Health Care Efficiency: No Miracle Cure

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Health care reform ideas are everywhere these days. As a radiologist, I'm all for controlling costs—but I challenge the assumption that national electronic medical records (EMRs) will magically make providers more informed and automatically decrease unnecessary tests.

It sounds great, but the idea and, at least, its partial implementation are nothing new. We know that most US hospitals have already used electronic records for years in their own systems—yet useful information is ignored every day, costing us all.

An extreme, but genuine, example involves a woman who recently came to a hospital complaining of abdominal pain. Her urinalysis showed blood. The emergency-department physician asked no further questions and reflexively ordered a CT scan, questioning whether there was a kidney stone.

Had he, his secretary, or the CT technologist looked at the computerized records, one of them would have noticed that the patient had undergone the same study, for the same symptoms, only two weeks before—and it was normal. So were multiple scans earlier this year and in preceding years, all listed in the information system and on the PACS. All told, the patient had an astounding 35 CT scans in five years, all essentially normal.

When I pointed this out to the emergency-department physician, he was embarrassed over the waste of resources. The number of normal scans did, at least, help him confirm the diagnosis that he was already suspecting: She was a narcotics addict, coming back for more painkillers. Her 35 patient encounters, all with CT scans, mean that well over 100 employees over the past few years could have questioned this woman who kept getting expensive tests—but get them she did.

Tainting urine with blood is an old trick to an experienced abuser of narcotics, and many tests, like her CT scans, are painless—at least until the bill comes due. One CT scan, of course, might cost hundreds of dollars. Add hospital charges, laboratory tests, and medications, and her total charges over the past few years are scary. Don’t forget her huge cumulative radiation dose. She doesn’t have cancer now, but she might someday, and who’s to say what might have caused it—or who will pay for its treatment.

An Institutional Dilemma

What about most patients, who aren’t faking? Many still get unnecessary tests because ordering physicians and other health care workers fail to consult records, and because clinicians might not understand what a test can or cannot do. It happens all the time. It might be an abdominal ultrasound to rule out gallstones, even though there were none last month. We average a couple pointless renal ultrasound studies a day for renal insufficiency to rule out obstruction, in patients with recent unenhanced CT or MRI studies that already show no urinary dilation.
One colleague recently read a negative leg Doppler study and gave his impression that there was no deep-vein thrombosis (DVT). When the study was repeated only a few days later for persistent leg swelling, and was again negative, his impression read: still no DVT.

Occasionally, physicians even order tests to evaluate organs removed years ago, unaware that their patient no longer has an appendix, uterus, gallbladder, or spleen. Such information would seem obvious to note in a patient's history, but sometimes that gets overlooked. Patients might consult multiple physicians, including specialists focused on their area of expertise. Information sometimes simply slips through the cracks, or is not looked for—even when it’s only a few clicks away from the user.

The general public might understandably think this behavior careless, or even lazy. Health care workers might blame busy work environments and the fear of malpractice suits if no test is ordered.

Don’t forget the patients: Why aren’t they always more forthcoming? Many sick or demented patients don’t remember or can’t communicate. Not all physicians speak understandably. Some patients are passive or don’t know any better. Reasons for poor communication are complex, but the result is the same: Unnecessary, expensive tests are performed every day, despite internal electronic records most places.

Radiologists are not entirely blameless here. We rely a great deal on the clinical history provided for a study. We also know that such histories are often incomplete, occasionally not quite accurate, and sometimes woefully inadequate. EMRs have been greatly beneficial to those of us who look up patients' laboratory