No abstract

Policy-based incentives for health care providers to adopt health information technology are predicated on the assumption that, among other things, electronic access to patient test results and medical records will reduce diagnostic testing and save money. To test the generalizability of findings that support this assumption, we analyzed the records of 28,741 patient visits to a nationally representative sample of 1,187 office-based physicians in 2008. Physicians' access to computerized imaging results (sometimes, but not necessarily, through an electronic health record) was associated with a 40-70 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. The availability of an electronic health record in itself had no apparent impact on ordering; the electronic access to test results appears to have been the key. These findings raise 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.H ealth policy experts, consultants, policy makers, and the Obama administration have argued that widespread adoption of health information technology will result in substantial cost savings. Reduced ordering of imaging and other diagnostic studies is often cited as a likely mechanism for cost savings related to health information technology. The use of imaging studies-particularly advanced imaging, or computerized tomography scans, positron emission tomography, and magnetic resonance imaging-has escalated dramatically. 8 In 2002 it accounted for more than 14 percent of Medicare Part B expenditures. 9Health information technology might be expected to decrease the use of diagnostic imaging in several ways. Providing physicians with electronic access to prior imaging test results might reduce redundant test ordering, especially for expensive advanced imaging. Even in the absence of prior imaging, the improved availability of data from previous physical examinations and diagnoses might reassure clinicians that a cur-

We studied 458 consecutive patient transfers from 14 ty studied, transfer is a common and potentially dangerous medical private hospitals to a public hospital emergency room during a sixintervention which appears to reinforce racial and class inequalities month period. The transferred patients were predominantly male, of access to medical care. (Am J Public Health 1984; 74:494-497.) young, and uninsured, and included large numbers of minority group members. We established criteria to identify patients at high risk for adverse effects of transfer and reviewed the clinical records of the 103 patients meeting these criteria. We judged that transfer resulted Introduction in substandard care for 33 of these patients, either because theyLittle is known about the transfer of patients between were at risk for life-threatening complications in transit or because hospital emergency rooms. Anecdotal reports suggest that such transfers are common, may be hazardous, and dispro- Of the 458 patients transferred to the emergency department, 272 (53 per cent) were admitted to the hospital, 22 of whom required intensive care. Thirty-two patients (7 per cent) were referred to the Department of Psychiatry, 9 (2 per cent) were taken into custody by judicial authorities, and 27 (6 per cent) were transferred to other institutions for further care. The study population of 458 patients with 272 admissions represented 2 per cent of emergency room visits and 6.5 per cent of all hospital admissions at Highland General.Half of the patients had suffered traumatic injuries; 8 per cent were thought to have taken drug overdoses; and 5 per cent had alcohol withdrawal syndromes.Each of the 14 private hospitals in Alameda County with an emergency room transferred at least 11 patients to the county hospital. The 12 private hospitals with full emergency services were responsible for 91 per cent of the transfers, with four of these accounting for 55 per cent of all transfers. Sixty-six per cent of patients were transported by ambulance, and the remaining 34 per cent provided their own transportation.Seventy-nine (31 per cent) of the White patients transferred were insured, while 90 (44 per cent) of the non-White patients had health insurance (Chi square df 1 = 7.5, p<.01). Clinical EvaluationOf the 103 patients whose charts were reviewed, only one patient was explicitly transferred for a medical indication, a service not available at the original hospital. In 11 cases, physicians indicated that the patient was transferred because of inability to pay. In no case did a physician or nurse accompany the patient during transfer.In 33 cases (24 males and 9 females), transfer was judged to have jeopardized the patient. Fourteen (42 per cent) of those jeopardized were non-Spanish surnamed Whites, while this group accounted for 56 per cent of nonjeopardized transfers (Chi square df 1 = 2.35, p=.12). Twenty-eight (85 per cent) of those imperiled by transfer were uninsured, a significantly greater proportion than the 62 per cent uninsured among tho...