0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Bridging the Chasm: Effect of Health Information Exchange on Volume of Laboratory Testing FREE

Esteban Hebel, MD; Blackford Middleton, MD, MPH, MSc; Maria Shubina, ScD; Alexander Turchin, MD, MS
[+] Author Affiliations

Author Affiliations: Harvard Medical School and Clinical Informatics Research and Development, Partners Healthcare Systems, Boston, Massachusetts (Drs Hebel, Middleton, and Turchin); Divisions of General Internal Medicine (Dr Middleton) and Endocrinology (Drs Shubina and Turchin), Brigham and Women's Hospital, Boston.


Arch Intern Med. 2012;172(6):517-519. doi:10.1001/archinternmed.2011.2104.
Text Size: A A A
Published online

Sharing of patient information between health care providers, including through health information exchanges (HIEs), has been proposed as one of the essential changes to improve the quality and efficiency of the health care system in the United States.1 It has been estimated that HIEs could decrease health care costs across the country by approximately $78 billion annually.2 Despite numerous potential advantages of HIEs, there are few studies documenting their benefits.3 This lack of objective information might have slowed down their acceptance.4 Studies that demonstrate tangible evidence of benefits provided by HIEs are urgently needed. Provider surveys show that reduction in duplicate testing is one of the most commonly expected benefits.5,6 We therefore investigated whether the introduction of an HIE between 2 academic medical centers was associated with a reduction in volume of laboratory testing.

We conducted a retrospective study to investigate whether the availability of laboratory test results from a nonencounter hospital reduced the number of subsequent laboratory tests at the encounter hospital. The institutional review board at Partners HealthCare approved the study.

All new outpatient consultations at 2 affiliated academic hospitals between January 1, 1999, and December 31, 2004, were studied. Encounters during the year 2000 when an internal HIE was being rolled out were excluded. We also excluded patients hospitalized for 10 days or fewer after the index encounter and patients with tests in both hospitals prior to the encounter.

A single new consultation encounter—the index encounter—served as a unit of analysis. The number of laboratory tests performed until the end of the day of the index encounter at the same institution as the encounter (postencounter on-site tests) served as the primary outcome variable. Presence of laboratory tests performed at either of the institutions during the 7 days prior to the index encounter and whether the encounter took place before (1999) or after (2001-2004) the HIE rollout served as the primary predictor variables.

A multivariable Poisson regression model was used to evaluate the effect of the recent preencounter tests on the number of postencounter on-site laboratory tests while covariates were adjusted for.

We identified 122 771 patients between January 1, 1999, and December 31, 2004. We excluded 5146 patients who were admitted to the hospital 10 days or fewer after the index encounter and 19 patients who had tests in both institutions during the week prior to the encounter. The remaining 117 606 patients were included in the study.

Of the 346 study encounters with recent off-site tests, 44 took place prior to HIE rollout. Among the 117 260 encounters without preceding off-site tests, 21 968 took place prior to HIE rollout. Patients with recent off-site tests had a mean (SD) of 22.07 (30.13) tests prior to the index encounter. Patients without recent off-site tests had a mean (SD) of 1.62 (10.61) tests prior to the index encounter. Most of the encounters without off-site tests (110 110 or 93.9%) did not have any tests in the preceding week.

In univariate analysis, the number of laboratory tests performed after encounters that had recent off-site laboratory tests decreased by 49% after introduction of the HIE (Figure). In multivariable analysis using a Poisson regression model adjusted for the patient demographics, Charlson Comorbidity Index, site of the encounter, season, encounter year, and the number of prior tests at the encounter and nonencounter institutions, the number of tests after the encounters with prior off-site tests decreased by 52.6% (95% CI, 16.6%-73.1%) after the electronic medical record integration (P = .01).

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Number of laboratory tests per encounter. Compared are the encounters with recent off-site tests with those without, before and after the implementation of the health information exchange.

The number of postencounter tests increased by 2.5% for each point increase in the Charlson Comorbidity Index (P < .001), and it rose up to 51.7% with every subsequent year (P < .001). The number of tests decreased by 0.84% for every $10 000 increase in the patient's median household income (P < .001). It was also 9.06% lower for the patients on Medicaid (P < .001) compared with patients with private health insurance.

