Lab Soft News

Dayhawk Radiology and the Decline of the General Radiologist

I have posted a number of previous notes about Nighthawk Radiology and the manner in which Nighthawk Radiology plus radiology networks, originally designed for off-hours support, have paved the way for auctions of the professional services of radiologists. KevinMD recently posted an interesting note about "dayhawk" radiology and the the possible decline in the number of general radiologists (see: Nighthawks, dayhawks, and the demise of the American radiologist). Below is the note with boldface emphasis mine:

More hospitals are resorting to so-called "dayhawk" radiology services to read their x-rays. It's modeled after the "nighthawk" model, where radiologists (via Shadowfax), in some cases as far away as India, remotely read films in the middle of the night. Now, the phenomenon is happening during business hours as well, which according to radiologist Giles W. L. Boland, means that "some radiologists can no longer assume long-term job security because their core value proposition can now be outsourced." This trend was entirely foreseeable. Cash-strapped hospitals are finding it cheaper to outsource x-ray readings, and furthermore, it seems that both nighthawks and dayhawks provide better service and more timely interpretations. This adds up to a declining need for an in-house radiology staff. That's bad news for some. Radiology departments at smaller hospitals may close, and eventually general radiologist salaries will come under pressure. The answer? Like everything else in medicine, radiology sub-specialists will increasingly be in demand. Expect procedure-based, interventional radiology to grow, since what they do cannot be outsourced. Health care costs will correspondingly rise. So, like primary care, don't be surprised if the days of general radiology are numbered.

As Kevin remarks above, the evolution from "nighthawk" to "dayhawk" was entirely foreseeable. As soon as hospital executive learned that they could depend on reliable interpretation of radiology studies at night and on the weekends from Nighthawk Radiology and its imitators, few barriers remained to using the same services during the daylight hours. An added advantage for the execs of this approach has been that the cost of these services are now more exposed to competitive forces in the market. Therefore, as an added benefit, the cost advantages to outsourcing on a 7/24 basis are now becoming more apparent.

Kevin is also correct that interventional radiology services can't be outsourced and so will continue to in demand at the local hospital level. However, I think that it may be a little premature to refer to the "demise" of the general radiologist, at least as a result of the day/night-hawk radiologist business model. The U.S.-based teleradiology companies will need to find their radiology talent somewhere and I am sure that some of the personnel they hire will be general radiologists. However, a shift may be occurring in terms of the employer for many radiologists from a hospital or local radiology group to a company like Nighthawk or its newly emerging competitors. You can find the names of many of them by merely Googling the term nighthawk radiology and paying attention to the top and right-hand paid-for advertisement columns.

Frankly, this shift of employers by radiologists to teleradiology companies seems to me to be similar to the pod lab phenomenon in pathology whereby urology practices build a histology lab within their office suite and hire a pathologist part-time or full-time to provide diagnostics services. A variation on this theme is for the urology group to submit their tissue specimens to a commercial surgical pathology lab for processing and then use their own in-house pathologist to interpret the prepared glass slides that are returned by the commercial lab. In fact, I have been told that many of the surgical pathologists who are practicing in this type of environment are very satisfied with their positions.

A New Resource for Information about the Medical Technologist Shortage

I have posted previous notes about the medical technologist shortage (see: Comments on the Medical Technologist Shortage; ARUP Labs Responds to the Lab Personnel Shortage). However, I have always been frustrated by the shortage of reliable information about this very important problem. I know that there is also widespread concern and interest about this issue because "medical technologist shortage" is one of the most common search terms used to conduct readers to this blog in spite of my scanty coverage of the issue. It seems that a new resource about this topic is now being made available by the Coordinating Council on the Clinical Laboratory Workforce, which is a task force formed by the American Society for Clinical Lab Science. This latter group is a professional society for clinical lab professionals. Here the vision statement for the CCCLW copied from its web site:

• Identify workforce issues and initiatives.
• Foster educational efforts at all clinical laboratory levels.
• Develop models for demonstration projects that are patient-focused and demonstrate the value of the clinical laboratory professional as it relates to positive patient outcomes.
• Promote partnerships with health care providers, industry,foundations, and organizations interested in the future of the clinical laboratory profession.
• Cultivate relationships with advocates external to the profession.
• Provide a balance between future vision and current clinical laboratory practice.

