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Electronic Access For Physicians To Prior Tests Did Not Reduce Costs

March 5th, 2012

Despite the widely held assumption that physicians having computer access to patients’ test results will reduce testing, doctors who have such access to tests in the ambulatory care setting are more likely to order imaging and lab tests. That’s the finding of a study in the March issue of the Health Affairs, released today.

The authors say their findings challenge one premise of the nation’s multibillion-dollar effort to promote widespread adoption of health information technology (HIT). They warn that the effort “may not yield anticipated cost savings from reductions in duplicative or inappropriate diagnostic testing” and, in fact, could drive costs up.

“Our findings should at a minimum raise questions about the whole idea that computerization decreases test ordering and therefore costs in the real world of outpatient practice,” says lead author Danny McCormick, a physician and assistant professor of medicine at Harvard Medical School. Referring to better access to results with computerization, McCormick says, “As with many other things, if you make things easier to do, people will do them more often.” McCormick co-wrote the paper with David Bor, chief of medicine at Cambridge Health Alliance, and Stephanie Woolhandler and David Himmelstein, both professors of public health at the City University of New York.

For their study, McCormick and colleagues analyzed data from the 2008 National Ambulatory Medical Care Survey, which includes 28,741 patient visits to a national sample of 1,187 physician-based offices. The survey excludes hospital outpatient departments and offices of radiologists, anesthesiologists, and pathologists.

They found that:

  • Point-of-care electronic access to electronic imaging results, sometimes through an electronic health record, was associated with a 40–70 percent greater likelihood of an imaging test being ordered. Physicians without such access ordered imaging in 12.9 percent of visits, while physicians with access ordered imaging in 18.0 percent of visits.
  • Women received more imaging studies overall than men, perhaps reflecting their use of mammograms and ultrasound studies—but not more advanced imaging.
  • Surgeons and other specialists were more likely to order imaging tests than primary care physicians.

Several studies have estimated that computerization in physician offices would save as much as $8.3 billion a year on imaging and lab testing. But McCormick and colleagues say the predicted savings from this technology were based on incomplete data, relying on a few “flagship” health care institutions with cutting-edge systems, and not generalizable to current medical practice, where computer technology is commonly an “off-the-shelf” product.

The authors say that office-based computerization may not yet reduce imaging use because current systems are cumbersome, insufficiently interoperable, or lack effective decision-support software. Although savings on imaging may emerge in the future if there is greater interoperability, the authors caution that high rates of testing were also identified in hospital-owned practices with the highest levels of interoperability and decision support. They add that curbing self-referral to imaging facilities in which doctors have a financial stake would have more impact.

The study does not examine the reasons for physician behavior when it comes to test ordering. And although the authors say that they are not criticizing investments in HIT, they contend that their findings “emphasize the importance of establishing the benefits of computerization rather than estimating them in the absence of data, or generalizing from small studies at a few atypical institutions.”

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2 Responses to “Electronic Access For Physicians To Prior Tests Did Not Reduce Costs”

  1. _Aaron_ Says:

    This study has weak methods and the wide attention it has garnered is wholly unwarranted. At some point, Health Affairs decided it should be more about making headlines than about publishing methodologically rigorous investigations.

    The title of this study implies a causal link that its findings do not prove. Would it really be that surprising if physicians who like to order tests decided to purchase machines that make it easier to view those tests? Or if physicians who tend to order tests have more money available to purchase such equipment? Of course not. And yet such behavior would lead these authors to conclude that adopting this equipment increases the tendency to order imaging tests. This is weak research.

  2. James Rickert Says:

    Many studies have shown that self-referral plays a very large role in excessive testing. Unfortunately, these HIT systems make it that much more convenient, and, therefore, profitable to order tests. Greater emphasis on curbing self-referral is needed to realize the gains of higher quality HIT.

    James Rickert, MD
    President, The Society of Patient Centered Orthopedics

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