Permanent Mark on Your Record

An important post by Sarah Kliff about electronic medical records demonstrates that sometimes reforms don’t work quite the way we anticipate—contrary to story, it turns out doctors with electronic medical records that share digital imagery or tests order more tests rather than fewer ones. You’d think that the ability to share tests would decrease the number of duplicate tests; sadly, this isn’t the case. The study’s authors’ speculation:

What about digital record-keeping that gets doctors to order additional care? The authors here think it has to do with the immediacy of results. “In borderline situations, substituting a few keystrokes for the sometimes time-consuming task of tracking down results from an imaging facility may tip the balance in favor of ordering a test,” authors Danny McCormick, David Bor, Stephanie Woolhandler and David Himelstein conclude. “This ‘convenience’ effect of computerized access might cancel out the potential decreases in ordering due to reductions in duplicate or unnecessary testing.”

It just goes to show you that the importance of any one tool is probably a bit overstated—it’s all about the context of care. (This isn’t the first story we’ve had about EMRs being used in a way we wouldn’t necessarily like—take also the story about hospitals using EMRs to microtarget advertising for various procedures and/or tests recently.) In both cases, we can see that a potentially promising tool is just that—a tool, which is used in a context which can make it helpful or unhelpful. If you don’t make the incentives and culture right, any given tool will tend to get used according to the priorities of the system—which, generally speaking, is in favor of intensive use. It’s in this spirit that Austin Frakt’s rumination that an “Amazon checkout” feature showing how much a test would cost should be taken—that is, that it’d be helpful in the context of a system that cares about cost and efficiency.

Furthermore, we should keep in mind that eliminating unnecessary imagery has important second-order consequences beyond just the saving of time, money and manpower. An interesting article worth reading in the journal Environmental Health Perspectives notes that unnecessary imagery implies the exposure of radiation to patients, which means that we’re increasing the cancer risk for the patients in question. (One study cited in the article estimated 29,000 cancers as a result of scans in 2007; that drew some fire, naturally, but gives you an idea of the potential implications. Also note the reality that some proportion of scans are poorly executed and end up delivering more than the intended dosage of radiation.). For scanning, then, more might mean less.