A key component of the American Recovery and Reinvestment Act of 2009, popularly known as Obamacare, has been the provision within it entitled Health Information Technology for Economic and Clinical Health or (HITECH). The law expends federal money for the adoption by health care facilities of information technology, specifically for the utilization of electronic health records. The impetus for the initiative is the expectation that by having a patient’s health care record immediately available, the decision making process will be influenced by the ready access to data. Consequently, unnecessary tests, especially perhaps those related to expensive imaging, will be reduced thereby ultimately decreasing health care costs [1].

On its face, this notion is compelling. We are far behind other well off countries in the comprehensive use of the electronic medical record. Finland and even neighboring Estonia have, for more than 5 years now, been completely wired and most of their health care indices surpass that of the United States despite the fact that aggregate cost of care as a percentage of gross domestic product there is less than two thirds of the 18 % of GDP we pay for here.

Two recent studies, contradictory in their conclusions, require us to consider this matter not as an article of faith in the redemptive power of instantaneous comprehensive access, but rather its adoption as a testable, measurable process involving incentivisation issues as well as electronic capability. The first study “Giving Office-Based Physicians Elective Access to Patients Prior Imaging and Lab Results did not Deter Ordering of Tests” by McCormack et al. appeared recently in Health Affairs. Examining the records of a sample provided by office-based physicians, they found that electronic access did not lower but actually increased the rate of ordering of imaging tests. The authors acknowledged that in academic institutions the presentation of recent results electronically could reduce redundant imaging test ordering but they suggested that for the totality of outpatient facilities the opposite was true. In contrast, a year earlier in the same journal in a study entitled “The Benefits of Health Information Technology: A Review of the Recent Literature shows Predominantly Positive Results”, Bernstein and her co-authors claimed that in both large and in small practices and in other care-giving organizations, the electronic medical record does change test-ordering behavior and therefore can reduce costs. Yet the authors also acknowledged that the incorporation of the electronic medical record into standard practice will meet with resistance before adoption becomes commonplace.

What might make its virtues more manifest in the American system of care? I refer specifically to its putative effect on the proper rather than the excessive use of imaging. For one thing, perhaps the most important, accompanying operational innovations should require the central participation of the radiologist. Now let me be clear here. By such participation I emphatically do not mean remote decision support schema and programs which incidentally are regarded by the ACR and by some well-meaning prestigious academic institutions as the perfect accompaniment to the EHR. The notion that resort to recipes i.e., the reliance on appropriateness criteria as a panacea is fundamentally wrong.