If you're planning to get sick outside of regular business hours, you'd be well advised to do it in the Netherlands.

Almost every Dutch primary care doctor — 97 percent, to be precise — has a nurse or physician backup who will see patients who get sick after hours, a new international survey has found.

The Netherlands also is where to go if you want a doctor who uses electronic medical records. Those computerized files contain information on laboratory test results, treatment guidelines and warnings about potential drug interactions. They also allow doctors to write and submit prescriptions without worrying about errors caused by bad handwriting.

More than 90 percent of Dutch physicians, as well as those in England, New Zealand, Norway, Sweden, Australia and Italy, use electronic medical records.

Fewer than half of U.S. primary care doctors use them. And just 29 percent of American family doctors have special arrangements for patients who get sick after hours. Here, ill patients often are sent to wait in overcrowded emergency rooms, where they're seen by a doctor with no access to their records and no familiarity with their medical histories.

Access to high-quality primary care always has been a big issue, but health care reform is pushing it to the forefront again.

Americans spend about twice as much per person on health care as the average of other industrialized countries. Yet the care we receive — from routine doctor visits to lifesaving interventions — often is no better than in other industrialized countries. Sometimes it is demonstrably worse.

The new international study of primary care, from the nonpartisan Commonwealth Foundation, is further proof of uneven quality.

The report showed strengths and weaknesses in care provided by doctors in each of 11 countries studied. American doctors were more likely to use guidelines outlining the best treatments for diabetes, asthma and high blood pressure than doctors in France or Germany.

American doctors were less likely to say patients faced a long wait for diagnostic tests or to see a specialist than doctors in those countries.

But doctors in England, Sweden, Norway and the Netherlands were even more likely to use treatment guidelines. English doctors reported even shorter waits.

American doctors were far more likely than those in other countries to report problems with patients paying for medications or treatment. And they're more likely to report spending significant amounts of time getting insurance approval for their patients' treatments.

As Congress considers adding health coverage for about 36 million people who now are uninsured, the United States still has no national primary care policy.

Most family doctors work alone or in small practices. Most deal with multiple insurance companies, each offering different plans with different coverage restrictions.

That makes it more difficult to implement basic steps shown to improve quality, like paying doctors more to achieve better outcomes.

Even something simple such as electronic medical records is fraught with pitfalls in the U.S. system. It represents a major expense to individual medical practices. And when it's done, there is no guarantee that the computers in doctors' offices can exchange information with those in nearby hospitals.

Expanding access to doctors is an important goal. The next big challenge for reformers is to improve quality. That probably will prove even more difficult.