On the landscape of American healthcare, a small medical practice in northwest Indianapolis is an outlier.

For the past seven years, Oliver Family Healthcare has used a fully electronic system to manage the practice. Everyone in the organization has a laptop or tablet computer. The office issues electronic prescriptions and makes electronic referrals. Its patients benefit from automated disease and health maintenance management. And a computer application mines patients' data and, when necessary, prompts calls to schedule visits"up to 2,500 appointments per month.

"The only time we use paper is when we get it from outside," says Dr. Gregory Oliver, the practice's only doctor. "We scan and shred."

One-doc shops that leverage health IT to the extent that Oliver's family practice does are about as common as doctors who make midnight house calls. According to the National Center for Health Statistics, solo practitioners make up about one-third of physicians and comprise about two-thirds of medical practices, yet they "are the least likely to use EMRs."

The percentage of family physicians at small practices who use electronic health records will be a leading indicator of progress toward the computerization of American healthcare. Raising that vital statistic is a primary goal of health IT provisions in ARRA. The law provides billions of dollars of incentives"$44,000 for doctors who become "meaningful users" of health IT"to promote adoption of information technology, particularly among general practitioners.

The goal is to create a cohort of 100,000 doctors who forego paper charts in favor of electronic medical records. Considering the negligible rate at which doctors now use health IT, it's safe to assume that reaching that goal, even with cash incentives on the line, won't be easy.

That is why Congress provided an additional $600 million for the creation of a national network of 70 extension centers that will help small family practices adopt health IT. A National Health IT Research Center will support the regional offices through consolidation of best practices and other activities.

"It's not just about technology, it's about changing the practices to make sure we get out of the technology functional interoperability in information exchange," said Dr. Farzad Mostashari, ONC senior adviser to the Office of the National Coordinator for Health IT, during a recent Web conference.

While ONC has been taking steps to set up a vast system of tech support, Government Health IT has been talking to a cross section of doctors, administrators and health IT consultants about the challenges of making the transition to electronic records. What types of IT and business training is most needed by small and medium-sized practices, we asked. What health IT curriculum should regional training centers prepare?

The Soloist
Dr. Oliver became interested in electronic records by accident. In the mid-1990s, he sold a growing practice"15 doctors and four offices"and became an employee of the purchaser, a hospital that asked him to investigate clinical EMRs. The hospital opted against buying the system recommended by Oliver, who by then had become a believer in the technology's potential to transform healthcare. Rebuffed, he left the hospital and started a new medical practice that would run on health IT.

"The day we started over was the day we started using electronic health records," said Oliver, who works with a nurse practitioner and two physician assistants.

It wasn't a completely smooth transition. The first mistake he made was to buy an EMR and a practice management system from different companies, assured by the vendors that the systems were compatible. They weren't.

Vendors "have a way of making everything look nice and rosy," says Oliver. "After two years we scrapped our practice management system, took a hit on the lease and bought a new system."

Despite the initial mis-step, going electronic paid for itself in the first year, saving $39,000 in transcription costs and $60,000 in salaries. Greater efficiencies allowed his practice to serve more patients.

"We've seen dramatic financial improvement," says Oliver, who intends to use the federal incentive money to purchase more IT, including waiting-room kiosks that will let people sign in and electronically remit co-pays.

When shopping for health IT, it is a mistake to make cost the sole selection criteria, says Oliver. He has discerned a common thread among colleagues who are dissatisfied with their electronic records.

"Everytime, they decided to go with something less expensive or cheap," he says. "You do get what you pay for."

Recognizing that even the best technology is only as good as its users, Oliver is an advocate of ongoing training. Every year he closes the practice for a day or two and sends his providers to a national training event put on by Allscripts.

Extension centers will be a welcome resource if doctors view them as honest brokers "with no horse in the race," Oliver says. "The key to everything is training."

The Consultants
To win over doctors, extension centers must overcome perceptions that can prejudice doctors against electronic records, consultants say.

"Their perception is that it will slow things down," said Dr. Kip Webb, a clinical-transformation consultant for Accenture.

That can be true at the outset as "doctors [who] never learned to type" and their front-and back-office staff adjust to new workflows. Adopting electronic records can also reveal previously unknown variations in the ways colleagues practice.

"The way doctors practice is a black box. They have no clue what the practice next door or their partners are doing," says Webb. "Initially, it will be very confusing."

Other impediments to a smooth transition include health-care providers who push back against clinical decision support services or other electronic features designed to prevent medical errors, such as warnings about drug interactions.

"Some doctors look at alerts as a nuisance." Webb said. "For some, it's an encroachment on their autonomy." Overcoming that resistance requires a pedagogical style that doctors are familiar with: instruction delivered in a clinical setting by an experienced mentor.

"Doctors like hands-on, just-in-time, super-user type training," Webb said. "They like doing [training] side-by-side with someone. There will be a real need [for extension-center trainers] to be at the doctor's elbow, showing them how to use the systems."

Variations in the way individual doctors practice medicine is complicated by the broad range of medical problems routinely encountered by primary care doctors.

"You see 20 patients a day and each person has a unique problem," said Daniel Inscore, an electronic medical records consultant with EthosPartners Healthcare Management Group. "Never underestimate the amount of training you need to prepare yourself for an implementation of EHRs. The worst thing is to be in front of a patient and not know how to get to the documentation piece of gallstones."

Making the transition to electronic records also requires a deep understanding of IT needs and entrenched workflows. Inscore advises using a third party to assess the current state of practice, including documenting the typical day in the lives of clinicians and patients.

"Vendors will recommend the best of the best. That can be overkill," says Inscore. An independent audit can determine needs and enable practices "to recognize red flags that would be impacted by the EMR, Inscore said. "The advice would be to truly understand day-to-day operations."

Preparing small practices for the nontechnical changes that accompany adoption of electronic records