Here also are some Fast Facts from the CCCLW web site about the med tech shortage obtained from the October 2008 issue of Critical Values:

• 44% of laboratories currently report difficulty in hiring [medical technologists].
  
• About 150,000 new technologists will be needed by 2014: 81,000 to replace retirees; 68,000 for new positions.
• There has been a 67% drop in new CLS/MT graduates since 1977: 6,519 graduates in 1977; 2,141 in 2000.
• 40% of the current workers will retire in 10 years.
• There has been a 71% decline in the number of accredited training programs since 1975: 770 NACCLS accredited programs in 1975; 222 in 2007.
• Average age of current workforce is 49.2 years.

I fear that the med tech shortage problem will get worse before it gets better. I have heard rumors that various schools are currently reducing or eliminating their medical technologist programs due to cost pressures and difficulty in recruiting qualified faculty members. I will try to provide more information about this issue in the future.

My thanks to Paul Epner for allerting me to the work of the CCCLW.

Possible Adverse Consequences of Increased Federal Investment in HIT

I have been observing the federal initiatives regarding increased funding of healthcare information technology (HIT) with a bit of a jaundiced eye. I have blogged in the past about the high failure rate for the deployment of hospital EMRs. Here is one example of such a note: EMR Failures and a Recipe for Their Avoidance in the Future. Many of the leading EMR products are expensive, outdated, and could possibly result in less efficient operations for hospitals installing them rather than productivity gains. A recent article in the New York Times provides what I think is an accurate assessment of the negative consequences that could result with an influx of federal money into HIT (see: Doctors Raise Doubts on Digital Health Data), Below is an excerpt from it with boldface emphasis mine. Read the whole article for other important insights.

Now that the federal government plans to spend $19 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent. Two articles, to be published [shortly] in the New England Journal of Medicine, point to the formidable obstacles to achieving the policy goal of not only installing electronic health records, but also using them to improve care and curb costs....In the [second] article, identified as a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements. Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications....In the Mandl-Kohane model, a software developer with a new idea for health record features like drug allergy alerts or care guidelines could write an application, and those could be added or substituted for a similar feature. Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run.

The lobbying pressure to channel money to the leading EMR vendors and stimulate an avalanche of new EMR installs in hospitals will be formidable. For example, the leading HIT membership society and professional accreditation group, HIMSS, actually described itself as a "trade association" in a press release (see: HIMSS Describes Itself as a "Trade Association" in a Press Release). This unfortunate, but accurate, description of the organization was quickly expunged from its web site. HIMSS execs will certainly be staking a claim on the newly available federal money on behalf of their favorite EMR companies. Hopefully, the hospital CEOs and CIOs will be able to withstand these efforts to purchase and install proprietary "pre-Internet era software" and hold out for the next generation of what hopefully will be superior products.

:: Update on 3/27/09 @ 9:18 a.m.

John Moore of Chilmark Research has additional comments on the topic above (see: Siloed, Tethered PHRs are a Dead-end).

Is My Chemo Working? -- FLT PET Scans May Provide the Answer

I spend a lot of time thinking about the future of healthcare diagnostics and the role of pathology and lab medicine within it. One of the criticisms of the current histopatholologic examination of tumors by pathologists is that, first of all, it is an in-vitro process. The tissue sample is first fixed in formalin and then various dyes are applied to the cells, producing a set of artifacts that pathologists are trained to interpret to render a diagnosis. A second problem concerns tissue sampling. The pathology report is usually based on a small tissue sample, often from a much larger piece such as an entire organ or large tumor. Although pathologists have become very skillful over time as diagnosticians, many assumptions are made about the "biology" of a lesion and how it will behave in the future.

I have posted a number of notes about molecular imaging in the past. The expectation is that this type of in-vivo imaging will produce a more accurate picture about the behavior of a tumor, its prognosis, and how it will react to a particular type of chemotherapy. There is a school of thought that holds that the optimal form of in-vivo imaging in the future will be PET scans, which provide a means to analyze the in-vivo biology of neoplasms. A recent article discussed value of PET scans in determining the comparative effectiveness of chemotherapy (see: Is my chemo working? Scans may give faster answer). I recently delivered a lecture on this general topic (see: Using Diagnostics to Monitor the Effectiveness of Treatment). Below is an excerpt from the article with boldface emphasis mine:

