Impact of Cost Display on Ordering Patterns for Hospital Laboratory
and Imaging Services
Mark T. Silvestri, MD, MHS
, Xiao Xu, PhD
Tasce Bongiovanni, MD, MHS
, Steven L. Bernstein, MD
, Sarwat I. Chaudhry, MD
Julia I. Silvestri, BA
, Marilyn Stolar, PhD
, Erich J. Greene, PhD
, James D. Dziura, PhD
Cary P. Gross, MD
, and Harlan M. Krumholz, MD, SM
Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, CT, USA;
Department of Obstetrics,
Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA;
Cornell Scott Hill Health Center, New Haven, CT, USA;
Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA;
Department of Internal Medicine,
Yale School of Medicine, New Haven, CT, USA;
Department of Surgery, University of California San Francisco, San Francisco, CA, USA;
of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA;
Yale School of Public Health, New Haven, CT, USA;
Zearn Math, New
York, NY, USA;
Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA.
BACKGROUND: Physicians Bpurchase^ many health care
services on behalf of patients yet remain largely unaware
of the costs of these services. Electronic health record
(EHR) cost displays may facilitate cost-conscious ordering
of health services.
OBJECTIVE: To determine whether displaying hospital
lab and imaging order costs is associated with changes
in the number and costs of orders placed.
DESIGN: Quasi-experimental study.
PARTICIPANTS: All patients with inpatient or observa-
tion encounters across a multi-site health system from
April 2013 to October 2015.
INTERVENTION: Display of order costs, based on Medi-
care fee schedules, in the EHR for 1032 lab tests and 1329
MAIN MEASURES: Outcomes for both lab and imaging
orders were (1) whether an order was placed during a
hospital encounter, (2) whether an order was placed on a
given patient-day, (3) number of orders placed per patient-
day, and (4) cost of orders placed per patient-day.
KEY RESULTS: During the lab and imaging study pe-
riods, there were 248,214 and 258,267 encounters, re-
spectively. Cost display implementation was associated
with a decreased odds of any lab or imaging being ordered
during the encounter (lab adjusted odds ratio [AOR] =
0.97, p = .01; imaging AOR = 0.97, p < .001), a decreased
odds of any lab or imaging being ordered on a given
patient-day (lab AOR = 0.95, p < .001; imaging AOR =
0.97, p < .001), a decreased number of lab or imaging
orders on patient-days with orders (lab adjusted count
ratio = 0.93, p < .001; imaging adjusted count ratio =
0.98, p < .001), and a decreased cost of lab orders and
increased cost of imaging orders on patient-days with
orders (lab adjusted cost ratio = 0.93, p < .001; imaging
adjusted cost ratio = 1.02, p = .003). Overall, the interven-
tion was associated with an 8.5 and 1.7% reduction in lab
and imaging costs per patient-day, respectively.
CONCLUSIONS: Displaying costs within EHR ordering
screens was associated with decreases in the number
and costs of lab and imaging orders.
KEY WORDS: cost display; electronic health record; physician ordering
J Gen Intern Med
© Society of General Internal Medicine 2018
Despite the need to control health spending, the costs of
specific health care services remain largely opaque to physi-
cians and patients. Public and private initiatives, including
consumer cost-searching websites, insurer reference pricing,
and state price transparency regulations, have sought to in-
crease availability and meaningfulness of cost information to
patients. The potential role of physicians, however, who
Bpurchase^ most health care services on behalf of patients,
has not been thoroughly examined. Physicians remain largely
unaware of the costs of tests and therapies they order and find
cost information inaccessible.
Nevertheless, physicians de-
sire cost information and believe it would change their order-
ing without negatively affecting patient care
them to forego ordering low-value tests or to switch orders to
less costly alternatives of equal clinical utility.
Studies from the 1990s suggested that cost information may
influence physician ordering behavior and decrease spend-
yet cost information has not become a standard part of
the ordering environment, and limited research in more recent
health care contexts has shown conflicting findings.
ern electronic health records (EHRs) with computerized phy-
sician order entry (CPOE) systems provide a scalable
This work has not been previously presented.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11606-018-4495-6) contains supplementary
material, which is available to authorized users.
Received July 28, 2017
Revised January 26, 2018
Accepted May 11, 2018