Rolling out electronic medical record systems is more than a complicated IT deployment, with all the challenges of any major business process reengineering effort. It's also a public policy issue, with the federal government preparing to spend more than $20 billion in stimulus funds to reimburse providers for EMR deployments.

The Obama administration hopes the money inspires a whole new wave of healthcare practitioners to deploy the systems. Done right, EMRs won't just change the way doctors and nurses work in big hospitals and small doctors' offices; they'll improve the quality of care and, hopefully, lower costs.

But deploying these systems is neither cheap nor easy, and plenty of problems could keep the U.S. from getting its $20 billion worth. Here are nine lessons learned the hard way during real-world implementations of EMRs. We present them not to just the healthcare industry; everyone has a stake in seeing healthcare IT leaders succeed.

[ 1 ] Be Ready For Sticker Shock

For large hospitals, EMR deployments cost millions. For instance, St. Elizabeth Healthcare, a northern Kentucky provider with 1,000 physicians and six hospitals, is spending $40 million on an EMR rollout. Doctors' offices can spend from $25,000 to $60,000 per physician to deploy a system. One of the lower-priced options is the eClinicalWorks EMR system that Wal-Mart is selling out of its Sam's Clubs outlets on Dell computers, using a software-as-a-service subscription model. But those costs generally cover only EMR hardware and software, not consulting, training, add-on software, and other related expenses.

Providers should plan to spend $5,000 to $10,000 just to hire a consultant to manage the project, says Micky Tripathi, CEO of Massachusetts eHealth Collaborative, a group that helps Massachusetts providers roll out these systems. Training is another place where they'll spend a big chunk of money, says Leanne Harvey, project director of EMR at Beth Israel Deaconess Medical Center and Beth Israel Deaconess Physician Organization. Most doctors and nurses practicing today trained before EMRs and need to learn a new clinical system as well as new work habits. On-the-job professional development can be anxiety-producing in any business, but particularly so when people's health and lives are at stake.

Many healthcare organizations will also need software to meet requirements the EMR doesn't cover, such as the special needs of a medical specialty practice or hospital department like a blood bank.

Also, glitches -- especially early on -- can disrupt processes like billing that can cause real cash-flow pain. That was the case for Hot Springs Health Program, the only healthcare provider in the 457 square miles covered by Madison County, N.C. When Hot Springs rolled out its EMR system in May 2006, code problems kept it from sending bills to patients for about a year. The practice continued to get reimbursements from insurers and other payers but didn't get a lot of the co-pays and deductibles owed by patients, seriously affecting cash flow, says executive director Robert Ford. "We're still recovering," Ford says. "We're getting about 10 cents on the dollar" from patients once they finally received bills.

Doctors and nurses also are likely to be less productive until initial problems are worked out. More on that later. Factoring in lost productivity, training costs, and expenses from unexpected problems, Ford says healthcare providers should add 50% onto EMR systems' cost.