Since the publication of the study by McCormick, et al., in Health Affairs challenging the notion that healthcare IT (HIT) necessarily results in fewer studies being ordered, mainstream media healthcare blogs have been buzzing with discussion about the value of his research.
The simple conclusion of the study—as currently implemented, electronic access does not decrease test ordering in the office setting and may even increase it—has been drawn into a number of different conversations, and even drew a high-profile critique from Farzad Mostashari, the National Coordinator for Health Information Technology.
Lead author Danny McCormick, MD, says he expected some push-back, given the stakes.
“I think it’s a study that perhaps flies in the face of common wisdom, and so I think some people are surprised,” McCormick says. “There’s a lot of people with investments, monetary and other, in the cost savings of health care IT.”
“Some of this is semantics,” he says. “We have here for the first time a federal database that collects data on a nationally representative sample of physicians practicing in the U.S., in actual practice, not in cutting-edge institutions.”
According to a press release from Health Affairs: “For their study, McCormick and colleagues analyzed data from the 2008 National Ambulatory Medical Care Survey, which includes 28,741 patient visits to a national sample of 1,187 physician-based offices. The survey excludes hospital outpatient departments and offices of radiologists, anesthesiologists, and pathologists.”
McCormick says his research makes “pretty measured conclusions,” and stops far short of any definitive claims “as to what might happen in the future.”
Speculating on Root Causes
Although McCormick acknowledged the study doesn’t help understand the causes of the increase in test orders he observed, he was willing to speculate about what might be behind it. HIT clearly makes ordering tests and retrieving their results a more streamlined process for physicians, and “if you make something easier for people to do, they will do it more often,” he says.
“The frustrating thing about a study like this is that the data were collected for a different purpose, so we just can’t get at the motivation piece,” McCormick says.
“Obviously, future studies are going to have to try and sort out this whole issue of how physician behavior is changed by health IT.”
Mostashari alleged that McCormick’s research was good for generating “attention-getting media headlines” but “tells us nothing about the impact of EHRs on improving care.”
(The same issue of Health Affairs in which McCormick’s study appears also published several complementary stories on both sides of the question, including one from Mostashari on the rapid advancement of HIT throughout the country.)
“I think what [Mostashari] is implying there is, ‘Hey, you guys described the world in 2008, but now we have something that we believe is going to be a game-changer’,” McCormick says. “That is yet another hypothesis that needs to be tested.”
Not a Comment on Meaningful Use
Interpreting the results of the study to imply that it somehow disputes the value of meaningful use measures is misguided, McCormick says.
“Our study doesn’t have anything to do with meaningful use,” he says. “We don’t talk about it and it didn’t exist in 2008.
“It’s logical that if you get physicians harmonized in the way they use health IT that that would help improve the effectiveness of HIT and decrease costs,” McCormick says. “The fact is that the same arguments have been made for 50 years prior to 2008 and that test ordering has gone up.”
Mostashari’s rebuttal also dings McCormick and his team for overstating the value of their research, saying the study “falls prey to the classic fallacy of using association to suggest causality.”
McCormick, who teaches courses on research methods at Harvard Medical School, says that if that’s the case, then so do the majority of published medical studies.
The only scientifically valid way of proving the existence of a causal relationship between HIT and increased test ordering would be to conduct a randomized control trial, which McCormick says would never happen due to the costs and logistics of arranging such an experiment.
If a systematic difference existed among patients who went to doctors that had HIT, analysis of those findings would have needed to account for that, McCormick says. As most policy studies are association