Digital divide widens in medicine

Dr. Lynda Young wants to track her patients' healthcare by computer instead of through the paper files stacked in her office.

Larger physician networks in Massachusetts are already reaping the rewards of going digital. But the $120,000 price tag for getting wired stands in Young's way, putting her small Worcester practice of three pediatricians at a competitive disadvantage.

''I would love to go to electronic medical records," she said. ''The bottom line why we haven't done it, obviously, is cost."

Nationally, the state is in the vanguard of electronic medical record keeping -- not surprising given the high concentration of teaching hospitals and medical technology. But most of the computerization of records is being done by large physician organizations with more resources, creating a widening technology gap in the medical community.

Physicians who use computers can monitor patients' care more efficiently and reduce the possibility of medical errors. As a result, they consistently score better in quality surveys. Moreover, they earn 3 to 4 percent more money in ''pay-for-performance" contracts with health insurance companies.

But thousands of doctors like Young remain on the sidelines, mired in paper and in danger of falling further behind the field.

Computer systems for medical records cost $10,000 to $60,000 for each physician. They require training doctors and office staff, which can be disruptive, and extensive manual data entry to transfer records.

''You have to be determined -- this is what you want to do," said Dr. Thomas Rosenfeld, a Worcester dermatologist who integrated electronic records into his small practice. ''Many times I thought I wanted to throw the computer out the window when I first switched."

Doctors also worry about investing in equipment that will become obsolete in a year or two, said Dr. B. Dale Magee, a Shrewsbury gynecologist and obstetrician who is vice president of the Massachusetts Medical Society and a major supporter of computerized medical records. The society is attempting to help small practices by providing lists of recommended vendors and offering to review office workflow to ease the transition from paper.

Without electronic records, physicians will have difficulty performing in the future under insurance companies' pay-for-performance contracts, said Christopher M. Jedrey, a healthcare lawyer at the Boston firm of McDermott Will & Emery.

The trend, he said, ''may lead to a world of haves and have nots."

Estimates vary, but 20 to 25 percent of the 30,000 doctors in Massachusetts have incorporated electronic medical records or an electronic medication prescription system into their practices. The majority are affiliated with large academic medical centers and physician groups like Partners Community HealthCare, Harvard Vanguard Medical Associates, Lahey Clinic, and Beth Israel Medical Center's physicians organization. Nationally, about 10 to 15 percent of doctors use electronic systems.

The clinical benefits of computerized records are clear to advocates, especially when it comes to primary care. Not only do the systems automatically warn doctors about dangerous drug interactions or allergies, but physicians can review medical tests online, send out reminders to patients to get tests and checkups, and monitor the health of patients with similar diseases.

The systems also allow them to better focus on patients who are the sickest and to control factors like diet, weight, and medications. That capability will help improve doctors' scores on quality-rating websites operated by insurance companies and organizations like Massachusetts Health Quality Partners, a nonprofit that today is expected to release scores for 150 medical groups.

Some doctors, particularly specialists, see little benefit in moving to electronic record keeping. Dr. James F.X. Kenealy, an ear, nose, and throat specialist in Framingham, said he is reluctant to invest in computers because his major sources of referrals are three primary care practices plugged into separate computer networks that can't communicate with one another.

''It's going to be very difficult for individual physicians to function as small independent practitioners in this environment," Kenealy said. ''You are going to see over time an amalgamation of individual physicians into groups."

And that could affect the relationship between doctors and their patients, he said. In larger groups, ''That individual connection can get lost."

Supporters of electronic record keeping say the ultimate goal -- better patient care -- is worth pursuing, and that the biggest players in the marketplace have a responsibility to lead the way.

Partners Community HealthCare, which is affiliated with Massachusetts General Hospital and Brigham and Women's Hospital, wants to use computers to more closely link its network of 5,900 physicians, allowing it to more accurately measure the health outcomes of its patients. It has 2,600 doctors already wired, and is working to get another 1,700 onto its computer systems, including 1,400 who practice outside of the major teaching institutions.

Dr. Thomas H. Lee, chief executive of the Partners physician group, said it is imperative for the system's small practices to join the rest of the system, because being able to demonstrate improved performance and patient care is going to directly affect a physician's ability to compete.

''At the end of the day, the reason to make this transition is its qualitatively better care," Lee said. ''The goal is to make patients better, not to preserve the way of life of autonomous single physician practices.

''If you don't perform well, you're not going to be able to grow. You're going to lose market share," he added.

Harvard Vanguard has established Health One, a physician network with about 700 doctors that is organized in large part around a networked computer system. The 70 doctors at Dedham Medical Associates decided to join HealthOne in part because electronic medical records were too expensive for it to finance alone, $1 million a year for seven years, said Dr. Michael Lee, Dedham Medical's former president.

Tufts-New England Medical Center established a physician group last year that will build a new computer system. Tufts-NEMC chief executive Ellen Zane said the system will be attractive to independent physicians who want more access to technology.

''I just don't see how doctors can stay in the game unless they are somehow plugged into an electronic medical record," said Zane.

Computerization may have plenty of backers, but public money to help fund the effort is scarce. President George W. Bush, in his state of the union speech last month, pledged to introduce wider use of the records, although his proposed 2007 budget only includes $169 million for healthcare technology initiatives, up from $100 million in 2006.

In an effort being watched around the country, the Blue Cross and Blue Shield of Massachusetts Foundation, a charitable arm of the state's largest health insurer, is bankrolling a $50 million experiment to wire virtually all hospitals, health centers, and physicians offices in Newburyport, North Adams, and Brockton.

Blue Cross and Blue Shield also is trying to seed the market with $5,000 annual incentive payments for individual community physicians who invest in computers for their offices. The company says it signed up about 1,700 Massachusetts doctors for the incentives in 2004 and estimates an additional 300 participated in 2005. Harvard-Pilgrim Health Care offers doctors incentives on a sliding scale to install technology. A doctor with a full electronic record and 350 Harvard Pilgrim members would receive an additional $4,200 a year. Tufts Health Plan has a website that allows doctors to log in and track what tests and services patients have received.

Even with incentives, some doctors don't intend to adopt computerized records, because they are in the twilight of their careers. Dr. Robert Lebow, a solo internist in Southbridge, is 61 years old. He said he might not be in business long enough to see a return on an investment of tens of thousands of dollars. He's not worried, either.

''I'm a bright guy. I'll figure out a way around it," he said. ''I've figured out a way to survive until now."

Christopher Rowland can be reached at crowland@globe.com.