Doctors typically must wait weeks or months to see if a treatment is shrinking tumors or at least halting their growth. But researchers are exploring a new use for medical imaging that could shorten the stay in purgatory, possibly revealing within a few days whether chemo is working....This experimental imaging relies on a familiar hospital workhorse: PET scans, typically used for things like detecting cancer or revealing the effects of a heart attack. Unlike CT scans or MRIs, PET scans can show a tumor's internal activity, not just its size.When used to assess the effects of cancer treatment, it can reveal inside information about what the therapy is doing to a tumor even when there's no outward sign....This scan is called FLT PET, after radioactive fluorothymidine. These scans show whether cancer cells are dividing. Uncontrolled division is a hallmark of active cancer, and stopping that division should be an early effect of successful chemotherapy....One report [on the value of this type of imaging] involved 28 patients in Korea who were treated for advanced lung cancer....The researchers reported that just one week after treatment began, they could tell with 93 percent certainty which patients would eventually respond to the drug and which would not.

There appears to be a substantial literature about the use of FLT (fluorothymidine) PET scans for both diagnostic and therapeutic assessments. Examples cited in these articles include the noninvasive assessment of proliferation in lesions like pulmonary nodules and monitoring tumor response to antiproliferative therapy. The take-home lesson is that in perhaps five years, we may look back at some of our current diagnostic tests with a sense of disbelief. At the very least, I think that we are on the verge of a new era for in-vivo diagnostics. This is one of the reasons why I have been a strong advocate for integrated diagnostics, by which I mean the merger of pathology, lab medicine, and radiology into the new field of Diagnostic Medicine. I believe that the specialists working in their various diagnostic silos will have much to learn from each other when they engage in closer collaboration.

Additional Comment on Results from Patient-Performed Home Lab Tests

In my note yesterday (see: Lab Test Results as Essential Components of PHRs), I wrote that the results from patient-performed home lab tests do not have the same standing as those performed by hospital or commercial clinical labs. I took special care in my choice of the work standing -- I thought that it was sufficiently ambiguous that it would not provoke any comment. I was wrong. William Shipley submitted the following:

Having just done my morning glucose finger stick and watched the numbers continue their steady track back to normality after the gastronomical delights of Las Vegas..., I read your comments on home glucometers not having the same standing as clinical tests. That's not particularly controversial, I've said it several times myself. But then I got to thinking about the assumption that a professional lab would do better than the 'free' glucometer in my hand. Well, clearly the technology is better. On the other hand, the drop of blood on my finger was most certainly mine -- no sample mis-identification. And while I don't run QC (and I even know better!), I nevertheless ask myself "does this make sense?" and repeat any outliers. My sample is also pretty fresh and has not suffered from handling, cooling, etc. Do I think I'm doing better than a professional lab? Probably not. But as we move toward personal health records and more self generated data, balancing that data with professionally gathered information will be an on-going issue. We should beware that we do not let our professionalism cause us to undervalue data gathered by the people who care about it the most.

I carefully chose the word standing because I did not want to disparage the use of patient-generated test results. After all, the patients themselves use these results to regulate their blood glucose levels. I have posted a number of previous notes about glucometers and believe that they are very useful extensions of hospital labs. I also favor the process of uploading and integrating these home results into hospital, office, and personal EMRs. Having said this, I also believe that the source of home glucometer results needs to be clearly identified in any electronic record.

It is a common practice for office or hospital-based physicians to repeat previously performed tests, particularly when they are important and the patient is new to them. In effect, they are questioning the standing of previous results. This is common practice and certainly relevant for home test results. Many test results are dynamic and it is necessary to assess the most current status of the patient. Physicians also tend to favor results from labs with which they have a long-standing relationship and therefore trust. This is partly a security-blanket and partly defensive medicine. The practice is also common in radiology and called over-reading. When a patient is admitted to the hospital, outside medical imaging studies are frequently reviewed by the in-house radiologists.

Finally, I want to refer to quality control (QC) of lab tests. I often refer to QC as the religion of lab professionals and they pursue it with a laser-like intensity. This bears on the accuracy of any test result not performed in an accredited lab. It is a mind-set not always understood or shared by other health professionals and probably not by healthcare consumers. I don't believe that patient-generated test results should be undervalued. I think that they are another set of data points available for interpretation. However, given that some of them may, in fact, be erroneous or misleading, they need to be placed into the proper clinical and information context, a phrase that I used in my previous note.

