Doubting the cost savings of health information technology

A recent Health Affairs article casts doubt on the cost-saving prospects of health information technology despite the significant investments made by hospitals, physicians, and the federal government to promote electronic records.

Reduced ordering of imaging and other diagnostic studies by physicians is often cited as a likely mechanism for estimated cost savings due to health information technology. Possible mechanisms include reduction in redundant (duplicated) tests secondary to better access to information or due to point-of-order decision support that helps providers  rethink the appropriateness of testing. However, these mechanisms and the purported savings are merely assumptions.

Harvard researchers assessed a large outpatient data set to evaluate the hypothesis that health IT (computerized availability of imaging or use of full EMR) reduces image test ordering. The study design was that of an observational cross-sectional survey. The primary outcome variable, or dependent variable, was the presence or absence of physician-ordered imaging (CT, MRI, any radiology imaging). The predictor variable, or independent variable, was the availability of computerized reporting of test results.

The data were derived from the National Ambulatory Medical Survey which was collected in 2008 (prior to the passage of the 2009 HITECH legislation that dramatically expanded federal financial incentives for adoption of health IT). The data include a nationally representative sample with 28,742 patient visits to 1,187 physicians scattered across the United States. Multivariate logistic regression modeling was performed to account for multiple confounding variables that affect a physician’s decision process to order imaging tests: computerized order entry, physician specialty (excluded orthopedics, neurology, cardiology which order disproportionately more imaging tests), physician affinity for technology, physician financial incentives, physician practice business profiles (owner or employee/contractor, prepaid practices, hospital-owned practices, solo practitioner, urban), and also patient factors (age, sex, ethnicity, insurance type, residence in poverty-level zip code, whether seen by physician before, and presence of chronic diseases: diabetes, heart disease, cerebrovascular disease, cancer). Patient outcomes, disease acuity, and ICD-9 disease-specific reasons for the images ordered were not measured. Additionally, whether or not specific images were duplicated in an individual patient was not measured.

Overall, the prevalence of imaging orders by physicians with computerized systems for accessing imaging results was 40-70 percent higher than without computerized systems. Of the 28,741 physician visits, 4,335 resulted in an order for imaging. Computerized systems for accessing imaging results were available for 13,401 visits (in 6,458 the actual images were viewable). Computerized order entry did not affect the likelihood of image ordering. Patient and physician practice characteristics were not associated with likelihood of image ordering. Physician affinity for technology and physician financial incentives did not change the likelihood of image ordering.

Commentary

Computerized order entry did not affect the likelihood of image ordering but access to computerized imaging results was associated with increased rather than decreased image ordering. However, the original assumption of the effect of health IT on reducing unnecessary imaging duplication was not evaluated; duplicate imaging per patient was not actually measured. It is the duplication of imaging per patient that is most likely the culprit for wasteful spending rather than the total orders of images within a health care system.

Several important factors that affect a physician’s decision to order images in the first place were not addressed: disease acuity, disconnected health IT systems, and defensive medicine.

Perhaps a better research question: does health IT reduce the duplication of image ordering in a population with matched disease acuity?

Researchers should also investigate how disconnected health IT systems (even within a single hospital) might affect image ordering duplication. For example, although a chest X-ray might have been ordered in the emergency department (ED), an inpatient physician without access to the ED health IT system may order another chest X-ray on hospital day 1 so as to have a desired clinical baseline for comparison. In this scenario, connected health IT systems within one hospital (not to mention across myriad sites of care) could likely reduce unnecessary duplication of imaging. For example, the inpatient physician could be liable in a malpractice case if the original ED X-ray could not be accessed or evaluated. Thus, the unnecessary duplication of a baseline X-ray is done only to prove that it was evaluated by the inpatient physician. This provides protection in the mind of the physician worried about liability and likely drives the escalating costs of defensive medicine.

Perhaps it is not enough just to have a health IT system but rather it is the quality of connectivity between health IT systems (coupled with a less litigious environment) that produces the anticipated cost-saving advantages of health IT and the true effects on physician behavior?

Jennifer Shine Dyer, a pediatric endrocrinologist, is Founder, EndoGoddess LLC and Chief Medical Advisor, Eproximiti DuetHealth.com. She blogs at EndoGoddess Musings and Policy Prescriptions.

