John brought up another important point: money.

Worthen: The leadership of our organization has understood that it is very hard to measure the ROI in strictly dollar terms. If you look at the better quality of care that we can practice, if you look at the better clinical outcomes and so forth, you can't necessarily translate those immediately into dollars. So they have not been very demanding compared to what they would probably want to see if we were to get a new machine of some sort.

Glaser: The advice that we would give is to plan out the nature of the mission, realizing there are limits to what you can do. Depending on your market, deploying an EHR is becoming something you have to do competitively. It is like online banking. [If you're a bank], you have to do it if you want to be around.

I think for a larger organization you can get an ROI. It takes a lot of work to get it, but you can get it. I do think there is a need for capital contributions for smaller organizations, which don't have much in operations to begin with. It's harder to get these ROIs. There are no clerks to [lay off] and not all that much process to make more efficient.

Brailer: We should bear in mind that, particularly in physicians' offices, the discussion about ROI is often moot. I say that because providers with EHRs bill markedly more. Doctors call this "better charge capture". Payers [such as Medicare and insurance companies] have a less friendly way of viewing this increased payout.

But whatever it is called, when EHRs go in, billings increase. I think doctors' groups have appropriately said that with these technologies, doctors have the ability to provide more documentation and to support and justify their work. But in the end, Medicare and other payers look at the money, and this is causing them to take a negative view of the financial promise of health information technology. In their view, these tools may or may not save money in the long term from safer care, but they are certain that they cost them a lot more in the short term.

Medicare and other payers pay for the volume of procedures doctors provide, not for quality or efficiency. Therein lies the challenge for IT. We can push IT a long distance, but the transformation will only occur when there are market fundamentals aligned toward quality.