"The other key finding is the value of the incentives looks really different depending upon whether you are a small or a large practice. These economies of scale go really far in large practices and in small practices they don't go very far," she says. "When you are in a one- or two-man shop it is hard to find the person who can step back and say ‘what do we need to do differently?'"
"The other big things in the small practices are the types of changes you need to make. A lot of them are around reducing staff. In these practices it is often someone's husband or wife who is the front desk person or they have a person who's been with the practice for 20 years. Just because you have EHR you are not going to cut their work hours by half or one-third because on a personal level it is so hard."
"I can understand why there was a one-size-fits-all incentive, but this data suggests that the economics of the EHR adoption look different in different practices. If I am a policy maker I am going to be concerned about the impact this is going to have on small practices."
Even though small practices face a significantly higher hurdle to successfully use EHR, Adler-Milstein says she still believes adoption is worth the hassles.
"We need to move to EHR forward for a number of reasons, but if I am a small practice I am going to really think about a few things," she says. "One is how to decrease the cost of adoption and the cost of the system itself. To the extent you can reduce the upfront cost that is going to help bring down the amount you have to figure out how to make up elsewhere. Increasingly there are new models taking this into account for small practices to decrease the big upfront costs."