"Nirvana is when in every transition of care, a clinical summary will be pushed to the next caregiver," says Halamka. Today, that information is still printed and forwarded on paper. If the patient is lucky, his new provider may scan the paper records into its own system, where they will be available as viewable but nonsearchable image files.

Robert Smith is associate chief of staff for health care analysis at the Veterans Administration San Diego Health Care System, which also participated in the regional exchange discussions. He thinks that the advantages in quality of health care and patient safety are "worth every cent."

The VA has developed its own EMR system and can share patient data with any VA hospital in the country, as well as with some US Department of Defense medical facilities. But VA San Diego can't exchange data with non-VA health care providers that its patients use.

The Duke University Health System has integrated the data from its disparate systems to create a unified EMR system. CIO Asif Ahmad says the benefits have been worth the considerable effort involved. The hospital is using business intelligence tools to comb through clinical data in an effort to improve the quality of patient care and is using predictive analytics to help avoid potentially adverse reactions to drugs and improve patient safety. But it is not yet sharing health care record data outside of its own provider network.

Show Me the Money

The lack of consistent standards and the plethora of proprietary vendor offerings contribute to the problem, but those issues are slowly being resolved. Improving interoperability will make building an EMR infrastructure and EHR exchanges easier and cheaper, but it won't solve the incentive problem.

First, there are the upfront costs for getting all practices on EMR systems. Leavitt says the typical cost of such a system ranges from US$15,000 to $50,000 per doctor. "Smaller practices can't amortize it," he says.

"Doctors are not going to do this on their own," says Halamka. "Hospitals have to pay for them to acquire it, and payers have to provide incentives for them to use it."

He says thanks to a 2004 reinterpretation of the Stark Law -- federal legislation that prohibits doctors from receiving subsidies from institutions to which they refer patients -- hospitals can subsidize up to 85 per cent of nonhardware implementation costs for private practices. By using a software-as-a-service model for delivering EHR systems, those practices can reduce upfront hardware costs. "Software as a service is cheaper because of economies of scale achieved through central hosting and procurement," Halamka says.

But although Beth Israel Deaconess has made it a policy to offer EHRs to nonemployee doctors, many hospitals, faced with tight budgets, are unlikely to fund such programs without an economic incentive to do so.