## Abstract

Duplication of medical testing results in a financial burden to the healthcare system. Authors undertook a retrospective review of duplicate testing on patients receiving coordinated care across two institutions, each with its own electronic medical record system. In order to determine whether duplicate testing occurred and if such testing was clinically indicated, authors analyzed records of 85 patients transferred from one site to the other between January 1, 2006 and December 31, 2007. Duplication of testing (repeat within 12 hours) was found in 32% of the cases examined; 20% of cases had at least one duplicate test not clinically indicated. While previous studies document that inaccessibility of paper records leads to duplicate testing when patients are transferred between care facilities, the current study suggests that incomplete electronic record transfer among incompatible electronic medical record systems can also lead to potentially costly duplicate testing behaviors. The authors believe that interoperable systems with integrated decision support could assist in minimizing duplication of testing at time of patient transfers.

## Discussion

This study presents an exploratory analysis of duplicate testing performed within a narrowly defined window of time in a unique patient population receiving care across two physically neighboring institutions. The purpose of the study was to document the potential extent of duplicate testing and estimate related costs related to early phase in-hospital care of patients recently seen at another institution, which were associated with a lack of electronic health record interoperability. This sort of problem will become increasingly common as healthcare institutions adopt diverse vendors' electronic medical record systems. The extent of clinically non-indicated duplicate testing documented in the study is of some concern. It related to transfer of patient care between two physically connected institutions, both with electronic health records systems, and in which direct clinician to clinician communication is facilitated. The potential for such duplications may be even greater in other circumstances that involve more complexity in information transfer. These include, for example, (a) admission to a hospital from a non-hospital-based clinician outpatient practice not affiliated with the hospital, or between two different non-affiliated hospitals, and (b) periodic change in healthcare providers, as typified by the estimated 800 000 or more seasonal migrants, many of whom are older and have established healthcare needs, from the northeast USA to the state of Florida.11

Study limitations narrow the potential applicability of results outside of the two hospitals studied; rather, current study results should stimulate further research. The study examined a highly specific patient population that is not necessarily representative of all patients receiving care. Further limitations include the strict requirement for a ‘duplicated’ test to occur in a medically stable tested patient and ordering behavior to be deemed ‘outside the standard of practice,’ for testing to be considered clinically ‘not-indicated’; as such, this analysis is likely an underestimate of excesses in routine practice. Medicare fees, or actual payments that would be made by Medicare for respective testing, were used to estimate costs to the healthcare system rather than actual hospital and physician charges, which are generally higher and often vary by hospital and physician. The current study addressed neither the socioeconomic influences on nor determinants of duplicate clinical testing, nor the physical or emotional impact of unnecessary testing on patients and their families.

The most common setting for duplicate testing identified in the current study happened on admission from an outpatient clinic site. Patients from outpatient clinic transfer to hospital admission via several paths, including entrance via hospital admitting services or directly to the inpatient ward, either escorted or unescorted by hospital clinical staff. While clinician to clinician passage of data regarding medical testing and status is recommended to occur in a timely fashion in such circumstances, this does not reliably occur. The authors believe that an interoperable health record conveying shared data with prior test results notification, alerts, and/or decision support could potentially improve the immediate availability of medical history and clinical status data, including testing results, between the various outpatient referral sources and the admitting institution. In addition, an interoperable electronic health record would make available expensive imaging studies, further reducing the need for potential duplicate studies. Based on estimates from current study results, implementation of an interoperable electronic health record system between the two study institutions would potentially result in at least modest savings in the narrow domain studied, and potentially larger overall savings. Other disease categories and patient populations where patients are treated across institutions could potentially reap a larger benefit from eliminating non-clinically indicated duplicative testing via integrated record systems with decision support. For example, a study of 104 trauma patients transferred between facilities in Massachusetts documented charges of \$639 per patient related to duplicate testing.12

Prior studies by Tierney and colleagues show that the provision of increased information pushed to providers regarding prior testing results at the time of ordering leads to a reduction in ordering.3 The current study and others12 show that transfer of records containing important clinical data is imperfect when patients are transferred from one healthcare institution to another, resulting in duplicate testing—even when both institutions have electronic record systems. An opportunity exists to improve timeliness of care and decrease through implementation of interoperable electronic health records (EHRs) between institutions. Current efforts to do so via healthcare information exchanges (HIEs) at local, regional, and national levels are under way.13–15 Recent Federal actions to define ‘meaningful use’ of electronic health records16 and to establish criteria for certification of EHR products17 through regulation are likely to further encourage electronic transfer of clinical data.

