Health Information Exchange and Ambulatory Test Utilization (Colorado)

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Summary:

Health information exchanges (HIEs) may improve the quality and efficiency of medical care because clinicians are able to make better decisions when the health information they need is easily accessible. In addition, HIEs are expected to reduce health care costs, partially by reducing redundant laboratory and radiology tests. Research suggests that when institutions implement electronic medical records (EHRs), the utilization of tests is substantially reduced because clinicians who have ready access to the results of prior tests are less likely to repeat those tests. Although it is intuitive that a similar result would occur from information exchange across communities with an HIE, there is little evidence to support this.

This study evaluated whether the adoption of a community-wide HIE reduces utilization and costs of laboratory and radiology testing. The study took place in Mesa County, Colorado, where there has been wide-scale adoption of the Quality Health Network, the regional HIE. The specific aim of this project was to:

  • Determine whether adoption of HIE in Mesa County, Colorado, is associated with a reduction in test ordering. 

The project used a retrospective, pre-post study design comparing providers working in Mesa County medical practices. The analyses took place at both the practice and the provider level. Claims data were used and matched to HIE adoption data. The effect of HIE adoption on testing rates and associated charges was assessed.

In the ambulatory setting, provider adoption of HIE was not associated with consistent reductions in overall rates of testing with HIE or of costs of testing. The project team concluded that ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, more coordinated, and higher-quality care.

Health Information Exchange and Ambulatory Test Utilization - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018749
  • Project Period: 
    May 2010 – January 2013
  • AHRQ Funding Amount: 
    $299,916
  • PDF Version: 
    (PDF, 196.95 KB)

Summary: One of the purported benefits of health information exchange (HIE) is that it can improve the efficiency of care by reducing redundant laboratory and radiology testing. There is evidence that test utilization is reduced substantially within institutions, such as medical centers, when they implement comprehensive electronic medical records. If physicians can easily access the results of tests that have already been performed, they are less likely to repeat them. However, while it is intuitive that HIE across organizations in a community would lead to a reduction in test utilization, there is little evidence that community HIEs result in such an impact. As the United States explores investments in HIE to improve the quality of care, policymakers and potential stakeholders in HIE, such as health plans, need more estimates of the degree to which HIE can improve the efficiency of care.

Mesa County, Colorado, is a rich resource for more definitive assessments of the effects of HIE. Quality Health Network (QHN), a regional HIE that started providing data exchange to Mesa County in 2005, captures nearly all the test results in the county, and has been adopted by more than 85 percent of the practitioners. There is also evidence that since HIE was introduced, reductions in laboratory and radiology utilization in Mesa County contrast with national trends of steady or increasing test utilization. This study is formally assessing whether adoption of a community-wide HIE reduces utilization of laboratory and radiology testing. The primary study design used was a retrospective pre-post HIE adoption comparison of providers working in Mesa County medical practices. The analyses, conducted at practice and provider levels, employed general linear mixed models. Rates and costs of tests were the outcome variables, and adoption over time from 2005 to 2010 was the primary predictor variable.

The electronic exchange of health information in communities may improve the quality and efficiency of medical care. Providers can make better decisions when the health information they need is on hand. By assessing whether a robust, mature regional HIE system increases medical care efficiency, this project will provide estimates of value that will prove useful for national decisionmakers and local stakeholders in HIE, and will help guide future HIE efforts.

Specific Aim:

  • Determine whether adoption of HIE in Mesa County, Colorado, is associated with a reduction in test ordering. (Achieved)

2012 Activities: The focus of activity was on data analysis and dissemination of findings. The study team completed its data analyses using the shifted slope model to address the preliminary finding of a negative shift in the slope of laboratory test rates while observing a positive shift in laboratory test costs. The project team continues to investigate this unanticipated finding. The project team also completed a sensitivity analysis comparing different ways of categorizing HIE adoption. The team looked at cost per test, as well as whether primary versus specialty care showed different levels of effect. Differential effects were depicted in a poster presented at the AHRQ Annual Conference in September 2012. A manuscript titled, Effects of Health Information Exchange Adoption on Ambulatory Testing Rates, was accepted for publication in the Journal of the American Medical Informatics Association.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track, and project budget spending is on target. There was an initial delay caused by the purchase of ManagedCare by TransUnion in late 2010. ManagedCare was the agency providing the project with claims data for the analysis, and therefore new business associate agreements had to be developed with TransUnion. Once the new agreements were signed, data became available, and the team was able to resume working at full effort. A 9-month no-cost extension was used to compensate for the delay in obtaining the study data.

