You also need a project manager, who probably shouldn't be a physician, says Rosemarie Nelson, a principal with the Medical Group Management Association Health Care Consulting Group. "They could be a nurse or any midlevel provider. The reason I recommend against a physician in this role is that doctors need to continue seeing patients, so they usually don't have enough time to monitor all the details of the project."

The project manager will be responsible for ensuring that hardware has been ordered and is being installed on schedule. She coordinates the training process. When there are separate vendors for practice management software and the EMR, the project manager monitors both vendors to ensure that the two systems will interact properly. As the rollout date approaches, the project manager helps develop templates to meet the practice's specific needs.

During the start and end of the implementation process, the project manager may spend only a quarter to a third of her time on the EMR. But just before and after rollout, expect it to be a full-time job. Nelson estimates that six months after the go-live date the project manager will be down to half time. However, she'll always need to spend some time maintaining the system as a whole, installing new software releases, and monitoring new functions that can improve the way the practice operates.

Finally, you need at least one person, and often more than one, to train as a "super user." These people will become thoroughly familiar with the software; they can help train and support staffers in a real-life environment after the formal training period ends. In a small practice, the project manager may fill this role, but in a larger practice, with two or more work sites, you need at least two people who can help other staffers learn and remember key software details.

When you go live

By the go-live date, all systems should be installed and operating correctly. This is the moment when practice sessions end and real use begins. Your software vendor will supply onsite training for all your staff during this period, usually for one to two weeks, depending on the size of the practice.

When you go live, it's a good idea to schedule fewer patients than usual. Ideally, allow double the usual appointment time.

Many practices follow a gradual implementation strategy. For example, a practice with several locations may implement an EMR at one site, then another. Or a practice may implement one module of the system at a time.

Diamond, whose practice followed this latter strategy, estimates it took about two months until everything was up and working correctly. At that point, some aspects still felt a bit strange and unfamiliar, like a pair of new shoes, he says. But by the end of six months, everyone was comfortable with the new system.

How much should you budget for the implementation process? Nelson advises practices to plan on $20,000 to $35,000 for EMR acquisition costs for each full-time physician (or full-time equivalent). That includes hardware, software, initial training for the physician champion and super-users, and onsite support for the whole practice during the "go-live" period. Vendors generally charge $100 to $180 per hour for on-site consulting, she says, and you may be able to negotiate a daily or weekly rate. Her estimate for acquisition costs includes about $7,500 per physician for the software license fee; after the first year, you can expect to pay 18 percent to 22 percent of that fee annually for software updates and continuing phone support.

Nelson advises practices to budget for an additional period of onsite vendor support, three months after the go-live date, and again six months afterwards. "What usually happens with technology is that we learn just enough to get today's job done," she points out. "Often we don't learn about all the functions we could use to make our jobs easier." She recommends an onsite visit so the trainer can observe people at their workstations, and note bad habits they may have developed, or shortcuts they aren't using.

eClinicalWorks president and CEO Girish Kumar Navani agrees that practices need to develop their software skills on a continuing basis, since some features of the software become more relevant over time. For example, if you see a patient for a recurring ear infection, the software remembers which antibiotic you used last time. These special features are difficult to demonstrate when the system has just been installed.

However, Navani doesn't think additional onsite visits are the most appropriate way to teach these additional skills, since most new functions are best learned in short training sessions. Instead, eClinical Works invites practices to sign up for its training Webcasts, of which it hosts eight weekly.

Stay positive

Installing EMR and practice management software means a major change in work processes for everyone who works at the practice. It's not surprising that this degree of change can be intimidating.