Lab Test Results as Essential Components of PHRs

Although I confess to a strong bias in this regard, I have always believed that lab test results are a critical component of any electronic medical record. This rule is particularly applicable for PHRs because many lab test results are both understandable and relevant for healthcare consumers. This is one of the foundations for the direct-access-testing (DAT) industry whereby consumers order lab tests for themselves without using a physician intermediary.

It's always satisfying when someone outside of the clinical lab industry independently arrives at this same conclusion. Such was the case for John Moore who blogs over at Chilmark Research and who is an expert on PHRs. Below is an excerpt from his note with bold face emphasis mine (see: Labs, PHRs, Platforms & Consumer Engagement: A Presentation)

The organizer [of Lab InfoTech Summit], Bruce Friedman...asked me to update the audience on what is happening in the PHR market and more broadly, what are the implications, either implied or explicit are trends in PHRs to pathology labs. Took me some time to think this one through, but finally a light-bulb went off in my head!  What are KP members most enthralled with in using the KP PHR - its getting their lab results quickly, online and with background information on what those results mean to take appropriate action(s).  Then, if one were to look at RHIOs & HIEs, what types of data are the first to move within these Exchanges, lab data and meds.  Stepping into ER, what does an ER doc most want to see when a patient presents in ER; labs, meds, and allergies.  The need to make lab data “liquid” was everywhere. This “aha moment” led to the creation of a presentation,... that folds in our previous research on PHRs, more recent research on Cloud Computing in healthcare, some even more recent work on RHIOs and HIEs with what all this means to the lab market.

John's coinage of the term "liquid" to describe lab test results is interesting. I take this metaphor to mean that they seem to flow effortlessly into various formats and systems, that they are ubiquitous, and that they can be quickly recognized for what they are and interpreted in a useful way. I believe that this all of this is true with but with one note of caution. My concern would be understandable to any lab professional but not necessarily by healthcare consumers. Lab tests can be misleading unless they are placed into a data context.

A test result never stands entirely on its own. For one thing, it must be accompanied by a so-called reference range. A normal results falls within such a range and an abnormal one is either lower or higher than the range limits. I have posted a previous note about lab test reference ranges (see: A Closer Look at the Standard Clinical Laboratory Reference Ranges). It's also useful to know the original lab performing a test. A blood glucose generated by a patient using a home glucometer does not have the same standing as one performed by an accredited clinical lab.

Some reports for esoteric tests, particularly genomic or proteomic tests, can take up multiple pages and can provide vital interpretive information. Many surgical pathology reports include images of the lesion accompanied by the diagnosis. When test results are replicated from a hospital-based laboratory information system (LIS), one of the challenges is ensuring that the "test result" is completely and accurately transmitted to the receiving information system such as a hospital EMR. This is particularly challenging when the lab report is a complex tabular array, commonly seen with a microbiology report, that may include the antibiotic sensitivities of a bacterial culture.

Genomic & Proteomic Lab Testing Will Require New Approach to Ordering

Until the recent past, lab tests have been the biggest bargain in hospitals. It is often stated that lab costs constitute about 5% of hospital budgets but test results contribute to 70-80% of all clinical decision-making. In spite of this, lab test ordering has been one of the favorite targets for cost-cutting in the past. However, the notion of lab testing as a relative bargain in hospitals is now changing because many genomic/proteomic tests carry large price tags.

Dr. Anand Dighe delivered a lecture at the recently completed Lab InfoTech Summit entitled: Information Technology as a Key Enabler for Enhanced Automation in the Core Laboratory. On slide 38 of this presentation, he shows that the Massachusetts General Hospital is experienced a 12-15% annual growth rate for overall reference lab testing expenses. On slide 40, he shows that genetic testing expenses have been rising an average of 26% per year since FY2002 while non-genetic testing expense has been rising an average of 6.5% per year since FY2002. 

Given that genomic/proteomic tests are frequently sent to outside reference labs, that their cost is frequently in the hundreds of dollars per test or set of tests, and that they are becoming increasingly common in diagnostic evaluations, there is an increasing need to exercise more control over physician test-ordering in hospitals. Attempts to achieve this goal in the past have largely been unsuccessful. Although hospital-based pathologists would seem to be the likely physician group to plan and execute such a policy, this has not proven to be the case.  With the exception of large teaching hospitals, most pathologists tend to focus on surgical pathology rather than clinical pathology. Moreover, many are reluctant to interpose themselves as the traffic cops in the practice patterns of their clinician colleagues.

