By Erik L. Ridley, AuntMinnie staff writer

January 30, 2014 -- Adopting health information exchange (HIE) between unaffiliated healthcare providers leads to significant decreases in repeat imaging studies in emergency departments (EDs) and could potentially save millions of dollars, according to a large study from the University of Michigan.

The researchers retrospectively analyzed repeat imaging rates for CT, chest x-ray, and ultrasound in 37 emergency departments in California and Florida that have initiated HIE. They compared the results with rates in 410 EDs that did not participate in HIE. Facilities that utilized HIE performed 44% to 67% fewer redundant imaging studies, depending on the modality, the group found.

"Our findings support the widely held notion that HIE can reduce redundant medical services and thereby produce cost savings," wrote lead author Eric Lammers, PhD, and colleagues in the journal Medical Care (December 26, 2013).

Little empirical evidence

HIE involves electronic sharing of information such as tests and imaging results, discharge summaries, and medication lists. Electronic HIE among unaffiliated providers represents a critical extension of electronic health records (EHRs) that is being emphasized in the meaningful use incentive program from the U.S. Centers for Medicare and Medicaid Services (CMS), according to Lammers.

"One of the reasons driving this emphasis is the hope that HIE can reduce redundant procedures that might otherwise occur if different clinicians serving a particular patient do not have access to better information about the patient's history of care," he told

While a few studies have projected billions of dollars in savings by reducing unnecessary tests and other efficiency improvements, there is relatively little empirical evidence to back that up, he said. At the same time, the use of imaging, particularly CT, has been on the rise in emergency departments and may present health risks due to the effects of radiation exposure.

As a result, the researchers sought to assess whether HIE adoption could lead to a decline in repeat imaging in EDs. They retrospectively accessed discharge data from the State Emergency Department Databases for California and Florida for 2007-2010, and then merged the data with information on hospital HIE participation from market research firm HIMSS Analytics.

During the study period, 37 emergency departments were found to have begun using HIE, compared with 410 that did not. The researchers used regression analysis to assess the impact of HIE on the rate of repeat chest x-ray, CT, and ultrasound imaging. A repeat imaging study was defined as the same study in the same body region performed within 30 days at an unaffiliated emergency department.

The sample yielded a total of 20,139 repeat CTs (representing 14.7% of those patients who received CT on their first visit), 13,060 repeat ultrasound (20.7% of ultrasound cases), and 29,073 repeat chest x-rays (19.5% of x-ray cases).

"Among patients who visited multiple EDs within a 30-day window and who received an imaging study on their initial ED visit, about 15% to 20% of second visits resulted in repeat imaging," he said.

However, the use of HIE was associated with reduced probability of repeat imaging in all three modalities, when compared with EDs that did not use HIE.

Effect of HIE use on imaging
Modality Decline in repeat imaging in EDs that use HIE
Chest x-ray 67%
CT 59%
Ultrasound 44%

Cost savings

The researchers also used the results to project conservative annual cost savings. If all hospital-based EDs in California and Florida fully participated in HIE, more than $2.9 million in payments could be avoided annually over the three categories of imaging studies, according to the researchers.

"Extrapolating these avoided payments to the nation, our findings suggest $19 million in annual savings for these three types of procedures if all EDs participated in HIE," the authors wrote.

In other findings, HIE may be especially valuable in larger EDs, which were shown to be more likely to perform some repeat tests, according to Lammers and colleagues.

"We speculate that this may be attributable to a cultural preference for more intensive use of medical technology in larger EDs, easier access to imaging (e.g., CT scanners physically located in the ED itself), or perhaps greater stress on staff resources in EDs that see more patients, thus leading to more intensive reliance on diagnostic technology," the authors wrote. "In any event, this suggests there may be unique challenges that must be overcome to realize the greater potential reduction of repeat testing from HIE in these settings."

Overall, the study's findings provide some cautious optimism that investments in HIE and EHRs will produce some reductions in redundant testing, Lammers said.

"However, more research is needed that examines the impact of HIE across all settings of care, not just the very circumscribed scenario we examined," he told "Also, it's important to note that our findings do not address the impact of HIE on patient well-being. Further research is needed into the effect of HIE on outcomes and other measures of quality."

The researchers are continuing to investigate the effects of EHR adoption and HIE on the costs of care and outcomes. Lammers is also part of another team evaluating the effect of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which established the meaningful use program, for the U.S. Office of the National Coordinator for Health IT (ONC).

"As part of that project we are looking at how both hospital and physician adoption of EHRs interact at the market level to affect, among other things, imaging costs, inpatient costs, hospital readmissions, and care for patients with chronic conditions," he said.

Copyright © 2014

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