In this large retrospective study we have demonstrated that the introduction of an internal HIE was associated with a significant decrease in the number of laboratory tests ordered for patients new to the provider when recent laboratory results were available from another institution. Importantly, our results indicate that the reduction in laboratory tests may be as high as 50%. This could potentially translate into significant savings in settings where patients frequently receive care at multiple institutions.

Our research therefore confirms the hypothesis that having access to the patients' laboratory test results influences the decision process in regard to ordering further tests, which supports the predictions of financial savings made in the HIE cost-benefit models.2 Further studies are required to evaluate the impact and direct financial savings associated with sharing other health information, including imaging studies, physician notes, and discharge summaries.

Correspondence: Dr Turchin, Partners HealthCare, 93 Worcester St, Wellesley, MA 02451 (aturchin@partners.org).

Author Contributions: Dr Hebel had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Hebel, Middleton, and Turchin. Acquisition of data: Hebel and Turchin. Analysis and interpretation of data: Hebel, Shubina, and Turchin. Drafting of the manuscript: Hebel. Critical revision of the manuscript for important intellectual content: Hebel, Middleton, Shubina, and Turchin. Statistical analysis: Hebel and Shubina. Administrative, technical, and material support: Hebel and Middleton. Study supervision: Middleton and Turchin.

Financial Disclosure: None reported.

Funding/Support: This research was funded in part by scholarship grants from the Fulbright Commission–Institute of International Education (Dr Hebel) and the National Commission for Scientific and Technological Research, Chile.

National Alliance for Health Information Technology.  Report to the Office of the National Coordinator for Health Information Technology on defining key health information technology terms [registration required]. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_848133_0_0_18/10_2_hit_terms.pdf. Accessed September 24, 2011
Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability.  Health Aff (Millwood). 2005;(suppl Web exclusives)  W5-10-W5-18
PubMed
Frisse ME, Johnson KB, Nian H,  et al.  The financial impact of health information exchange on emergency department care [published online November 4, 2011].  J Am Med Inform Assoc
PubMed  |  Link to Article
Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use.  Ann Intern Med. 2011;154(10):666-671
PubMed
Hincapie AL, Warholak TL, Murcko AC, Slack M, Malone DC. Physicians' opinions of a health information exchange.  J Am Med Inform Assoc. 2011;18(1):60-65
PubMed   |  Link to Article
Wright A, Soran C, Jenter CA, Volk LA, Bates DW, Simon SR. Physician attitudes toward health information exchange: results of a statewide survey.  J Am Med Inform Assoc. 2010;17(1):66-70
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Number of laboratory tests per encounter. Compared are the encounters with recent off-site tests with those without, before and after the implementation of the health information exchange.

Tables

References

National Alliance for Health Information Technology.  Report to the Office of the National Coordinator for Health Information Technology on defining key health information technology terms [registration required]. http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10741_848133_0_0_18/10_2_hit_terms.pdf. Accessed September 24, 2011
Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability.  Health Aff (Millwood). 2005;(suppl Web exclusives)  W5-10-W5-18
PubMed
Frisse ME, Johnson KB, Nian H,  et al.  The financial impact of health information exchange on emergency department care [published online November 4, 2011].  J Am Med Inform Assoc
PubMed  |  Link to Article
Adler-Milstein J, Bates DW, Jha AK. A survey of health information exchange organizations in the United States: implications for meaningful use.  Ann Intern Med. 2011;154(10):666-671
PubMed
Hincapie AL, Warholak TL, Murcko AC, Slack M, Malone DC. Physicians' opinions of a health information exchange.  J Am Med Inform Assoc. 2011;18(1):60-65
PubMed   |  Link to Article
Wright A, Soran C, Jenter CA, Volk LA, Bates DW, Simon SR. Physician attitudes toward health information exchange: results of a statewide survey.  J Am Med Inform Assoc. 2010;17(1):66-70
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Types of Instruments and Tests in Medicine

Users' Guides to the Medical Literature
Was the Diagnostic Evaluation Definitive?