What percentage of family physicians would you guess use electronic medical record (EMR) systems — 3 percent, 5 percent, 10 percent? Whatever the number is (and I'm not aware of good data bearing on the issue), I am pretty confident that the figure is low. Given that EMR systems are often talked about as the way of the future, the low percentage might well surprise an outsider. And it may in fact be lower than it should. But I bet you are not too surprised to hear it.

After all, look at the arguments against installing EMR systems: They require retraining of the whole staff, they force physicians to become transcriptionists, they bring all the headaches that come with new hardware and software, they probably don't talk to your billing and scheduling programs, they require time you don't have and, above all, they cost money you don't have.

Big business and small practices

That money issue seems likely to be a big one for a long time, especially given an unfortunate dynamic of the relationship between EMR vendors and their customers. The practice that sets out to computerize its charts almost invariably starts by comparing available systems on the basis of features. Knowing this, vendors tend to compete on the basis of features. And adding features to their systems drives up the costs beyond the point where most practices can afford the systems. Nowadays, a sophisticated system can easily cost more than $10,000 per physician.

More than that, without being sure, I suspect that most vendors are set up on business models that favor big sales to big organizations. To paraphrase a comment I heard at a recent meeting on EMRs, if it takes a six-person sales team to sell an EMR system and a consultant to install it, it pretty much has to be expensive. Or, to put it another way, no two-person practice is likely to be able to afford a system that needs a six-person team to sell. It's not surprising that some vendors have virtually written off small practices —“small” sometimes meaning practices with less than 50 physicians.

And consider this: “The business case” for an EMR system — the financial justification for the expenditure — often includes reference to the money saved on transcription. While it's true that the savings can be considerable if an EMR system really makes transcription unnecessary, how many small practices have the luxury of transcription now? The family physician in a small practice whose progress notes flow from the end of a pen would be hard-pressed to show significant savings in the ballpoint budget.

This is all particularly unfortunate given the promise that EMR systems hold — including clinical information that is more legible, more accessible, more searchable, and more usable than the paper equivalent, together with coding support, decision support, preventive care reminders, clinical flowcharts, and error-prevention tools such as drug interaction checkers. Why should only a small percentage of family physicians be in a position to benefit from EMRs?

First steps

The meeting I referred to previously, titled “Advancing Information Technology in Primary Care,” was organized by the AAFP to address this issue. It brought together representatives of the AAFP, the American Academy of Pediatrics, the American College of Physicians - American Society of Internal Medicine, and several vendors of EMR systems and related information technology. While I can't say that any solutions emerged from the meeting, several good ideas did arise, and it was promising as the beginning of a dialogue between the primary care specialties and the industry. For that matter, just opening the lines of communication between the specialty societies could prove to be quite useful in moving toward primary-care-friendly EMR systems and business models.

For now, however, small family practices that computerize their records will continue to be the exception. Adoption of EMR systems in these practices will continue to be driven largely by the adventurers and the enthusiasts in the specialty. But these early adopters are demonstrating that electronic medical records can have a place in the family practice — and even, to some extent, that they can earn their keep. The article in this issue by Matthew W. Levin, MD, describes the ultimate in small-scale EMR implementation: one physician, working virtually single-handedly to establish a computer network, install an EMR system on it, and make it work in his practice. The road Dr. Levin has taken is not for everybody, but he and other pioneers of the small-practice EMR system are helping to mark out what will eventually be a paved highway.