EMR adoption in small practices

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The past year has seen some important changes that could help drive electronic medical record (EMR) adoption.


The health IT community is recognizing we are unlikely to meet President Bush’s target of comprehensive EHR adoption by 2014 (1). Multiple studies cite low rates of adoption in practices, especially smaller practices, which constitute 60% or more of the care delivered. Adoption will occur, but not until 2024 based on predictive modeling (2).

In Health Information Technology in the United States: the Information Base for Progress, the factors influencing adoption decisions include financial incentives/barriers, laws and regulations, technology barriers, and organizational influences (3). The local physician community also influences the adoption decision in small practices (2).

Stark and anti-kickback law revisions

Three recent changes can influence the rate of adoption. The first are the revisions in the Stark regulations (CMS) and Office of the Inspector General anti-kickback laws (October, 2006). These changes now make it possible for hospitals to share technology with physicians (4). The revisions were enhanced by an IRS ruling in April, 2007 clarifying the tax implications for hospitals, particularly non-profits who were concerned about potential threats to their non-profit status (5).


The next change is an extension of the CMS DOQ-IT project. In April, 2007 DOQ-IT U became a web-based educational support system, accessible to anyone with access to a web browser (6). The training modules include guidance in the analysis of a medical practice as it prepares to make a decision on EHR adoption, and implement the system. research papers

ASP and Utility Computing

The third change involves evolution of technology and the marketplace. Smaller practices are now looking at application service provider (asp) models as a lower cost option to integrate an EHR into their practice. The asp model shifts EHR adoption from a capital expense to an operational cost for small to mid size practices, while shifting the burden of system maintenance (hardware, software, security) to the service provider. For small practices, these are fundamental shifts that make EHR adoption feasible (7).

While the asp model has been around, its application to EHRs is still emerging. It is interesting to note that DOQ-IT U gives only brief treatment to the model, reflecting its recent emergence.

Not even mentioned is the advent of a utility model of service delivery (8). Under this model, practices can choose from among qualified vendors, and can bundle their service package, combining EHR with practice management applications, for instance (9). The asp/service model is not for all practices, as noted by First Consulting Group. However, for small practices that have reliable broadband access and lack extensive technology skills/support it is an important option that could accelerate EHR adoption to attain a tipping point (9).


  1. Ackerman, K. Report finds low ehr adoption rates. iHealthBeat. 2006 October 12.
  2. Ford, E.W., Menachemi, N., Phillips, T. Predicting the adoption of electronic health records by physicians: when will health care be paperless? Journal of the American Medical Informatics Association. 13(1):106-112, 2006 Jan/Feb.
  3. Blumenthal, D., Jha, A. Health information technology in the united states: the information base for progress. Robert Wood Johnson Foundation. 2006 Occtober.
  4. First Consulting Group. Loosening the rules for hospitals providing the computers to physicians, executive insights. 2007 January.
  5. Harlow, D. IRS finally green-lights hospital underwriting of physician EHR systems. 2007 May 14. http://healthblawg.typepad.com/healthblawg/2007/05/irs_finally_gre.html
  6. Medical News Today. Centers for medicare & medicaid services launches DOQ-IT university, USA. 2007 April 16. http://www.medicalnewstoday.com/medicalnews.php?newsid=67899
  7. First Consulting Group. Physician practices: are application service providers right for you?. 2006 October.
  8. DOQ-IT University. SCORM Course Window. Assessment/budgeting for your ehr/how to finance the ehr?
  9. Steve Waters, President, Semper Vivo. Personal interview conducted 2007 April 13.