With 68% of all physician-patient encounters occurring in physician groups of 4 or fewer, improvements in small practices will be necessary to close the well-documented national gaps in consistent delivery of high-quality care. Many believe that adoption of electronic health records (EHRs) is the key to success, and that improvement will almost automatically follow. However, EHR adoption occurs today in an environment shaped by paper chart thinking, which may limit success. Having successfully implemented an EHR in their small practice, the author and his practice colleagues attempted to use it to support a simple project to improve their mammography rate. Although they achieved a real 10% improvement in their rate with only modest additional expense, their experience highlighted critical elements for success beyond the adoption of the EHR, including physician appreciation of structured data, the need for widespread adoption of standards, and a restructuring of the primary team with additional resources. An approach supporting EHR adoption along with these system changes could substantially affect public health.