A story in this week's New York Times with implications for electronic health records certainly has a lot of folks riled. It concerns a study [subscription required for full access] published in the March issue of the influential journal Health Affairs that states in its abstract:
"Physicians’ access to computerized imaging results [sometimes, but not necessarily, through an electronic health record] was associated with a 40 to 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."
These findings seemingly contradict the long-held expectation that electronic access to health information will reduce the number of medical tests doctors order, and therefore, significantly reduce a major health care cost driver.
One of the co-authors, Danny McCormick, an assistant professor of medicine at Harvard Medical School, stated that the 2008 study raises "the possibility that, as currently implemented, 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."
"We conclude 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."
Nothing like sticking a red hit poker in the eye of EHR advocates!
EHR advocates, including David Blumenthal, also a professor at the Harvard Medical School and who was the former national coordinator for health information technology in the Obama administration, and David Brailer, who was the first national coordinator for health information technology in the George W. Bush administration and current chairman of Health Evolution Partners, dismissed the study, according to the Times.
They said that the study was done in 2008, and therefore was before all the new governmental standards/incentives for EHR meaningful use were put into place. They also said that it was only one of a "small minority of studies" that questioned the value of EHRs, whereas the vast majority of studies found opposite results. They also said that McCormick's wasn't a controlled study, it used a dubious source of data, and probably more to the point, didn't indicate why doctors seemed to order more rather than fewer tests.
McCormick admitted the latter criticism was true, and "speculated that digital technology might simply make ordering tests easier," the Times story reported. You can also read a blog post at Health Affairs that provides more of his comments along these same lines.
For me, the most interesting reaction was found in the hundreds of, shall we say, robust comments that appeared at the New York Times, many not about the findings of the study itself but about the impacts and expectations, both positive and negative, of health information technology on U. S. healthcare in general. Quite a few doctors and other medical professionals are weighing in, and the discussion is more respectful and on-topic than most.
Even with its limitations, I think that what the McCormick et al. study points out is that the ways in which the digitalization of healthcare changes (or not) healthcare worker and patient behavior has been probably understudied, especially in relation to the presumed reductions in healthcare costs as well as patient outcomes. As the work of Shoshana Zuboff has shown, digitalization of an industry creates behaviors that are not always what were predicted or assumed.