An expansion of this study to include additional patient populations, additional institutions, and a wider timeframe between services provided at the institutions will provide additional data about duplication and how widely this study can be extrapolated. Studying inter-hospital transfer between health systems with interoperable medical records and decision support would provide further insights. Future research may also explore duplication prior to the implementation of electronic health records at both institutions to determine whether this phenomenon existed when paper medical records were utilized between institutions.

Despite efforts to minimize non-clinically indicated duplicate testing between institutions without interoperable electronic health records, duplication exists. Results from this study show that approximately 20% of the patients in the study encountered non-clinically indicated duplicate testing resulting in added costs to the healthcare system.

None.

## Provenance and peer review

Not commissioned; externally peer reviewed.

## References

1
Embi
PJ
Yackel
TR
Logan
JR
et al
.
Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians
.
J Am Med Inform Assoc

2004
;
11
:
300
9
.
2
Overhage
JM
Perkins
S
Tierney
WM
et al
.
Controlled trial of direct physician order entry: effects on physicians' time utilization in ambulatory primary care internal medicine practices
.
J Am Med Inform Assoc

2001
;
8
:
10
.
3
Tierney
WM
McDonald
CJ
Martin
DK
et al
.
Computerized display of past test results: effect on outpatient testing
.
Ann Intern Med

1987
;
107
:
569
.
4
Wang
SJ
Middleton
B
Prosser
LA
et al
.
A cost-benefit analysis of electronic medical records in primary care
.
Am J Med

2003
;
114
:
397
403
.
5
Girosi
F
Meili
R
Scoville
RP
.
Extrapolating evidence of health information technology savings and costs
.
Santa Monica, CA, USA
:
Rand Corporation
,
2005
.
6
May
TA
Clancy
M
Critchfield
J
et al
.
Reducing Unnecessary Inpatient Laboratory Testing in a Teaching Hospital
.
Am J Clin Pathol

2006
;
126
:
200
6
.
7
Walker
J
Pan
E
Johnston
D
et al
.
“The Value Of Health Care Information Exchange And Interoperability”
.
Health Affairs: Web Exclusives
:
2005
;
W5-10
W5-18
.
8
van Walraven
C
Taljaard
M
Bell
CM
et al
.
Information exchange among physicians caring for the same patient in the community
.
CMAJ

2008
;
179
:
1013
18
.
9
Balas
A
Al Sanousi
A
.
Interoperable electronic patient records for health care improvement
.
Stud Health Technol Inform

2009
;
150
:
5
.
10
US Department of Health and Human Services, Centers for Medicare and Medicaid Services
.
2008
.
“2008 Fee Schedule”
.
11
Smith
SK
House
M
.
Snowbirds, sunbirds, and stayers: seasonal migration of elderly adults in Florida
.
J Gerontol B Psychol Sci Soc Sci

2006
;
61
:
S232
9
.
12
Thomas
SH
Orf
J
Peterson
C
et al
.
Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer
.
Emerg Med

2000
;
18
:
156
8
.
13
Adler-Milstein
J
Bates
DW
Jha
AK
.
“US Regional health information organizations: progress and challenges”
.
14
Halamka
JD
.
“Making smart investments in health information technology: core principles”
.
15
Hripcsak
G
Kaushal
R
Johnson
KB
et al
.
“The United Hospital Fund meeting on evaluating health information exchange”
.
16
Centers for Medicare and Medicaid Services
.
Health information technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology; interim final rule
.
Fed Regist

2001a
;
75
:
2013
47
.
17
Centers for Medicare and Medicaid Services
.
Medicare and Medicaid Programs; Electronic Health Record Incentive Program; proposed rule
.
Fed Regist

2001b
;
75
:
1843
2008
.

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