Electronic health records have long been touted by Democrats and Republicans alike as a sure-fire way to lower health spending. When doctors have easy electronic access to a patient’s records, advocates argue, they are less likely to order the duplicative and unnecessary tests that drive up the cost of health care in America.
But that assertion is not necessarily proving to be true. Doctors who use EHRs may actually order more diagnostic testing, and therefore make health care even more expensive, according to a study published in the the journal Health Affairs.
Researchers found that office-based physicians were actually 40 to 70 percent more likely to order an imaging test if they had access to computerized imaging results. The study is based on data from the 2008 National Ambulatory Medical Care Survey of 28,741 patient visits to 1,187 physicians.
EHRs may be yet another example of a health care solution that looks great on paper, but “when you actually try to implement it in real world settings with real patients” it may have some “unintended consequences,” says lead author Danny McCormick, a primary care physician and assistant professor of medicine at Harvard Medical School.
EHRs have been estimated to save $77.8 billion annually, largely by avoiding imaging such as MRIs and lab tests. Doctors can view a patient’s previous tests in real time, and can use this information to determine whether another test is really needed. In addition, software in the EHRs can help a doctor make this decision.
But EHRs also make diagnostic images easier to order and easier to review. Imagine a doctor sitting with a patient, says McCormick. If the doctor orders an MRI on one of these systems, he “knows with certainty the report will show up the next day on [his] computer screen with no hassle. But without a computer record, [he] might have to struggle to get it,” requiring an investment in staff time to request a fax of the study, which may then be difficult to read.
This “convenience effect” may subtly shift the doctor’s incentives, encouraging him to order diagnostic tests more liberally.
While EHRs may still improve health care quality and efficiency, says McCormick, the study results do not bode well for the federal government’s multibillion dollar plan to save money by encouraging doctors to adopt health information technology.
The study “should prompt us perhaps to look elsewhere for answers to the cost crisis plaguing the U.S. health care system,” McCormick adds.
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So interesting! Well maybe now after the 70 year experiment with third party payers we try a free market solution.
Health care information technology is part of the solution for health care spending, but not all of it. What HIT, particularly clinical applications, can do is to offer information on who does what best, what interventions work better, and for whom. However, in the absence of payment reform, the technology can become another tool to inflate health care costs. At the recent HIMSS meeting, officials from the ONC and CMS took pains to point out the interlinked nature of the two initiatives.
What continues to be troubling are the analyses performed looking at one intervention in a vacuum that show little to no effect. The US healthcare system is gigantic and enormously complex. It would be naive in the extreme to expect that any single “magic bullet” would fix its problems.
We will need to attack this national challenge on multiple fronts. Information, incentives and integration (of the delivery system) will all be required more or less simultaneously to avoid some of the more draconian solutions (such as price controls) that will probably result should delivery system reform fail.
What this study (based on 2008 data) really shows is that an EHR is a great magnifier and when you implement one in an integrated systems (payer and provider and perhaps even patient) are on the same team the costs go down as they have at Mayo and Kaiser and when you work in a system that rewards you for ordering tests they go up.
The serve as a magnifier to what you are already doing and drive you even faster either into the wall or to a solution. To blame the EHR for highlighting the flawed in our current payment systems is a canard and we run the real danger of missing an opportunity to get a tool in place so that we can in fact improve quality, effectiveness, safety and patient centric care.
The real outcome of EHR’s will be the push towards physicians either working in larger systems or forming virtual ones of their own. Those that fail to adopt will quickly fall behind on the cost quality curve and be forced to adopt at the end of this transition.
The doctors may order more tests knowing the information will be more readily available, but the duplication of testing should decrease, such as when a patient has an x-ray at one facility that has to be repeated at the orthopedic clinic because they cannot access the original study.
The study referenced in this article is $13 – $30 to obtain from the journal of Health Affairs. Anyone know if its on the internet?
brian
I think selection bias is a big factor in this report. What hospitals had EMRs in 2008? Big teaching hospitals (still probably true today – these things are expensive). What hospitals always ordered more tests? Big teaching hospitals. And just because they looked at doctors offices, does nothing to mitigate this bias, in fact it probably enhances it – no stand alone Dr office had an EMR in 2008 – but really big teaching hospitals had remote access to their EMRs for doctors.