by Steve Lohr

A government-sponsored survey of the use of computerized patient records by doctors points to two seemingly contradictory conclusions, and a health care system at odds with itself.

The report, published online on Wednesday in The New England Journal of Medicine, found that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care. Yet fewer than one in five of the nation’s doctors has started using such records.

Bringing patient records into the computer age, experts say, is crucial to improving care, reducing errors and containing costs in the American health care system. The slow adoption of the technology is mainly economic. Most doctors in private practice, especially those in small practices, lack the financial incentive to invest in computerized records.

The national survey found that electronic records were used in less than 9 percent of small offices with one to three doctors, where nearly half of the country’s doctors practice medicine.

Dr. Paul Feldan, one of three doctors in a primary care practice in Mount Laurel, N.J., considered investing in electronic health records, and decided against it. The initial cost of upgrading the office’s personal computers, buying new software and obtaining technical support to make the shift would be $15,000 to $20,000 a doctor, he estimated. Then, during the time-consuming conversion from paper to computer records, the practice would be able to see far fewer patients, perhaps doubling the cost.

“Certainly, the idea of electronic records is terrific,” Dr. Feldan said. “But if we don’t see patients, we don’t get paid. The economics of it just seem so daunting.”

Private and government insurers and hospitals can save money as a result of less paper handling, lower administration expenses and fewer unnecessary lab tests when they are connected to electronic health records in doctors’ offices. Still, it is mainly doctors who bear the burden making the initial investment.

“We have a broken market for electronic health record adoption because the people who gain financially are not the people who pay,” said Dr. Blackford Middleton, a health technology expert at Partners Healthcare, a nonprofit medical group that includes Massachusetts General Hospital in Boston.

To fix the market, Dr. Middleton, like others, recommends that the government play a role in providing incentives or subsidies to speed the use of computerized patient records in the United States, whose adoption rate trails most developed nations.

The government took a step in that direction last week, announcing a $150 million Medicare project that will offer doctors incentives to move from paper to electronic patient records. The program is intended to help up to 1,200 small practices in 12 cities and states make the conversion.

Individual doctors will be offered up to $58,000 over the five-year span of the project, which is intended to test the impact of incentives on the spread of electronic health records. Further programs across the country are planned.

The report published in the journal also found that electronic health records were used by 51 percent of larger practices, with 50 or more doctors.

Indeed, electronic health records are pervasive in the largest integrated medical groups like Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic, University of Pittsburgh Medical Center and others. These integrated groups not only have deep pockets. By combining doctors, clinics, hospitals and often some insurance they can also capture the financial savings from electronic health records.

The findings of the study, which was paid for by the Department of Health and Human Services and a grant from the Robert Wood Johnson Foundation, broadly echo previous research on the adoption of electronic health records. Large medical groups have long been the early adopters, and small practices have struggled.

But the new study is based on a large sampling — more than 2,600 doctors across the country — and a detailed survey, making it more definitive than past research, experts say. The results, they say, also show a strong endorsement of electronic health records by doctors who have them, especially for what the report termed “fully functional” records, which include reminders of care guidelines, based on a patient’s age, gender or medical history.

For example, 82 percent of those using such electronic records said they improved the quality of clinical decisions, 86 percent said they helped in avoiding medication errors and 85 percent said they improved the delivery of preventative care.

“Those numbers are huge and very encouraging,” said Dr. David J. Brailer, the former health information technology coordinator in the Bush administration.

Dr. Brailer also pointed to the 54 percent of doctors without electronic health records who said that not finding an electronic health record that met their needs was a “major barrier” to adoption. In short, they are not satisfied with the existing products, which tend to be designed for hospitals — big customers — instead of small practices.

“What we see is a deficit in innovation, and that is something innovators and the capital markets can address,” said Dr. Brailer, who leads a firm that invests in medical ventures, Health Evolution Partners.

One wave of innovation is coming from big technology companies, like Microsoft and Google, which recently have begun services that offer consumer-controlled personal health records over the Web, which are stored in the companies’ data centers. These consumer-controlled health records are intended to link up and exchange information with electronic patient records in doctors’ offices and hospitals.

Dr. Peter Masucci, a pediatrician with his own office in Everett, Mass., embraced electronic health records to “try to get our practice into the 21st century.”

He could not afford conventional software, and chose a Web-based service from Athenahealth, a company supplying online financial and electronic health record services to doctors’ offices.

Dr. Masucci was already using Athenahealth’s outsourced financial service, and less than two years ago adopted the online medical record.

Today, Dr. Masucci is an enthusiast, talking about the wealth of patient information, drug interaction warnings and guidelines for care, all in the Web-based records.

“Do I see more patients because of this technology? Probably no,” Dr. Masucci said. “But I am doing a better job with the patients I am seeing. It almost forces you to be a better doctor.”