For many physicians in small office practices, the thought of adopting electronic medical records to meet federal "meaningful use" guidelines and timelines is a daunting one at best.

"There's a whole bunch of obstacles that are making us hesitate," says Paul Speckart MD, a San Diego internist in a five-physician practice. "We're in a different spot than the large hospital-owned clinics and practices, in that all of the EMR burden falls squarely on our shoulders."

For starters, he says, doctors aren't sure the systems they buy will be "interoperable" with their hospitals or will meet certification standards. And they're not sure the government will make good on its promise to provide stimulus reimbursement.

And what if they need interoperability with several hospitals where they have staff privileges, but those hospitals are on different systems?

"We get promises that there will be bridges. But who's going to be making these bridges, and who's going to be paying for these bridges?" he asks. He says the large Scripps hospital system, where he has staff privileges, has not said it intends to provide that for independent practices.

The estimated cost, he hears, is "between $60,000 to $80,000 to start, plus the maintenance. That's a lot of money," when doctors are facing possible Medicare pay cuts of 21.5% in March.

Speckart, whose practice now has some electronic systems to exchange imaging, pharmacy, and lab reports, believes that EMR systems have great potential to improve quality of care because of their reminders and communication with hospitals.

"But you have to remember, we feel like we're at the battlefront, and people are shooting at us day and night. We're not interested in great grand performance, because we're worried the next shot will get us. You open the doors and hope you survive until the doors close at night."

Steve Waldren, director of the Center for Health Information Technology for the American Academy of Family Physicians(AAFP), agrees that many of his 95,000 member doctors are delaying implementation because of worries about buying the wrong system.

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