Preliminary Impact and Findings: The study showed a statistically significant decrease in the rates of laboratory testing rates associated with HIE. Claims submitted by 306 providers in 69 practices for 34,818 patients from the second quarter of 2005 to the fourth quarter of 2010 were analyzed. The rate of testing per provider was expressed as tests per 1,000 patients per quarter. For primary and specialty care providers, the rate of laboratory testing increased over the time span and shifted downward with HIE adoption. There was no observed significant effect on the cost of testing, for which the study team is examining potential explanations, such as the possibility that HIE adoption might be associated with fewer but more expensive laboratory tests. For radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges in either provider group.

While the reduction in laboratory testing rates confirms that HIE adoption can result in more efficient care, the short-term economic benefit may be less than anticipated. This study was limited in its ability to differentiate effects of HIE adoption from other secular trends. Future research on the impact of HIE to improve care coordination in ways that go beyond the effects on testing rates may hold much promise for the study of HIE.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

HIE and Ambulatory Test Utilization - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018749
  • Project Period: 
    May 2010 - April 2012
  • AHRQ Funding Amount: 
    $299,916
  • PDF Version: 
    (PDF, 189.14 KB)

Summary: One of the purported benefits of health information exchange (HIE) is that it can improve the efficiency of care by reducing redundant laboratory and radiology testing. There is evidence that test utilization is reduced substantially within institutions, such as medical centers that implement comprehensive electronic medical records. If physicians can easily access the results of tests that have already been performed, they are less likely to repeat them. However, while it is intuitive that HIE across organizations in a community would improve the coordination of care, there is scant evidence that community HIE results in a reduction in test utilization. As the United States explores investments in HIE to improve the quality of care, policymakers and potential stakeholders in HIE, such as health plans, need more estimates of the degree to which HIE improves the efficiency of care.

Mesa County, Colorado, is a rich resource for more definitive assessments of the effects of HIE. Quality Health Network (QHN), a regional HIE that started providing data exchange to Mesa County in 2005, captures nearly all the test results in the county and has been adopted by more than 351 practitioners, which is more than 85 percent of practitioners in the county. There is also evidence that since HIE was introduced reductions in laboratory and radiology utilization in Mesa County contrast with national trends of steady or increasing test utilization. This study will formally assess whether adoption of a community-wide HIE reduces utilization of laboratory and radiology testing. The primary study design is a retrospective pre-post comparison of providers working in Mesa County medical practices. Analyses are being conducted at the practice and the provider level. These analyses employ general linear mixed models, with rates and costs of tests as the outcome variables and adoption over time from 2005 to 2010 as the primary predictor variable.

The electronic exchange of health information in communities may improve the quality and efficiency of medical care. Doctors can make better decisions when the health information they need is on hand. By assessing whether a robust, mature regional HIE system helped doctors provide more efficient medical care, this project will provide estimates of value that will prove useful for national decisionmakers and local stakeholders in HIE, and will help guide future HIE efforts.

Specific Aim:

  • Determine whether adoption of HIE in Mesa County, Colorado, is associated with a reduction in test ordering. (Ongoing)

2011 Activities: The study team conducted a crosswalk of the numeric practice ID and practice name from QHN, which allowed the team to complete the necessary data cleaning and quality checks. The crosswalk was necessary because the study team found that practices that had not adopted HIE by December 2010 were not reliably identified in the dataset. However, they were able to recover several "never-adopters" by reviewing these data.

In writing and running the SAS code for the descriptive analysis of data, the team also discovered an issue related to the interpretation of the "ordering provider." Therefore, a new algorithm for attributing an ordering provider to laboratory and radiology claims was implemented to better support the analysis and modeling phase of the project. Since then, a simple descriptive analysis of the data has been completed, as has the initial work on developing the analytic model.

Next steps will include finalizing the data analysis of the effects of health information exchange on rates of test ordering. The investigators, in conjunction with the CEO of QHN, will present initial findings at the national Healthcare Information and Management Systems Society meeting in February 2012. Manuscript development will also take place in the final year of the project.

As last self-reported in AHRQ's Research Reporting System, project progress and activities are on track and the project budget is underspent. The budget underspending was due to the delay caused by the purchase of ManagedCare by TransUnion in late 2010. Because ManagedCare was the agency providing the project with claims data for the analysis, new business associate agreements had to be developed. Once the new agreements were signed, data became available and the team was able to resume working at full effort.