For me, the solution to this problem seems obvious. First of all and particularly in large complex hospitals, an increasing percentage of physicians are now house officers and hospitalists. As hospital employees, they exercise less political power than community physicians who admit patients to the hospital. Given this setting, I suspect that the time is now ripe for new web-based or telephone-based systems for triaging physician orders for expensive lab tests. I am not saying that such an approach will be warmly greeted by physicians -- only that I see it on the horizon. I don't envision such a system being tightly integrated into the EMR-based test-order-entry process. Most such systems have all that they can handle managing routine transactions.

In order for physicians to order tests with a cost over some ceiling (e.g., $500), I predict that the EMR lab test-ordering application will require a reference code or some other form of authorization. In order to obtain this code, a physician or nurse working with a physician will be required to log-on to a web application requiring input of the relevant clinical data necessary to justify the test. In lieu of, or in addition to, this web-based approach, a substitute would be a conversation via telephone with an expert in genomic/proteomic testing or a consultation request to a hospital-based resource. As "bundles of care" become more common, an alternative approach will be to offer pre-authorization for specific genomic/proteomic tests within each of these various bundles of care.

PowerPoint Lectures from the 27th Annual Lab InfoTech Summit Now Available

Listed below in the order of presentation are the workshop and plenary lectures presented at the 27th annual Lab InfoTech Summit. This conference was held on 16-18 March, 2009, at the Venetian Hotel in Las Vegas. Each title is a link to the PDF version of the PowerPoint lecture. Many of the files are large so please allow sufficient time for them to load on your computer. The few missing links will be supplied as soon as they become available.

• Implementing data-driven feedback and learning mechanisms in surgical pathology (Audio link)
  Jeffrey L. Myers, M.
• Detecting and avoiding errors in the clinical pathology labs with special emphasis on lab automation (Audio link)
  Charles D. Hawker, Ph.D., M.B.A
• The Innovator’s Prescription: An Examination of the Future of Healthcare through the Lens of Disruptive Innovation (Audio link)
  Jason Hwang, M.D., M.B.A.
• Introduction to LITS-Interop: Providing Out-of-the-Box Connectivity for LISs (Audio link)
  Ulysses J. Balis, M.D.
• Using Standardized Reporting and New Software to Improve Lab Safety and Quality (Audio link)
  Steven A. Raab, M.D.
• The “Omics” Revolution Meets Microbiology and Infectious Disease Reports (Audio link)
  James Versalovic, M.D., Ph.D.
• Information Technology as a Key Enabler for Enhanced Automation in the Core Laboratory (Audio link)
  Anand S. Dighe, M.D., Ph.D.
• Using Diagnostics to Monitor the Effectiveness of Treatment (Audio link)
  Bruce A. Friedman, M.D.
• Effective Management of LIS Personnel (Audio link)
  Kathy M. Davis, MT (ASCP)
• Pain Points for Hospital Labs and Their Reference Lab Partners: Making Them Go Away (Audio link)
  Ronald L. Weiss, M.D., M.B.A.
• Demystifying the LIS Purchase Cycle: All You Need to Know about RFPs and Contracts (Audio link)
  John P. Ellison, J.D.
• Personal Health Records (PHRs): A New Form of Electronic Records That Will Affect the Clinical Labs (Audio link)
  John Moore
• The Evolution of the Digital Pathology Department: A Step-by-Step Strategic Road Map (Audio link)
  Ulysses J. Balis, M.D.
• The LIS Redesign Challenges Prompted by Emerging Molecular Diagnostic Testing (Audio link)
  Federico A. Monzon, M.D.
• Integrating Customer Relationship Management (CRM) Software into Your LIS (Audio link)
  Murilo Melo, M.D.

All Media is One: Convergence and Accessibility of Medical Knowledge

Jeff Jarvis in his blog Buzz Machine informs us, at least from the perspective of the CUNY Graduate School of Journalism and its curriculum, that media is becoming singular, which is to say that all media are converging (see: What’s a medium?).

The bigger point is that media is becoming singular. Especially as newspapers die and more people watch what we used to call TV online or on mobile, it will be absurd to separate the forms. In my day (picture me blogging that from a rocking chair), we had to pick our medium once for a career. Now, every time a journalist goes out to cover news, she must be equipped and prepared to gather and share it in any and all media. That’s what we mean when we say convergence.

