Thursday, March 15, 2012

Will health information technology make medical care MORE expensive?

“Doctors using computers to track tests, like X-rays and magnetic resonance imaging, ordered far more tests than doctors relying on paper records,” reports the New York Times on the findings of a controversial new Health Affairs study.

The study’s authors write that “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,” suggesting to them that “electronic access does not decrease test ordering in the office setting and may even increase it, possibly because of system features that are enticements to ordering.” From this, they go on to make the sweeping conclusion that:

“Use of these health information technologies, whatever their other benefits, remains unproven as an effective cost-control strategy with respect to reducing the ordering of unnecessary tests.”

Not so fast, says Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, who issued a response to the Health Affairs article, taking issue with its methodologies and conclusions, which in turn invited a response to his response from the study’s authors. You can read an excellent account of the back-and-forth on this in an American EHR blog post by my ACP colleague, Dr. Michael Barr.

I don’t claim to be an expert on health information technology or on the methodological debate over the Health Affairs research, but my sense is that the study raises an important question—do health information technologies that make it easier to order and then read the results electronically also make it more likely that an unnecessary test will be ordered? I don’t think we definitively know.

But at the same time, there are enough questions about the study and its limitations to reach any sweeping conclusion on the value of health information technologies in reducing costs. Plus, as Dr. Barr points out in his blog post, the world of health information technology is changing rapidly, including the new stage 2 “meaningful use” proposed rules that will encourage adoption of clinical decision support tools, based on evidence-based guidelines on appropriateness, in computerized order entry systems.

Of greater significance than this one study alone is that it adds to a growing body of research and opinion (exaggerated and magnified by news reports and the blogosphere) that suggest that some of the most popular remedies offered to bring down rising health care costs won’t work. Last week, I blogged about the limitations of price competition, transparency, high deductible HSAs, and private contracting in bringing down costs; today, it is heath information technology that at least this one study says won’t deliver the bang for the buck. And my next post will be about studies that raise questions about the value of care coordination in lowering overall spending.

My concern is that the message that could be received by the public and policymakers is that nothing being contemplated today will be effective in bringing down health care costs. So why bother trying? Or let’s just pull the plug on the ones that aren’t working?

Healthy skepticism about the cost control idea of the day is good. More research is good. But at some point, showing the limitations of current cost control interventions and suggesting more studies won’t be enough. Instead, we will have to come up with an American way that will actually work to lower health care costs, or policymakers will end up on the tried and true cost control measures used in other countries: explicit rationing of services, and even more price and capacity controls.

Today’s question: What do you think about the research questioning the value of health information technology in lowering costs?


Jay Larson MD said...

We have been using a certified EHR for the past 6 months. Meaningful use criteria was met within 100 days. We embrace electronic information technology because we can be better health care providers. The initial learning curve is done and now we are enjoying the capabilities of providing visit summaries and Continuity of Care documents to patients (electronically if they use the practice portal). The ability to search for patients due for preventive services has been invaluable. Patients now have in-hand a concise/complete medical record that they can carry to any other healthcare provider. Then that healthcare provider is more informed and can make better decisions for patients.

As far as the having “information” about the patient at the finger tips…well that has been a blessing. I remember the days when a patient would show up stating they had a diagnostic test and then spending the next 10 minutes tracking it down. Having the actual images on the computer to show patients really helps patients grasp their medical malady.

Technology has been a major driver to rising health care costs. Much of the new technology still lacks solid evidence that it actually improves people’s lives better than less expense older technology. Health information technology gets physicians the right information at the right time, which leads to the right decision for patient care.

We still need the capacity to share lab and diagnostic imaging so that these services are not duplicated. This is what will lead to reduced ordering of “unnecessary” tests.

InformaticsMD said...

Re: "do health information technologies that make it easier to order and then read the results electronically also make it more likely that an unnecessary test will be ordered? I don’t think we definitively know."

I agree. There are many issues around health IT that are unknown, such as costs, and injury and death rates, and the evidence on benefit is conflicting in 2012 (see "HIT Reading list" at this link).

I must ask: why are we rolling the technology out nationally with these unknowns?

Would drug companies or other medical device companies be allowed to do that?

See my academic website at Drexel University's College of Information Science & Technology, for more on these issues.

Scot Silverstein, MD
Institute for Medical Informatics
Drexel University
Philadelphia, PA

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