The term "perfect storm" is bandied about too casually, but there’s one that now truly seems to be bearing down on Hawaii.

In a state that for years has been battling a chronic doctor shortage in specific specializations, particularly in its more rural communities, the operational changes that are coming with health care reform appears to be driving more of the existing doctors to leave their practices.

This presents a crisis for Hawaii that demands action, just as urgently as the government’s need to jettison its computer systems, which range from the archaic to the nonexistent. Some of the scary projections, including the estimate that puts the shortage at 747 doctors this year and almost 1,500 by 2020, were presented at Saturday’s 2013 Hawaii Health Workforce Summit in Waikiki.

In fact, the worry extends across the country as more of "Obamacare," formally titled the Patient Protection and Affordable Care Act, or ACA for short, is implemented in January.

Doctors already are frustrated at low reimbursement rates for Medicare patients, and many are refusing new patients — or even dropping the ones they already have — just as baby boomers are moving rapidly toward retirement.

What’s accelerating the flight from practice now is concern that, under the ACA rules, doctors who haven’t converted to electronic medical and prescription records will face penalties on top of that.

One of the driving forces behind health care reform was the number of uninsured patients who delayed medical care until it was bad enough to land them in the emergency room. Bills from the ER typically are unpaid, and the losses ultimately get recouped through higher charges — and higher premiums — for those who do have coverage.

Now many more of the nation’s poorer residents will be covered by an expansion of the Medicaid program, which will help many hospitals with their bottom line. But at hospitals and clinics alike, there will be more accountability required on how well the patient fares with treatment. The idea is right: Our health care dollar should pay for quality, not quantity, of care.

But among the challenges that should be addressed by the U.S. Department of Health and Human Services is finding the proper balance between accountability and administrative burdens.

One way Uncle Sam is helping is through support funds, including a $1 million planning grant the state is seeking, said Beth Giesting, the state health care transformation coordinator. The general idea is that the state would work with doctors in private practice on collaborations that support them in adapting to the ACA requirements. In addition, she said, reform will direct patients to teams headed by doctors, but increasingly, other health care providers will deliver more of the care.

In the meantime, institutions such as Hawai‘i Pacific Health are trying their own innovations, said Dr. Ginny Pressler, HPH executive vice president of strategic business development. In addition to the conversion to electronic medical records and administrative support for its staff doctors, HPH plans to invite community physicians to integrate their own businesses with the HPH back-office system while remaining in private practice.

Pressler said the painful overhaul in the industry now unfolding does not come as a surprise.

"We are seeing a major change in the industry," she said. "We’ve predicted it for years, but it’s actually happening now."

Finally, in the state Legislature, House and Senate conferees are working through the details of funding for Senate Bill 665, an important measure aimed at bolstering Hawaii’s homegrown medical workforce.

This includes money for repaying medical-school loans for doctors serving primary-care needs in rural areas, expanding the number of Native Hawaiian doctors, and increasing faculty for the Family Medicine Residency Program at the John A. Burns School of Medicine.

The transition to a different model of health care delivery is going to be a bumpy road, and a fair number of the medical establishment inevitably will veer off.

Encouraging more of them to remain engaged in this critical profession, and preparing the next generation of health care providers to work in a changed landscape, will require help from Washington, D.C., and a focused effort at home as well.