Quick True or False question to brighten your day: If you switched doctors and your new doctor had access to your previous x-rays and lab tests, you’d probably not need to re-do your tests again.
If you answered true, great, you’re far more optimistic than what this study in Health Affairs reveals about doctors’ test-ordering propensities. According to the study (which BTW I haven’t fully read yet, having read only the abstract and the write-up about the study in the Health Affairs blog), doctors who had access to prior tests and images – tended to order more tests, not fewer, contrary to what one would expect.
One of the big reasons why EMRs are being so heavily touted from the government downwards is because they’re expected to reduce redundancies and save costs. Except that they might not.
Here’s a rundown of the study, based on what I read in the abstract as well as blog entry:
– The study analyzed 28,741 patient visits to 1,187 doctors offices in 2008.
– Access to computerized imaging results was associated with a 40-70% higher chance of a test being re-ordered. Access to such tests was not necessarily through an EHR.
– The presence of an EHR was not the key factor affecting the results found by the study. Rather it was the access to prior test results which was the determining factor. According to the blog post, “Physicians without such access ordered imaging in 12.9 percent of visits, while physicians with access ordered imaging in 18.0 percent of visits.”
– Also according to the blog, specialists tended to order additional imaging tests compared with primary care physicians. There were also gender differences with women receiving more tests than men.
– It’s not clear why. The blog quotes a researcher as surmising that perhaps if you make something easier to do, people will tend to do them more often, presumably referring to the ease with which a test can viewed, and later ordered from an EHR.
Of course I’m interested in knowing more about what’s going on and more importantly why.
– The finding about specialists might even make sense if the study had delved into how sick the population visiting the specialists was. Specialists typically see patients after they’ve been seen by a PCP, and maybe they’re seeing a sicker population on average.
– I also want to know more about the quality of images and how easily they can be accessed by the physicians across various. If my hospital or practice uses Vendor A’s EMR and I’ve been allowed to view Patient B’s records on Vendor X’s EHR, maybe I will just order a new test to get the same data into my own system.
– I’m also wondering what the insurance company’s take on all this is. I’ve not had much experience with imaging and tests and the like, touch wood, so this is a genuine doubt, no matter how stupid it sounds to you readers. I get a test done today, and a month later a different physician orders the same test, will my insurance company refuse to cough up for my second test?
Interesting study, nevertheless. Go check it out here or here.
This is a perfect example of defensive medicine, dosed with a nice helping of corporate profitability.
In court, it’s very unlikely that a physician who doesn’t order another test will be treated well. What he or she will hear is something like “So, doctor, you didn’t even care enough about this patient to order another x-ray to confirm your diagnosis?” The plaintiff and the jury don’t care about costs, and they don’t care if the test was just ordered X days/weeks/months ago. What they care about is drama, and that type of statement coming from a plaintiff’s attorney is just dripping with it.
And don’t underestimate corporate concerns. Doctors are not rewarded for being efficient in their utilization of billable resources – they are warned. If it’s rewards they want, the best way to get them is to generate the most revenue.
EMRs can simplify the process – the only surprise here is that Dr. Mostashari claims to be surprised. It implies that he may be dangerously out of touch with the real world of medicine in America – but that comes as no surprise to most practicing physicians.
Finally, insurers don’t care. Unlike physicians and hospitals, they have not up until now suffered from the price controls imposed by the government; they just tack on their desired profit margin and pass the costs along to employers and patients.
An EMR puts you adrift in a sea of semi-relevant data. Without it, you have time, experience, judgment, and a good conversation with your patient. With it, you have a multitude of lingering mysteries that need tidying up. I find the more time I spend at the bedside, the fewer tests I order. The more time I spend pointing and clicking, the more nagging issues come up that might have been settled just by spending more time with the patient. (Although I concede order sets have a lot to do with over-ordering as well.)
[…] being said, other studies — such as this one appearing in Health Affairs — have found that doctors who see earlier tests and images […]