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Customer Experience and Design

Do EHRs reduce test requests or make them (too) easy to order?

Two recent studies have published conflicting results regarding the correlation between EHR/ HIE usage and the number of tests ordered by physicians. First, a general comparison of the studies and their outcomes:

The study Bridging the Chasm: Effect of Health Information Exchange on Volume of Laboratory Testing concluded that doctors order fewer lab tests when they have access to a patient’s electronic medical records.

The above Archives study:

  • Was based on medical records of >117,000 patients treated in outpatient departments of Brigham and Women’s and Massachusetts General Hospitals between 1999 and 2004. Their HIE was created in 2000 as part of their Partners HealthCare collaboration.
  • Determined that the overall number of tests ordered for each patient in the study fell from an average of 7 to 4 with their HIE implementation.

These results seem to support the generally accepted mantra that a by-product of adoption of EHRs and participation in HIEs will be a reduction in the ordering of redundant tests.

It is, however, in direct contrast to another recent study that was published in Health Affairs, Giving Office-Based Physicians Electronic Access To Patients’ Prior Imaging And Lab Results Did Not Deter Ordering Of Tests.

The Health Affairs study:

  • Analyzed data from the 2008 National ambulatory Medical Care Survey which includes 28,741 patient visits to a national sample of 1,187 physician offices. It excludes hospital and outpatient departments as well as offices of radiologists, anesthesiologists and pathologists.
  • Concluded that:
  • Point-of-care electronic access to electronic imaging results, sometimes through an electronic health record, was associated with a 40-70 percent greater likelihood of an imaging test being ordered. Physicians without such access ordered imaging in 12.9 percent of visits, while physicians with access ordered imaging in 18.0 percent of visits.
  • Women received more imaging studies overall than men, perhaps reflecting their use of mammograms and ultrasound studies–but not more advanced imaging.
  • Surgeons and other specialists were more likely to order imaging tests than primary care physicians.

This conclusion flies in the face of the assertion that access to electronic medical records will reduce the number of tests required. That fundamentally doesn’t make sense, does it? If you have access to information at your fingertips, why would you need to run the test again?

The second study didn’t delve into the physician behavior behind the increase in tests ordered, so let’s do a little brainstorming:

  • Perhaps the physicians surveyed are chronic offenders to ordering repeat tests and this is a behavior that needs to be modified/ re-learned.
  • What if there is a financial benefit to the physician for self-referrals to affiliated imaging centers? Again, a behavior that may need to be modified.
  • What if the quality of the report resulting from the previous image does not leave the physician comfortable with determining the appropriate course of action?

While some EHRs and HIEs are able to support links to the actual image result, the majority of results based clinical documentation tools are only able to support the actual communication of the dictated report. Do we know that was the case with the EHRs that the above physicians were using? No, but think about it. If the access to the EHR included the actual image and the dictated report what else would be needed? Because they have access to an EHR which likely facilitates the test ordering process, it would be much easier and quicker to reorder the test than to try to retrieve the actual original image.

So, what am I proposing that we conclude from the above study? Remember: it makes a clear distinction between physicians with EHRs and those without. Those with EHRs most likely do not receive or have easy access to a paper file, so they may not get the actual image to review. Those without EHRs rely on a more manual process such as pulling a file to read the report then viewing the image. They have to request the result manually if they don’t have it.

I’m suggesting that some of the issue may lie with what is actually available via the EHR, i.e. can you access the actual image or just the dictated report? I’m sure the ease of reordering the test on-line via the EHR vs. requesting the original report be faxed is contributing to the duplication of tests.

I think there is definitely the opportunity to improve care and reduce costs with the utilization of a quality EHR application that can provide the necessary clinical information in the format(s) necessary to make an educated decision.

What are your thoughts?

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