JOHN CARROLL

Ten years ago, electronic medical records (EMR) were offered up as a bright hope for the future; a high-tech approach to practicing medicine that would weed out unnecessary medical errors, help doctors coordinate care and stamp out wasteful spending. And four years ago the Bush Administration jumped on board, laying out plans for putting every American’s health record on an electronic system in 10 years.

But a funny thing happened on the way to the tech revolution. Most doctors never signed on. And a string of new reports released this summer underscore that long years after the revolution was declared, providers are still not willing to pay the price of enlistment.

In one study published in the New England Journal of Medicine, only 4 percent of doctors reported owning a full EMR system. Slightly more than one in 10 had a basic system in place. In most cases, doctors cited a familiar barrier: Cost. Exactly two of every three doctors surveyed in the NEJM study said the price tag on these new systems was simply too steep a barrier to overcome.

"They can cost anywhere from $15,000 to $40,000 per doctor in a small group practice," said Neal Neuberger, executive director for the Institute for e-Health Policy. "And that’s huge, if for no other reason than practices haven’t figured out a business case for this."

Small practices face the biggest challenges. Even in California, where Kaiser Permanente’s large, integrated health system has helped push utilization to 37 percent, cost remains the highest hurdle, according to a California HealthCare Foundation report released earlier this year. A total of 59 percent of physicians say they can’t pay the freight on EMRs, and 42 percent add that just the cost of maintaining a system remains daunting.

"Cost is a real showstopper for a lot of physicians," said Jonah Frohlich, senior program officer for the California HealthCare Foundation. To get around that barrier, he added, payers will have to substantially reengineer incentive plans to cover more of the price. Major progress also needs to be made on making these electronic systems more user friendly and less of a chore to master. And taking a new approach to leasing software and hardware through companies like Athenahealth and eClinicalWorks will go a long way to overcoming sticker shock.

Both companies avoid selling systems to physicians and use an online subscription model, where a practice pays a monthly fee to be able to use a PC and Internet connection to handle billing and EHR. That kind of approach, said Frohlich, eliminates the gamble of buying a system and simplifies the task of adopting a new approach.

"The outsourcing model, where the practice does not have to host all the software and servers and backup–making sure there is redundant storage, backing up every day, making the practice a mini-IT shop–is getting much better," said Frohlich. And it’s an approach with which physicians are often already comfortable. "The model for a lot of practices is an outsource model. There’s outsourcing for billing, and some new companies are really offering top-notch services."

But even the most optimistic analysts still don’t believe the change from paper records to electronic records will get easy anytime soon. The security issue alone raises hackles – and fears. Recent headlines highlighting the vulnerability of healthcare records to prying eyes simply underscore how much security work needs to be done.

"These are highly disruptive technologies," said Neuberger. "Work flow is effectively changed in a big way. There’s a potential for errors, by omission and commission, and a question of the accuracy of data coming from various sources. What if data is self reported but wrong? What if it is correct, but in such a crush of data that when it comes in they don’t have time to go through all of the information? What if it’s accurate and they haven’t acted on it? What’s the liability issue?"

It also wouldn’t hurt if everyone’s expectations about electronic health records were brought down closer to earth.

"Part of the problem is that people view an EMR as a panacea that’s going to solve quality and cost equations in healthcare," said Frohlich, "and it’s not."