He's right of course. However, allow me to to extend his point to the convergence and now broad accessibility of medical knowledge. Physicians previously gained new knowledge about their field by reading their medical journals and by attending conferences in their specialty areas which were not available to healthcare consumers. By way of contrast, healthcare consumers acquired watered-down medical information from popular magazines such as the Reader's Digest or other media of this type. In short, the norm was two different medical information streams with little overlap between them.

Today, healthcare consumers have ready access to the same electronic journals as physicians via PubMed and perhaps even more free time to read them. If consumers have a Twitter account, they can follow services such as biotech RSS and receive notice of breaking news about the pharmaceutical industry in near-real-time. They can also read blogs like this one or KevinMD and learn what is going through the minds of physician bloggers. New medical research is almost simultaneously reported in the web and on cable news channels such CNN.

By and large, physicians and healthcare consumers today are feeding at the same information trough. In other words, there is convergence of the media regarding medical knowledge and near-parity in terms of accessibility. Does this convergence and broad accessibility of medical turn medical consumers into astute clinicians? The answer to this rhetorical question is most certainly no. Does it mean that the patient sitting in the doctor's office may have acquired a deep understanding of his disease and perhaps even new research relating to it? The answer to this second question is yes.

I have blogged in the past about the increasing use of the term coach in healthcare (see: "Cancer Coaches" Start to Play Significant Role in Cancer Care, Local Pharmacies Emerge as Centers for Care of Diabetics. It refers to a knowledgeable individual who can provide helpful support in a heath matter to a consumer/patient. Now, I suspect that many physicians would react negatively to being described as a health coach. In a number of examples (e.g., major surgery), the term is not applicable. There is little interaction between surgeon and patient in the operating room. However, in other areas such as preventive medicine and the treatment of chronic diseases by a physician, the term does have broad applicability. With the advent of the health team which is at the core of the medical home model, the use of the term coach for physicians may be increasingly relevant and applicable. Media convergence and medical knowledge is paving the way for the health coach model for the delivery of health services.

Upcoding Can Result in Greater Healthcare Costs After EMR Deployment

We are now beginning to consider the question of whether the federal stimulus funds being allocated to hospitals and physician offices in support of the accelerated deployment of information technology will be beneficial. I have always been a strong advocate for the use of healthcare information technology but I want to interject a note of caution here. The deployment of outdated or poorly designed technology in various healthcare settings can also be harmful.

It's also useful to keep in mind the various incentives that are in play when discussing IT deployment in healthcare. In a previous note (see: Why the Prices Charged by Hospital for Inpatient Care Are Irrelevant), I quoted Steve Lipstein, CEO of the BJC HealthCare System in St. Louis who made the following point in a podcast: the entire healthcare reimbursement system is broken and needs reform. One large component of the "brokenness" of our healthcare system is the design of the reimbursement within that system. KevinMD made a similar point in a recent blog post commenting on one potential risk of pouring billions of dollars into the current generation of electronic medical records (see: How the widespread adoption of electronic medical records can raise health care costs). Below is an excerpt from his note:

One of the pillars of health care reform is modernizing our antiquated health records system. That means pouring billions of dollars into the current generation of electronic medical records (EMRs), despite both the flaws, and the myriad of reasons why doctors are so resistant to go digital. In an excellent piece, orthopedic surgeon Scott Haig points to why electronic records are not likely to save money, and worse, can further balloon health spending. The major reason is the physician payment system....Indeed, EMRs make it very easy to "upcode," or easily pick a diagnosis or service level that will pay more money....So, be careful when you hear that digital records can cut costs. With the current generation of systems geared towards gaming the flawed physician payment system, it's unlikely that EMRs will save any money at all.

In an ideal world and in an ideal healthcare system, all of the incentives support the efficient use of resources to deliver top-notch care. In our real world, one of the primary drivers for EMR deployments over the last several decades has been billing optimization, which is to say increasing revenue from payers for services rendered to patients. Algorithms within automated billing systems analyze the billing codes assigned to patients and suggest different ones that are still justifiable but which result in greater reimbursement for the provider. This is called "upcoding" and is the norm for all of the financial modules that are components of EMR systems. Hence the suggestion in the article quoted above that greater adoption of hospital and physician office EMRs can increase the cost of healthcare. In other words, no good deed goes unpunished.