Mostashari Disputes Study Questioning Savings from Meaningful Use

Farzad Mostashari, national coordinator for health information technology, is taking issue with a new study in the March issue of Health Affairs that concludes having electronic access to medical imaging and lab test results increases the ordering of additional tests.

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Comments (3)
I am the CEO of an HIE that provides services to 9,000 organisations across New Zealand, Australia and soon Canada (mostly physician offices). Each year we enable the exchange of 65 million pieces of clinical information across 9,000 medical organisations, we have been in business for nearly 20 years. We are a privately held organisation working in partnership with governments.

In both New Zealand and Australia there is 97% GP EMR uptake and universal information exchange. We can see clear-cut benefits with better linkages between primary and secondary care,faster and more efficient patient transfers and higher levels of physician satisfaction (See Commonwealth Fund surveys) and a host of other incremental improvements that have contributed to making our health systems some of the most efficient in the world.

With respect to improving efficiency of diagnostic test ordering we are using technology to coach requesters to be more efficient and enabling them to immediately identify if the test they want has already been performed recently and delivering it to them. Our ordering patterns and usage is steadily becoming more and more efficient.

Dr Mostashari you are doing a great job and you are headed in exactly the right direction. Please don't take your foot off the accelerator.

Tom Bowden CEO HealthLink Ltd, (Auckland, Sydney, Brisbane, Perth, Melbourne and Vancouver).
Posted by T0mBowden | Thursday, March 08 2012 at 1:22PM ET
A sanguine review of the study and stated conclusions leads to concurrence with Dr. Mostashari. In addition to not accounting for decision support and related functionality mentioned by Dr. Mostashari, the study authors apparently ignored the sample bias of physicians who were early adopters of EHRs vs non-adopter cohorts. They claim to have accounted for this by "adjusting for patient and physician characteristics," but the one characteristic ('and what may be one of the most important ones) is that they were comparing the workflow and technology characteristics of the minority of docs who were early adopters of EHRs vs the majority of non-adopters physicians. Keep in mind that the study time period pre-dates the most recent uptick in EHR adoption so the sampling bias is even more substantial than it would be had the data come from 2011 or 2012. With that in mind the study data seems to indicate that docs who willingly choose and use technology in their offices are more likely to order technology-based tests for their patients. This is akin to proving that those who were first to buy an iPad were more likely to give on as a gift. Also of note is the fact that docs who were early adopters of EHRs were more likely to be employed by organizations where tests are performed, highly accessible and a source of institutional revenue- but that's another story.

If the authors really wanted to demonstrate the impact of EHR adoption on physician imaging and test ordering they would have had to compare the ordering habits for the SAME docs before and after EHR adoption- or to otherwise create a real control group and do a real test. Dr Brailer quoted in the related WSJ review of the study referenced the same flaw when he stated that he was unconvinced by the study's conclusions because they were based on a correlation in the data and were not the result of a controlled test.

EHRs may have an impact on imaging and other clinical test ordering. The referenced study doesn't seem to shed any meaningful light on the topic
Posted by ed.fotsch | Thursday, March 08 2012 at 1:34PM ET
I suspect that that while there are flaws in the study, the conclusions may not necessarily be dismissed because of particular issues that critics may have of the methodology. Medicine is not altruism any more than building homes for families, providing music lessons for children, or manufacturing drugs for AIDS/HIV patients is. As long as physicians believe that it is primarily insurance that pays for healthcare and not the patients themselves and as long as an attorney is waiting at the door to make hay of an honest or perceived mistake, the urge to order more tests will be omnipresent. As a computer programmer and user for more than three decades, I can unreservedly say that one of the behavioral patterns I have seen is that when something is objectified by putting on a computer monitor as an element of data, it tends to be more readily manipulated. You see this pattern among those who work with databases. It is common for a database programmer to work on production data in ways that border on being negligent, only because it is so easy to do so. When a patient's condition boils down increasingly to the sum of conditions, checkboxes, and radio buttons, I can readily see that ordering another test here or there to "round out" the picture of the patient in the name of defensive medicine would become ever easier to do.

That doesn't make this good medical practice, but it suggests to me that the headlong rush toward computer this and digital that is well thought out. So far, what I have read of the public discussion of HIEs and EHRs dwells on what borders on being advertisements for being "Thoroughly Modern Millies" of the medical sort. The benefits are not yet known because the costs are not yet known. We have yet, for instance, to have to deal with a major loss of EHR data or a major snafu at an HIE that redirects data to multiple and wrong destinations. We have yet to see the public's and the government's reaction to what happens when doctors are forced en masse to go digital or go out of business and the costs that become associated with practitioners who are all thumbs around computers.

Many, many doctors don't think the way that programmers do, and much of the software that now exists for physician and practitioner use employs screens that don't reflect at all how medical workers work. They don't allow people to be efficient, dragging the pace of medical delivery. That's is why so often doctors end up scribbling something on a piece of paper and then telling an underling to put it into the computer. Not only is the practice inefficient; it's dangerous, especially if the transcriber of the data doesn't understand what the doctor meant to say originally.

My suggestion is, as a programmer, that the industry as a whole needs to take a few steps back and take a breath. We are racing toward a future with the belief that we have it all figured out, yet from my vantage point, it seems like wild horses running to the edge of a cliff.
Posted by rdefazio | Thursday, March 08 2012 at 3:47PM ET
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