There are secondary costs as well. Staffers must learn a new EMR system and often must change their business practices to accommodate the way it works. In some cases, the implementation of a system can take four to six months and cut back the number of patient visits by as much as 50 per cent, says Grannis. "That's a big barrier to face. And they're not computer scientists, so it's a strange new world," he says. While practices do see some savings by reducing costs in areas such as filing, "none of these value propositions are home runs," says Grannis.

HL7's Jaffe says that if the market isn't providing incentives to doctors to make the transition, the government should do so in order to improve public heath. "In the US, [the government] has budgeted $75 million for health care IT. In England, it's £1 billion. It's disheartening," he says.

The US Department of Health and Human Services does have one small program under way. In what project officer Jodi Blatt calls a "pay for performance demonstration," the Centers for Medicare & Medicaid Services are in the process of recruiting 2,400 practices in 12 locations this year to participate in a study. Physicians can earn up to US$58,000 -- group practices up to $290,000 -- in incentives over the course of the five-year program by demonstrating improvements in patient care as a result of having implemented EMR systems. "We believe the incentives are substantial enough to reduce the barriers to practices," she says.

However, there are 921,904 physicians, 723,118 practices and 5,756 hospitals in the US, according to the American Medical Association and the American Hospital Association. Given those numbers, it's not clear that the incentive program will enable the industry to meet President Bush's stated goal that it provide most Americans with interoperable EHRs by 2014.

Brokered Solution

If all hospitals and physicians used EMR systems and met the standards for interoperability, more regional exchanges -- and even national information exchanges -- could start to develop. "A hospital in Miami could contact a hospital in San Diego and do some sort of exchange. That's in the ideal world," says Blatt.

But who will pay for that remains unresolved. Grannis says Regenstrief is working to find a sustainable economic model for health information exchanges by providing value-added services beyond basic health-record sharing. For example, the institute has received separate, ongoing funding for a service that uses data in the EHR exchange to quickly identify disease outbreaks. But today, Grannis acknowledges, the exchange still depends on "a patchwork of funding."

He says he thinks that efforts by Microsoft, Google and others to build personal health record repositories -- Web-based services where individuals can aggregate health records from multiple providers and add their own data -- will put pressure on the industry to embrace EMRs. But it will be too complicated and costly for providers to establish bidirectional transfers with every other provider. Local exchanges such as the one in Indianapolis will be required, and to assuage competitive concerns, neutral third parties will need to step in to manage those exchanges, Grannis says.

That's the tack taken with the nonprofit Massachusetts Health Data Consortium's MA-SHARE program. It enables the exchange of clinical document summaries and e-prescribing data among 17 hospitals, using Web services protocols. But even in Massachusetts, with its many advanced teaching hospitals, 50 per cent of doctors still don't use EMRs, and Halamka's nirvana of consolidated EHRs that follow the patient remains a distant vision.