New technology

Computerized system alerts docs to costs

It’s critical that physicians are made aware of costs of tests at the moment when tests are actually being ordered, emphasizes J. Marc Overhage, MD, PhD, assistant professor of medicine at the Regen strief Institute for Health Care and Indiana University School of Medicine, both in Indianapolis.

At Indiana University Medical Center, Overhage and other physicians developed an electronic medical record that alerts physicians to information about tests at the time of ordering.

"You need to bring that information to the clinician in a very compact, condensed format they don’t have to seek out. Thinking that physicians are going to look up information on a Web site is fantasy. In reality, they are not going to do that," he says.

Physicians spend up to 25% of their time looking for information but fail to find the needed information as much as 10% of the time, he notes.1 The electronic medical record can be read by providers anywhere in a system that includes eight hospitals and 40 sites throughout the city, including satellite clinics, neighborhood health centers, and physicians’ offices.

With the electronic medical record, use of testing was decreased by 10% to 15% without compromising quality of care received by patients, Overhage reports. "Eighty percent of health costs come off the doctors’ pen. We drive costs by the orders we write. So changing what we think and do is critical, because it’s such a huge chunk of the health care budget."2

The computerized system is effective in reducing ordering of tests because no effort is required on the physician’s part.

"When you know people have been waiting two or three hours to see you, it’s hard to pause and look up a bit of information you need," he says. "It may seem easier to just do the test over. Or physicians may not think too hard about the choice and just go ahead and order the test to be on the safe side."

Among other benefits, the computerized record does the following:

1. Curtails use of inappropriate tests while encouraging ordering of appropriate tests.

"Cost and quality are two sides of the same coin. You can’t manipulate one without manipulating the other," Overhage notes. "If we make the right clinical choices, that will save money in the long run."

The goal isn’t just to reduce tests, but to order tests appropriately. This may mean increasing ordering of certain types of tests. "For example, ED visits in some settings are good places to get immunizations done. But that’s not something most ED physicians will think of, " he says.

2. Reduces patient anxiety.

When a physician orders a diagnostic test, there is a probability of about 5% that it will come back abnormal even though nothing is wrong. "There won’t be needless anxiety for the patient if an unnecessary test is not ordered in the first place," he says.

3. Provides information about previous tests.

When a patient comes to the ED, the physician receives a one-page summary that lists recent lab data, including test results from other facilities in which the patient has received care. "That is in the clinician’s hand when he goes to see the patient," Overhage says. "So instead of flipping through a chart or starting at ground zero, you already know a patient has had abnormal EKGs and previous MIs. That information may dramatically shift how you care for a patient."

Focusing on specific patient data is key, he says. "If you can bring things to the physician’s attention, such as the fact that a patient had a CT of the head yesterday or that an MRI costs $972 and has only a 3% probability of finding an abnormality, physicians will make better decisions," he explains.

4. Points out commonly overutilized tests.

The system presents physicians with data that suggest certain tests are unnecessary. Here are some examples:

Diagnostic tests for pancreatitis. "There is good evidence that you don’t need both tests for pancreatitis. The system reminds the physician that there is little value to the second test " says Overhage.

Differential CBCs. These typically are ordered by habit but are often not necessary, he notes.

Urinalysis. It’s common practice in many EDs to order both a urinalysis and culture, but this is often a wasteful practice, Overhage says. "There are obviously cases where there is the right thing to do, and you would never want a system to override the physician’s judgment. But the system can point out, Do you really want to continue that practice, which costs $60 and won’t change what you do for this patient?’"

References

1. Eisenberg JM, Williams SV. Cost containment and changing physicians’ behavior. JAMA 1981; 246:2,195-2,201.

2. Mamlin JJ, Baker DH. Combined time-motion and work sampling study in a general medicine clinic. Med Care 1973; 11:449-456.

3. Wilson GA, McDonald CJ, McCabe GP Jr. The effect of immediate access to a computerized medical record on physician test ordering: A controlled clinical trial in the emergency room. Am J Public Health 1982; 72:698-702.

4. Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med 1990; 322:1,499-1,504.

5. Tierney WM, McDonald CJ, Hui SL, et al. Computer predictions of abnormal test results: Effects on outpatient testing. JAMA 1988; 259:1,194-1,198.

6. Tierney WM, McDonald CJ, Martin DK, et al. Computerized display of past test results. Effect on outpatient testing. Ann Intern Med 1987; 107:569-574.

7. Overhage JM, Tierney WM, Zhou XH, et al. A randomized trial of corollary orders’ to prevent errors of omission. J Am Med Inform Assoc 1997; 4:364-375.