Recent Study: Get the Facts

Dr. Farzad Mostashari | March 6, 2012

Apparently, doctors who order a lot of imaging tests are more likely to have electronic systems that let them view those images in their offices.

That is the finding of an article appearing in the March 2012 issue of Health Affairs by McCormick and colleagues. This is not a particularly surprising observation. What is surprising is that the authors go far beyond the scope of their research to conclude that “the federal government’s ongoing, multibillion-dollar effort to promote the adoption of health information technology may not yield anticipated cost savings from reductions in duplicative diagnostic testing. Indeed, it is possible that computerization will drive costs in this area up, not down.”

While such interpretations may make for attention-getting media headlines, it’s important to get the facts. There are several reasons why McCormick’s study ultimately tells us little about the ability of electronic health records (EHRs) to reduce costs, and why it tells us nothing about the impact of EHRs on improving care.

The Study Was Not About EHRs At All, Much Less Their “Meaningful Use”

McCormick’s article considered how physicians react to electronic viewing of imaging results, not EHRs. In fact, when the authors  looked at EHR use, they found that “use of an electronic health record system showed no association with test ordering.” Also, the study data were from 2008, before the passage of the HITECH Act and the linking of payment incentives to the meaningful use of EHRs.

Moreover, the authors did not consider clinical decision support, which helps give providers the data tools they need to make appropriate care recommendations and the ability to exchange information electronically. These are two of the most critical features of certified EHRs, which  have been shown in multiple well-designed studies to reduce unnecessary and duplicative tests.

The Study Falls Prey to the Classic Fallacy of Using Association to Suggest Causality

Ordering more tests may lead to buying an image viewing system, not the other way around. As my predecessor David Brailer pointed out in the New York Times Exit Disclaimer , this was not a randomized trial, but an observational study (the National Ambulatory Medical Survey) that was not designed to answer the question of cost, or associations between EHRs and quality.

As a result, many other variables that could affect physician behavior could not be examined in this study, including:

  • Having a sicker patient population,
  • Level of physician training,
  • Approach to defensive medicine, and, importantly,
  • Financial arrangements.

The authors themselves correctly note that physicians who have a financial stake in imaging are more likely to purchase systems with image results capabilities, making self-referral a likely explanation for their results.

The Study Did Not Consider the Appropriateness of Imaging Tests

The study also looked at the quantity of tests ordered without any regard to whether the tests were medically necessary. As both patients and providers well know, an appropriate follow-up for a suspicious nodule is a test you want to have. Clearly, we need to assess the success of EHR systems based on how they improve the care that patients receive, not just the number of tests ordered. Unfortunately, this study focused on the numbers, while ignoring the patients.

Reducing Test Orders Is Not the Way that Health IT Is Meant to Reduce Costs

The ultimate impact of EHRs on reducing cost will be through improvements in the coordination and quality of care, and the prevention of unnecessary and costly complications and hospitalizations. Providers who are embracing new delivery and payment models such as Accountable Care Organizations and Patient-Centered Medical Homes know that meaningful use of EHRs is a critical foundation for being able to improve quality while reducing cost.

Don’t Believe the Hype

Systematic reviews Exit Disclaimer of the evidence show that EHRs have the ability to give providers the information and tools to provide better care and reduce waste. A 2011 study in Health Affairs itself found that 92 percent of studies on health IT were “positive overall” about the prospect that technology would improve efficiency, reduce unnecessary tests, and improve the quality of care that patients receive.

Seemingly surprising headlines can be tempting, but it’s important to get the facts. The evidence shows we are on the right track to establishing the health IT foundations for a true 21st Century U.S. health system where patients get better care, while we reduce health care costs.