A new analysis by a Washington health care consultancy suggests that despite the incentives for adopting e-health records in the stimulus legislation, some doctors may be better off financially sticking with pen and paper.

The stimulus law calls for giving Medicare providers up to $44,000 apiece for adopting e-health records and reducing their payments by up to 5 percent if they fail to use EHRs by 2015.

But the Avalere Health analysis concludes that a doctor still will have to shell out $70,000 over five years for an EHR system, or about $14,000 a year, beyond the incentive payments. The maximum penalty for non-adopters would amount to $8,500, Avalere officials said.

"These are incentives" in the stimulus bill, "not 100 percent subsidies," said Jon Glaudemans, a senior vice president of Avalere.

He said the gap between the cost of EHRs and the incentives will be felt most acutely in practices with one to three physicians -- the same practices that so far have been most resistant to using health IT. Practices with fewer than four physicians account for half of all medical offices nationwide.

Glaudemans said the federal government can encourage doctors to adopt health IT by clarifying speedily how the new law will be implemented. For example, the incentives can be paid only to doctors who demonstrate they are making meaningful use of the EHR technology.

"We need to define meaningful use sooner rather than later," Glaudemans said. The Department of Health and Human Services will issue regulations to clarify this point and others. HHS also must define minimum interoperability standards for qualifying systems.

Despite the lack of a Senate-confirmed HHS secretary, Glaudemans said, "I think there's a general sense of urgency at the department" and rule-writers already are at work.

"Absent this guidance, even the most enthusiastic provider may defer HIT investments indefinitely," in view of the subsidy levels and the economic climate, he added.

The Avalere analysis relied on figures published by the Agency for Healthcare Research and Quality, which found the average EHR implementation cost $32,606 per physician, although smaller medical practices paid nearly $5,000 more. AHRQ estimated monthly maintenance and training costs at $1,500.