With electronic files, patient records are not stuck on pieces of paper in endless files, but are on a screen at the touch of a key. The computers alert doctors to do medical tests and avert errors by warning when they write a prescription for the wrong drug or the wrong dose. Patients can often see their own files and even make their own appointments, online, from their homes.
But most doctors have balked. The systems cost tens of thousands of dollars, and doctors worry that the companies selling them and providing support will go out of business. Many use computers to file health insurance claims, but only 20 percent to 25 percent of the nation's 650,000 licensed doctors outside the military and the Department of Veterans Affairs are using.
Now, however, Medicare, which says the lack of electronic records is one of the biggest impediments to improving health care, has decided to step in. In an unprecedented move, it said it planned to announce that it would give doctors--free of charge--software to. An office with five doctors could save more than $100,000 by choosing the Medicare software rather than buying software from a private company, officials say.
The program begins next month, and the software is a version of a well-proven electronic health record system, called Vista, that has been used for two decades bywith the Department of Veterans Affairs. Medicare will also provide a list of companies that have been trained to install and maintain the system.
Given Medicare's heft, the software giveaway could transform American medicine, said Dr. John Wasson, a Dartmouth Medical School health care researcher.
But, Dr. Wasson added, it may take a while. "If you look at it from a five-year point of view, it will make a huge difference," he said.
At first, he predicted, many doctors will bide their time, to see just how good Vista is.
Dr. Alan Garber, a Stanford University economist and internist, said of the Medicare plan: "It's a good idea. It's not foolproof."
But, Dr. Garber added, Medicare's investment and the program's many appealing features "are all signals that it might be around for a long time and a doctor in a small office would not be taking an enormous risk."
Medicare has not estimated what its software giveaway is worth. But Duncan Pringle, chief Vista technologist at Perot Systems, said that each doctor in a practice paid about $20,000 to $25,000 to get started with a commercial system, including costs of software, a license fee charged to each doctor, installation and servicing.
Installing Vista would cost $10,000 to $12,000 for an entire medical practice. That means that a practice of five doctors might pay $100,000 to computerize, but if the doctors used the Medicare system they might pay only $10,000 for the whole office.
A pricey prescription
The problem is that Vista has a reputation for being extremely difficult to install. Medicare says it modified and simplified it for doctors' offices, but it remains to be seen whether doctors will want it.
Doctors are well aware that even with free software, no system is really free.
"Vista is a good system and it all sounds great," said Dr. Thomas Jevon, a family physician in Wakefield, Mass. But, he added, "anyone who uses a computer can get frustrated and waste time trying to make it work."
And for doctors, whose time is typically valued at $250 an hour, that time adds up.
"If a program takes 10 minutes away from your hour each day, that is costing you tens of thousands of dollars a year," Dr. Jevon said. "That's what's bugging doctors."
There is little doubt that computerized offices can help. For instance, Dr. Kevin Toppenberg recently saw an emergency patient who had injured his leg at the beach and arrived at his office wincing in pain. The patient's regular doctor, one of Dr. Toppenberg's 14 colleagues, practiced in another of the group's three offices in Greeneville, Tenn., and was taking the day off.
In a typical medical practice, the man's records would ordinarily be in a paper file in his own doctor's office and a colleague in another office would have no way of getting them. Dr. Toppenberg, like many other doctors, would rather send such a patient to an emergency room than see him without a medical record.
"To just be working blind is scary for doctors," Dr. Toppenberg said.
But Dr. Toppenberg's newly installed computer program let him see the man's record immediately, on a computer screen. After examining the man and diagnosing a probable torn muscle, Dr. Toppenberg sent him to an orthopedist. Then Dr. Toppenberg added his findings to the man's record so his colleague would have them instantly when he needed to consult them.
The Vista project began a few years ago when Medicare officials realized that help for small medical practices was in its own backyard. The federal government had already paid hundreds of millions of dollars to develop Vista, and now uses it in the Veterans Administration's 1,300 inpatient and outpatient facilities, which maintain more than 10 million records and treat more than five million veterans a year. Why not give Vista to doctors?
In fact, though few knew, Vista had been available all along to anyone who submitted a Freedom of Information Act request.
Over the years, the program had accrued a passionate following and even an organization, World Vista, founded in 2002 mostly by V.A. employees to help spread it throughout the world. One reason for their enthusiasm was that no company owns Vista so anyone can modify and enhance it.
It is, said Joseph Dal Molin, director of World Vista, a survival of the fittest. "What's good survives," he said.
One feature, for example, was suggested by a V.A. nurse. Why not put a bar code on a prescription bottle to identify the drug and its dose, put a bar code on the patient's wristband to identify the patient's prescription, and then scan the drug label and the patient's wristband before administering a drug? If there was a discrepancy, Vista could catch it before an error was made. Programmers added that feature, and V.A. drug errors plummeted by 80 percent overnight.
Help from the Hardhats
Still, it is one thing to use a system that someone else installed and someone else maintains. It is another to get a set of disks in the mail and do it yourself.
Giving out a version of Vista is "a great idea," said Dr. David Kibbe, director of the center for health information technology at the American Academy of Family Physicians, a group that has been working on the project. "But at the beginning, there was a lot of wishful thinking. They said, 'We'll just release it.' I said, 'Where's the fairy dust?' "
Those who tried to install Vista on their own would agree.
Dr. Nancy Anthracite, a family physician in Washington, needed endless hours of help from a group of Vista enthusiasts who call themselves the Hardhats and volunteer their time. Getting started with Vista was so daunting, Dr. Anthracite said, that even when the V.A. demonstrated its program at medical meetings, almost no none of those in attendance wanted to use it on their own.
"You go to meetings and they show you things doctors can do with Vista and everyone's going , 'Wow, wow, wow,' " Dr. Anthracite said. "But no one installs it."
So for three years, Medicare and its contractors worked to make the program easier to use.
They even gave it a new name, VistaOffice, to signify that was intended for small-office practices, not the huge V.A. system.
Some, including Dr. Toppenberg, decided not to wait for the August release of the new program. Last year, he learned that he could get the unmodified V.A. version of Vista and decided to try it.
"I started looking around," Dr. Toppenberg said. "The newer systems tended to be about $15,000 per doctor, not counting the ongoing support fees. Then I found out that the Vista system was available. You just have to figure out how to get it to work."
He did--but it took him six months.
Anyone who wants the new Vista, which is expected to require far fewer steps to install than the V.A.'s version, must wait until August. Some, like Dr. Meyer Cohen, an internist in Boca Raton, Fla., want to see how it works before committing time and money to it.
But a few, like Dr. Ismet B. Kursunoglu, director of the Alaska Clinic in Wasilla, Alaska, cannot wait.
"There are a lot of fantastic vendors," Dr. Kursunoglu said, "but, realistically, we're in a time period where reimbursement is going down and costs are rising. This is free."
"This," he said, "is a fantastic opportunity."