Carousels that used to hold paper medical charts sit empty in nurses' stations at Kaiser Permanente Medical Center in Fresno.
At Children's Hospital Central California in Madera County, doctors grab a computer -- not a pad -- to write prescriptions.
And in the emergency department at Kaweah Delta Hospital in Visalia, laboratory results pop up on computer screens.
It's all part of a sweeping move toward electronic medical records at hospitals and medical offices across the country.
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There are many reasons to make the switch: Electronic medical records improve efficiency and reduce medical errors, health experts say. Doctors and nurses don't have to run around the hospital searching for charts. Nurses don't struggle to decipher scrawled doctors' orders. And computers flag doctors when they prescribe a drug that could cause an allergic reaction or dangerous interaction.
But there are obstacles. Building an electronic-records system can be expensive. A doctor in solo practice can spend $150,000. Big hospitals can spend millions.
Yet hospitals in the central San Joaquin Valley are moving to electronic medical records as fast as they can, hoping to cash in on millions of dollars in federal stimulus money available to help them join the electronic age.
Adding to the urgency: Medical providers face penalties if they don't make the electronic transition by 2015. They could see reduced Medicare and Medicaid payments from the federal government.
It's inevitable that paper patient charts will disappear, health experts say.
"At some point, everyone will have some form of electronic medical record," said Sean McFarland, a nurse at the veterans hospital who has a master's degree in nursing informatics, an emerging field of health information technology.
The paper barrier
Still, there is a long way to go before the last paper chart.
According to one recent survey, only 1.5% of 3,049 hospitals have a comprehensive electronic-records system.
And only an additional 7.6% had a basic system, meaning electronic records in at least one clinical unit, according to the nationwide survey given from March to September 2008 to hospitals that belong to the American Hospital Association.
The researchers -- who reported their findings in The New England Journal of Medicine -- said a policy focusing on financial support and training would be necessary to spur hospitals to adopt electronic-records systems.
Money to buy systems was the most common barrier cited by the hospitals. Seventy-four percent expressed that concern.
Valley hospitals have come face-to-face with the costs.
Madera Community Hospital, for example, has purchased software and expects to have electronic medical records in place within the next two years, said Mark Foote, vice president of finance. But the hospital will spend $2.5 million to $3 million for it. Other than a new building, "it's probably one of the single largest purchases" for the hospital, he said.
Foote questions the government's plan to help.
"The way the stimulus bill is written, it's a carrot with a stick," he said. Hospitals must build a system before they can apply for stimulus money, Foote said. And they can be punished if the system doesn't meet government standards.
For Community Medical Centers in Fresno, the cost is about $75 million over seven years to build an electronic-records system for Community Regional Medical Center, Clovis Community and Fresno Heart and Surgical Hospital. Community is two years into the process, said George Vasquez, chief technology officer.
The tab can be prohibitive to doctors in solo practice, said David Ford, associate director of medical and regulatory policy for the California Medical Association.
Software can cost $25,000 to $40,000 for a solo practice, Ford said. The total cost to implement a system is $100,000 to $150,000.
Most hospitals roll out electronic medical records in increments, both to spread the cost and to give time to work out kinks in the system and train staff.
In March, Kaweah Delta will introduce a bar-coding system for medication given at the bedside. The system will verify that the medication being given is the correct drug and dose for the patient.
Later this year, doctors at Kaweah will begin typing medication orders into the electronic system. The system will alert doctors of potential allergic reactions and interactions with other medications, for example.
And at Children's, by the end of this year nurses will make notes and doctors will enter medical orders directly into computers.
Some federal stimulus money is starting to be available to medical providers. In September, Clinica Sierra Vista, a Bakersfield-based federally qualified community health system, received $1.9 million to create electronic medical records at its health centers in Fresno.
A group of health institutions in the Valley applied Feb. 1 for $19.5 million to expand a small health information exchange in east Kern County. It expects to hear in March if it is among 15 of 150 applicants that will receive money.
The East Kern County Integrated Technology Association now includes a hospital, three rural health clinics, seven doctors' offices and a medical group. The grant would allow it to add hospitals and medical providers in nine counties in the San Joaquin Valley from Stanislaus to Kern County, said Jami Young, vice president of Believe Health. Believe Health is a consulting agency for the East Kern County association.
But Valley hospitals are forging ahead regardless of government help.
Kaiser Permanente Medical Center in Fresno converted to electronic medical records throughout the hospital last summer. The change took time for some on the staff to accept. But others welcomed it.
Susan Burr, a Kaiser registered nurse, likes the new system now that she is used to the computers. "We always have the chart with us, we don't have to hunt it down," she said.
She now spends more time with patients, she said. "I can do my charting in the room with them, telling them what I'm charting and I can answer questions."
Younger doctors at the hospital almost see the electronic system as a benefit, said Dr. Rob Lonjers, the Fresno physician over all technology at the Fresno Kaiser.
But Lonjers, 54, said he is a "techy guy." Some doctors were resistant to the change, particularly the older physicians, he said.
And California has an older doctor work force. Twenty-eight percent of its physicians are over 60 -- the highest of the states, Ford said.
Doctors worry about the reliability of computer systems, Ford said. "A paper chart may be less efficient, but you don't have to worry about it crashing in the middle of the afternoon."
Electronic records, however, are inevitable, Ford said. As patients get more comfortable with them, they'll start demanding them, he said.
Lonjers said a hospital's transition to electronic medical records takes time and money, but in the end, it's worth it.
"We're really sure it's providing better care," he said.