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  • http://twitter.com/karimjessa Karim Jessa

    Jennifer, this is a great review.  I would go one step further to say that standardized order sets and templates encourage or facilitate duplicate ordering unless it is tied to Clinical Decision support which prompts the clinician ordering if they want to reorder a recently completed test (lab, xray).  The easier the test is available the more likely the test will be ordered in my experience.  Lovely post.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Your title seems like the article would focus on a myriad of HIT scenarios; however, given that it focuses mainly on imaging I would like to add that the new round of EHR meaningful use requirements focus on connectivity issues.  As this progresses, it will be interesting to revisit this hypothesis and see how the results change.

    As for other areas of HIT, I point out in my most recent newsletter that in the ambulatory clinical setting it is of great benefit in terms of patient safety.  One only look at ePrescribing to see the benefits both in terms of safety and savings for the clinical site.

  • Ginger

    A very good critique of that widely disseminated article.

    It is too bad that outcomes or other quality assessments were not factored in.  I’m sure this would have been terribly complex to reconstruct from whatever kind of transactional data was used to conduct the analysis but I don’t like to think about costs without considering whether they contribute a quality outcome. 

     

  • Jim Jaffe

    what is the basis of your assertion that the real issue here is duplicative imaging rather than total imaging done?  thanks.

    • Jennifer Shine Dyer

      See references 10-13 in the intro of the paper for prior studies that have shown that duplication or reduntant testing frequently occurs without access to prior information. In clinical practice this occurs very frequently as I mentioned in the example that I gave for ordering a chest xray during a hospitalization.

  • buzzkillersmith

    HIT has been, is, and will be a scam, designed to enrich vendors and employ consultants, not to improve care or lower costs. We in HC are simply whales and are being hunted for our blubber. Wake up.  A more interesting question is this:  After HIT fails, how will the business types next pull the wool over our eyes?

  • davemills555

    With regard to prehistoric warfare, scientists say that warriors from the Neanderthal period all thought that nothing could possibly be a more effective weapon than a heavy stick with a thick end called a club. Then, along came the inventor of the spear. 

  • davemills555

    From everything I’m reading, regardless of any decision from the Supreme Court, the health care industry will move ahead with plans to overhaul how health care is delivered. The game will change and those that dig in their heels and hope that the status quo survives are in for a rude awakening. Doubting the cost savings of HIT? Those doubts are coming from frightened people with the most to lose if an ACO opens up their doors in the neighborhood. Are you hoping that high end boutique health care and expensive designer health care will escape the fierce competition that’s coming very soon? Are you hoping that somehow you’ll never be forced to convert to electronic record keeping? I’m afraid that those hopes may be in vain. A tsunami is coming. Smart people see it and are getting prepared. Average consumers can not play the game any longer. You’ve milked the cow dry. The goose that lays the golden eggs is on life support. Status quo health care has become way too expensive. Fee-for-service medicine is the enemy of the consumer. Fee-for-service medicine needs to become a thing of the past.

    • Jennifer Shine Dyer

      I agree with you. This paper simply isn’t asking the right research question. Health IT (when connected) most certainly will help to reduce redundancy in orders of imaging…and likely reduce healthcare costs. The reduncancy of imaging ordering isn’t the only factor driving healthcare costs but health IT improvements should help some in reducing healthcare costs.

      • davemills555

        Even of more concern for providers these days is redundancy in billing. Especially Medicare billing. CMS is getting lots of pressure these days from Congress and from HHS to identify and prosecute fraud. Paper record keeping is fraught with mistakes. While a computer system can be easily programmed to check the input of data and search for unusual entries, paper record keeping often results in those same mistakes slipping through the cracks. As innocent as they may be, such mistakes could result in double and triple billing. Those innocent mistakes could result in costly investigations and, in the worst cases, may even result in fines or restricting providers from further participation in Medicare. Unlike paper record keeping, HIT has the ability to look for the “unusual” entry. Double and triple billing against a single patient is easy for a computer to spot. It’s a piece of cake! This feature alone could save CMS billions of dollars in overpayments and thus begin the process of reducing the over costs of Medicare going forward. 

  • Bradley Evans

    Another Health Affairs article, called “It’s the prices, stupid!”, said that the problem with the costs of American health care was the costs. Is Health IT going to decrease the costs (prices)?

    Another claim, from Gammon, is that bureaucracy is the problem with health care. You can see that government programs never go away, they just layer on top something else that supposed to provide a fix. The end result is more paperwork and more bureaucracy. Parkinson’s Law indicates that bureaucracy grows from intrinsic motives of bosses. Is Health IT going to decrease bureaucracy?

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