A controversial study in Health Affairs this month has provoked a series of articles and public exchanges about the potential for health IT to reduce costs while improving quality. Why so much attention to this article? The conclusions of the study call into question whether health IT will result in lower healthcare costs. Here are some headlines:
- “Digital Records May Not Cut Health Costs, Study Cautions” (The New York Times, March 5, 2012 — requires login)
- “Doctors order more X-rays, not fewer, with computer access” (Washington Post)
- “Physicians Who Use EHRs Order More Imaging Tests” (iHealthBeat)
- “When EHR Critics Jump to Bad Conclusions” (InformationWeek Healthcare)
- “New study casts doubt on EHR cost savings” (EHRWatch.org)
- “Study Challenges Theory on Tie Between Electronic Access to Test Results, Cost Savings” (AAFP News Now)
- “Docs more likely to order additional imaging tests with electronic access” (FierceHealthIT)
The authors of the Health Affairs report (Danny McCormick, David H. Bohr, Stephanie Woolhandler, and David U. Himmelstein) concluded that:
- We found no evidence that office-based physicians with electronic access to imaging or blood test results order fewer imaging tests or blood tests, respectively. Indeed, at least for imaging, the reverse may be true: Facilitating physicians’ access to test results through computerization may increase diagnostic image ordering.
- Physicians’ access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40–70 percent greater likelihood of an imaging test being ordered. The electronic availability of lab test results was also associated with ordering of additional blood tests. The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key.
Their conclusions are based on analysis of the 2008 National Ambulatory Care Survey (NAMCS). The authors describe their methodology in detail, but many of the criticisms of the study are based on the source of the data and their extrapolation of the analysis to the policy implications offered at the end of their article:
We examined two indicators of physicians’ access to imaging results. The first was whether the practice had what the survey called “a computerized system for viewing imaging results” — that is, a system that presents a text report of a physician’s interpretation of the imaging study, an actual visual electronic radiologic image, or both. The second was, for those practices with such a system, whether “electronic images [were] returned” — that is, whether in addition to or in place of a text report, the actual visual images were returned electronically.
Dr. Farzad Mostashari, National Coordinator for Health Information Technology, Office of the National Coordinator (ONC) issued a response through ONC’s HealthIT Buzz. Dr. Mostashari’s issues with the study can be summarized in the following statements from his post:
- 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.
- … 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.
- The study also looked at the quantity of tests ordered without any regard to whether the tests were medically necessary.
Of course, this led to a response from the authors posted on the Health Affairs Blog, which addressed each point raised by Dr. Mostashari. In reaction to one of Dr. Mostashari’s key criticisms was this statement:
Dr. Mostashari offers his own explanation for our findings, suggesting that doctors who are inclined to order more tests are also inclined to purchase health IT for viewing test results electronically rather than on paper. He offers no evidence for this assertion and ignores the fact that we explored (and rejected) this explanation by analyzing subgroups of doctors who are unlikely to be the decision maker for IT purchases, e.g. employed physicians, those working in an HMO setting, etc. In other words, electronic access to results predicted more test ordering whether or not the ordering physician was responsible for health IT purchases.
The authors end their response with this provocative statement:
Finally, Dr. Mostashari’s unbridled faith in technology is mirrored by his belief that ACOs are the next panacea for health costs and quality. That health policy flavor-of-the-month also remains wholly unproven.
AmericanEHR will continue to track the public dialogue because this debate comes at at critical time. Many organizations and individuals are reviewing the Notice of Proposed Rule-Making (NPRM) on Stage 2 of Meaningful Use and the corresponding proposed rule on certification. Here are some snippets from the CMS proposed rule about computerized physician order entry (CPOE) and imaging that are relevant to this discussion:
- Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local and professional guidelines to create the first record of the order.
- We propose to continue to define CPOE as entailing the provider’s use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is then documented or captured in a digital, structured, and computable format for use in improving safety and efficiency of the ordering process.
- CPOE improves quality and safety by allowing clinical decision support at the point of the order and therefore influences the initial order decision. CPOE improves safety and efficiency by automating aspects of the ordering process to reduce the possibility of communication and other errors.
- We propose that to be considered CPOE, the CPOE function must be utilized to create the first record of any type for the order. This removes the possibility that a record of the order could be created prior to CPOE, but not be part of the patient’s medical record. In a practice, this means the originating provider (the provider whose judgment creates the order) must personally use the CPOE function, verbally communicate the order to someone else who will use the CPOE function, or give an electronic or written order that must not be retained in any way once the CPOE function has been utilized.
- Proposed Measure: More than 60 percent of medication, laboratory, and radiology orders created by the EP or authorized providers of the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE.
- Proposed Objective: Imaging results and information are accessible through Certified EHR Technology. Making the image that results from diagnostic scans and accompanying information accessible through Certified EHR Technology increases the utility and efficiency of both the imaging technology and the CEHRT. The ability to share the results of imaging scans will likewise improve the efficiency of all health care providers and increase their ability to share information with their patients. This will reduce the cost and radiation exposure from tests that are repeated solely because a prior test is not available to the provider.
- Proposed Measure: More than 40 percent of all scans and tests whose result is one or more images ordered by the EP or by an authorized provider of the eligible hospital or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period are accessible through Certified EHR Technology.
If McCormick et al are correct (i.e. that access to imaging and laboratory results leads to increased ordering of images and tests), will the proposed objectives/measures in Stage 2 Meaningful Use counter this effect? Proponents of the requirement that Eligible Professionals enter the orders through CPOE argue that this would ensure that the ordering clinician is subjected to the clinical decision support and full context of the clinical record to avoid duplicate/redundant/unnecessary testing. If Dr. Mostashari’s point that the results of McCormick’s study are, in part, the result of the absence of such guidance, will we see a decrease in unnecessary testing — but perhaps an increase in appropriate testing as gaps in care are identified and hopefully narrowed?
The proposed Clinical Quality Measures for Stage 2 include the following National Quality Forum (NQF) endorsed measures relative to potentially inappropriate imaging:
- #0052 — Use of imaging studies for low back pain which measures the percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis
- #0312 — Low Back Pain: Use of Repeat Imaging which measures the percentage of patients with back pain who received inappropriate imaging studies in the absence of red flags or progressive
symptoms (overuse measure, lower performance is better).
- #0562 — Melanoma: Overutilization of Imaging Studies in Melanoma which examines the percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.
Are these metrics sufficient? What other measures of appropriate/inappropriate utilization of tests/imaging could/should be included? The Annals of Internal Medicine published an article (lead author, Dr. Amir Qaseem) from the American College of Physicians (ACP), which is part of its High Value, Cost-Conscious Care Initiative. In that article, ACP identified 37 different situations where, “more testing is not better but rather may provide no benefit or may be harmful.” This is, in part, a response to Howard Brody’s call, in the New England Journal of Medicine (NEJM) for professional societies to create a “…Top Five list [that] would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.”
Whether you agree or disagree with the conclusions of the Health Affairs article, the key point is that unless and until there is clear, incontrovertible evidence of quality improvement, appropriate cost reductions, and appropriate increases in utilization in multiple different practice situations and organizational entities, these issues will continue to rise. Measuring the critical elements of overuse/underuse is important. Designing and certifying EHRs to help promote changes in practice towards these ends should be a major focus of Meaningful Use. Is it? If not, how can the proposed rules be improved?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.