Preliminary Impact and Findings: The project has no findings to date.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

HIE and Ambulatory Test Utilization - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 018749
  • Project Period: 
    May 2010 – April 2012
  • AHRQ Funding Amount: 
    $299,916
  • PDF Version: 
    (PDF, 300.82 KB)


Target Population: General

Summary: One of the purported benefits of health information exchange (HIE) is that it can improve the efficiency of care by reducing redundant laboratory and radiology testing. There is evidence that test utilization is reduced substantially within institutions such as medical centers that implement comprehensive electronic medical records. If physicians can easily access the results of tests that have been done before, they are less likely to repeat them. However, while it is intuitive that HIE across organizations in a community would improve the coordination of care, there is scant evidence that community HIE results in a reduction in test utilization. As the United States explores investments in HIE to improve the quality of care, policymakers and potential stakeholders in HIE, such as health plans, need more estimates of the degree to which HIE improves the efficiency of care.

Mesa County, Colorado, is a rich resource for more definitive assessments of the effects of HIE. Quality Health Network (QHN), a regional HIE that started providing data exchange to Mesa County in 2005, captures nearly all the test results in the county and has been adopted by more than 351 practitioners, which is more than 85 percent of practitioners in the county. There is also evidence that the reductions in laboratory and radiology utilization in Mesa County since HIE was introduced contrast with national trends of steady or increasing test utilization. This study will formally assess whether adoption of a community-wide HIE reduces utilization of laboratory and radiology testing. The primary study design is a retrospective pre-post comparison of providers working in Mesa County medical practices. Because the timeframe for adopting HIE varies across practices, a differences-in-differences modeling approach is being utilized. This approach allows studying the treatment effect of HIE adoption in different subgroups and is used to eliminate observed or unobserved differences that remain constant over time. The approach will include a basic description of cross-sectional patterns for test ordering in each year from 2004 to 2009, examination of trends from 2004 to 2009, and a cross-sectional, time-series analysis. Physician-level data files will be constructed using data collected at the patient encounter and practice level.

The electronic exchange of health information in communities may improve the quality and efficiency of medical care. Doctors can make better decisions when the health information they need is on hand. By assessing whether a robust, mature regional HIE system helped doctors provide more efficient medical care, this project will provide estimates of value that will prove useful for national decisionmakers and local stakeholders in HIE, and will help guide future HIE efforts.

Specific Aim:
  • Determine whether adoption of HIE in Mesa County, Colorado is associated with a reduction in test ordering. (Ongoing)

2010 Activities: Institutional review board (IRB) materials were submitted to the Colorado Multiple Institutional Review Board and final IRB approval was obtained in August 2010. The data use agreement for the Mesa County regional health information organization, QHN, was completed and signed by both parties in July. However, there was an unanticipated sale of ManagedCare.com, the agency providing claims data for analysis, to TransUnion shortly after the start of the grant period. This triggered the need to re-write the complex set of business associate agreements among TransUnion/ManagedCare.com and the Mesa County stakeholders, including QHN, Rocky Mountain Health Plan, and the Mesa County Physicians Independent Practice Association. While this process caused a delay in the receipt of the anticipated data extracts, all revised agreements were signed by mid-November. This allowed TransUnion/ManagedCare.com to send a claims dataset to QHN in late November for merging with the “HIE use” dataset and de-identifying providers and patients. A revised dataset was required in early December after missing fields were discovered. The revised dataset of more than 10 million records was being cleaned and undergoing quality checks as of the end of December 2010. The project team is developing descriptive statistics on a 0.1 percent random sample of the data. A more powerful computer was purchased in December to speed analysis of the complete dataset, given its relatively large size.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project was stalled in meeting several aims and milestones due to the sale of ManagedCare.com to TransUnion. However, activities have resumed and there is a plan to get back on track in many of the stalled areas. The project is currently under-budget due to the aforementioned project delays, but expenses are expected to increase now that the delivery of datasets for analysis has occurred.

Preliminary Impact and Findings: There are no findings to report at this time.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

Health Information Exchange and Ambulatory Test Utilization - Final Report

Citation:
Nease D. Health Information Exchange and Ambulatory Test Utilization - Final Report. (Prepared by the University of Colorado - Denver under Grant No. R21 HS018749). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 199.36 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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