is to save you money, right?

    You don’t need a transcriber anymore (wrong).
    You can get rid of X staffers (maybe, but adding IT help)

    Imagine how many lost sales there would be if a laundry list of parts was added?

    To not get screwed in this type of project, one that is a MAJOR project for most practices, it is smart to hire somebody to manage the project for you.

  • Another reason to go with a free EMR. No hidden costs and you only need a few half-way decent computers and internet access to get going.

  • Whether it is free or costs a bundle it is alwys good to get some advice on what you need from a technoilogy perspective. Maybe the REC’s can help?

    As for sales people hiding the information from their clients that is so short sighted. At least with a free EHR you have the ARRA money to pay for unexpected costs. Also look for a “Virtual Medical Community” An EHR which is in soft copy does not give everyone the information they need to make SMART decisions because it still resides in the doctors office, and not with the people that need it.

    Better still…..Look for a “FREE” HIE/EHR/PHR. then your cooking!!!

  • Who needs to get into this nonsense. Just continue to record the encounter in ‘free text’ (transcription, dictation, or even handwriting which are all allowed) and get the incentive funds by using a MU/eRx module (a mere $125/mo, less than your cell phone bill). Dropdowns, menus, clicks and buttons do NOT do as good a job of describing the patient in front of you as the old fashioned ‘note.’ The huge cost of Complete EHRS is created by the companies that sell them. KISS.


  • Stanford,
    Biggest problem I see with your suggestion is that then you won’t be using a “certified EHR” and so you wouldn’t qualify for the incentive money.

  • Certification can be achieved via Certified modules. A ‘Complete’ Certified EHR is NOT necessary. If the MU and eRx are Certified, the actual encounter can be entered in ‘free text,’ and the result is eligible for all federal incentive funds. The ‘free text’ component need NOT be certified to qualify. Many people do not understand this and are trying to deal with the dropdowns, menus, templates, etc that have been included in the big guys EHR programs. That way of entering the encounter, as well as the practice mgmt component are not essential to qualify. The encounter templates and need to change practice is what is blocking acceptance by practitioners. Check it out, and, as I said, KISS.

  • Somewhere between 40-60% of pediatricians won’t even qualify for ARRA, so who cares about certification? Especially when it will only tighten the leash and increase your obligations. Focusing on the ARRA “free money” is a shell game. In fact, the expense of the EHR in question should be a secondary issue.

    GET THE EHR THAT SUITS YOU BEST. Even a 5% difference in efficiency between EHR A and EHR B will be worth the price over time.

    You know what EHR is your most expensive? Your _first_ one.

  • Stanford,
    Even if you’re using certified modules, then you still have to combine all of those certified modules to create essentially a virtual “complete certified EHR.” You’re right that you can use multiple certified modules to achieve this certification requirement. You’re right about it not being a current requirement to use templates instead of free text sections to meet meaningful use stage 1. I’ll be interested to see what they do with meaningful use stage 2 and 3 to see if this matters more. Although, with NLP across the freetext notes, you might be able to still get away with freetext areas and meet meaningful use.

    I agree. I’ve been arguing the idea of implementing an EHR because it’s the right thing to do for your office instead of doing it to get the government hand out for a long time. Any government incentive money should be seen as a bonus if everything else works out, not the main goal of adopting an EHR. We’ll have a lot of unhappy doctors if they adopt EHR for government money.

  • Chip
    You are right. The cost of the first EHR is the most expensive but it is not always the EHR that costs the most. There was a great post on this blog about all the hidden costs to implementation. AND who knows what will be required in MU 2 and 3? Dr Vovan at Mitochon Systems wants physicians to be able to keep their money in their pocket for MU 2 and 3 so he provides a free , certified, HIE/EHR/PHR. Check out Mitochon Systems. It is web based and allows you, the physician, to use your money where you need it to build your practice.

  • Take it from someone who has worked as a physician and tried to describe a patient via dropdowns, menus, etc. When another physician reads the stack of pages created from the visit, he/she has almost no idea what is wrong with the patient. There are just too many variables to describe a visit and a pithy note, dictated or handwritten, gets that across, especially with matters of patient mood, obstacles at home, obstacles from the insurance company that is rationing options. We cannot fit even one patient into a mold. If there was enough time to click on every item that describes the situation, there would be only one patient seen a day. Even the research centers, like Hopkins and Mayo, do not make their doctors work that way. Get penetration with ‘free text’ and certified MU/eRx modules, collect federal money, let the doctors see that the first step is not so bad, and better options will develop in the marketplace.

  • Stanford,
    I know the old template based systems that you’re talking about that rely on dropdowns and menus and create a slew of “regulars” that have nothing to do with the visit. However, I wonder if you’ve looked at some of the newer EHR companies out there. In the past month I’ve seen a couple different EHR companies that have taken your comments to heart and really refined what we consider a “template” while still preserving the pithy note that you’re not embarrassed to send to another doctor.

    My point being that the interface for doctors to document has been making huge strides. We’ll just have to see if enough doctors find these newer interfaces or if they get roped in by the marketing machines.

  • Yes, those are really interesting and it may be that technology is going to catch up with needs. However, to convince doctors to move gracefully, they should be able to start small (ie reasonable costs), and be able to transition painlessly to more complex solutions (assuming there is some assurance of portability) as these technologies mature. Most now believe they will be wasting money by not making the right choice (528 EHRs are out there, according to a survey), and will be adding inefficiency to their practice. Free text for the encounter is totally portable (TIF or PDF), even though unsophisticated, but, coupled with a MU and eRx module, would get them started at minimal cost and time. Perhaps they can then add a template module (some are marketed) to ‘learn’ with each encounter and create new templates on the fly. Much like adding an app to a phone.

    I just think that trying to put the doctor into an expensive Complete EMR leads to the pushback we are seeing. Our healthcare ‘system’ is too broken for physicians to be comfortable with its future, adding to their worry about the value of a big investment in EHR.

  • I agree completely that doctors should choose an EMR that’s a “reasonable cost.” In fact, some of the best EMR I’ve seen have been in the reasonable cost range.

    The idea of portability is a great one. Sadly I’ve only seen one EMR vendor fully embrace what you describe. I’d love to find a way to get more EMR vendors to adopt it.

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