Last year, the US government set aside $19 billion in stimulus funds to lure providers into adopting electronic health records (EHRs). But while large hospitals and networks take the lead, small physician practices, which make up the majority of health care providers, could lag behind.

Under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, there are financial incentives for doctors who digitize, as well as penalties for those who don't. The effects, however, are relative; larger providers face larger incentives and penalties, whereas smaller providers might find that the cost of implementation cancels out the incentive.

The numbers might even go so far as to make it financially optimal—at least in the short term—to stick with paper records and pay the penalty: a 2009 study by the advisory firm Avalere Health found that upgrading to EHRs could cost $124,000 for a single doctor or small practice, easily outweighing the $44,000 in government incentives, as well as the $5,100 yearly penalty for nonadopters.

On file: Small clinics cling to paper trail Credit: Istockphoto

And for years small practices have indeed lagged behind. In a survey of nearly 2,800 physicians, those in practices of five or fewer doctors accounted for nearly half of all physicians who hadn't yet adopted EHRs (N. Engl. J. Med. 359, 50–60; 2008). Similarly, a 2003–2004 survey by the US National Center for Health Statistics found that only 13% of physicians in a practice of four or fewer used electronic medical records. Those same physicians, however, accounted for nearly three-quarters of ambulatory care visits at that time.

Not just a modernization issue, the electronic records gap could prove a problem for research, too. The government's Agency for Healthcare Research and Quality (AHRQ), for example, is putting $300 million in stimulus funds toward comparative-effectiveness research—studies comparing one treatment option to another—with projects including a national network that would cultivate data from EHRs.

Although the network would be able to incorporate smaller practices and their data, that may be a ways off. According to Jean Slutsky, director of AHRQ's Center for Outcomes and Evidence, future research “will take advantage of existing EHR networks,” but whether small practices are ready to contribute their vast data in the near term “is up for question.”

Reeling in small providers, then, might require extra help from Washington. Last June, Kathy Dahlkemper, a congressional representative from Pennsylvania, introduced a bill that would establish a government loan program for small-practice physicians who want to implement electronic systems. As Nature Medicine went to press, the bill was still in the hands of a Senate committee.