"I would never go backwards," says Valencia ophthalmologist Craig Helm, MD. "Having gone through the transition, I am sold on the benefits of electronic medical records."

As with every story of a doctor's office converting over to EMR from paper records, Dr. Helm's experience involved a great deal of pre-purchase study. Then followed the headaches of installation, implementation and training. But in the end, his office wound up with a system that works well. "It was difficult, and I would say it slowed us down at first. We lost efficiency initially, but by three months afterwards, we were running smoothly," Dr. Helm says. "We have been using more and more of the features of the software as time has gone on ... for instance, there's internal messaging within the system, which I find to be very beneficial--we don't have stickies all over my office door or my desk anymore. It's been great."

So what took Dr. Helm so long to implement an EMR? After all, electronic medical records systems are not exactly new. The answer is simple: "I would say cost," Dr. Helm responds. As every doctor knows, adopting an EMR is an enormous undertaking. Finding any mechanism to help defray the upfront cost would go a long way toward encouraging more offices to take the step into digital medicine. But help is hard to find.

"That's a question that we get a lot from the physician offices we work with that have not yet adopted a system," says Jennifer Clarke, a healthcare information technology consultant with Lumetra, a San Francisco-based healthcare consultancy and quality improvement organization--or QIO--for California. Asked what doctors can do to save money on or subsidize an EMR, Clarke and other sources tick off a surprisingly short list of options, three of which we delve into here. But for those physicians with the time and inclination to take advantage, they might well be worth the effort. One option is the recent relaxation of regulations resulting from a 1972 anti-kickback law and 1993 legislation by California Rep. Pete Stark. Another option, alternative pricing schemes, results from technological and organizational innovation among vendors. And then there is the mixed bag of quality reporting initiatives, which although capable of encouraging EMR adoption, are not entirely beloved by doctors.

The Costs of EMRs
The typical cost to implement an EMR system for a small office is around $10,000 to $40,000 for software and basic equipment, but that figure fluctuates wildly depending on several factors. "I think initially our outlay was about $45,000, but when we expanded to a new office, the licensing was an additional $20,000 to $25,000," Dr. Helm says about his practice's expansion from about 8 terminals to 25.

"We have eight doctors--in a year's time, we probably budgeted $100,000 for this, and the software was about $10,000 or $12,000," says Chester Griffiths, MD, a Los Angeles-based otolaryngologist. And like mushrooms after the rain, the sudden non-software costs spring from a large number of sources. "You have to have your printers, your scanners, your computers ... the actual software itself is like an afterthought. Then you need IT support for all of that--you need to have a technician who's available 24 hours a day, because if you go down, you don't have a medical record," he says. "You need to have everything backed up [with] fairly immediate access-recovery systems to get yourself back online. If you don't have that, you lose a whole day of patients and you're [in trouble]," he adds.

Dr. Griffiths also mentions the significant direct cost of training staff how to use a new EMR system, as well as the cost of lost productivity, due to time the practice takes out of the workday for training. Simply weighing the EMR options can take a real toll. "It's like going to buy a car and having four wives with you trying to decide which one would be the right one to get," says Erik Zeegen, MD, an orthopedic surgeon based in a seven-physician practice in Los Angeles. Since the market doesn't offer any EMR systems specialized for orthopedic surgery, Zeegen and his team worked hard to create templates that were geared toward their day-to-day work. "The other issue is at the beginning it totally changes the workflow," continues Dr. Zeegen. "I was used to seeing a patient, walking out of the room, picking up my Dictaphone and dictating a quick little note, in front of the computer and trying to figure out what I have to click next, how I can get this screen to pop up, how I incorporate this into my notes."

But if your practice manages to make it through to the other end, there are eventual savings to be had, both in direct dollars and efficiency. In addition to eliminating the cost of transcription, "once you get [menu navigation] down, it becomes a little smoother. There are certain situations where it's actually faster than the old way," says Dr. Zeegen. "You invest in it the first year, you break even the second year, and then you make some money or cost-save in the third year," Dr. Griffiths says, describing the approach his practice has taken. While scanning soon-to-be-obsolete paper records into an EMR can be expensive, and using the two systems at the same time harms efficiency, there are eventual savings that can balance out the costs, he says. For example, space formerly devoted to paper records can become productive clinic or office space. An EMR allows many doctors to stop retaining a medical record specialist. "I think it's probably a break-even at the end of the day," Dr. Griffiths concludes.