Electronic Prevention

Prevention may not save money, but that doesn't matter to billionaire businessman, public health philanthropist and New York Mayor Michael Bloomberg. He knows a good deal when he sees one.

Bloomberg's charitable foundation has put $27 million toward providing New York City physicians with electronic medical record (EMR) systems that are preprogrammed to emphasize disease prevention.

That donation has been augmented by money from the state and federal governments, insurance companies and the doctors' medical practices, making a total of about $60 million. The goal is to have 1,000 physicians using the prevention-oriented EMR and 1 million patients under their care by the end of this year.

"The reason to do it is not to save money, it is to try to get more health value for our health dollars," said Thomas Frieden, New York City's health commissioner, who is helping implement the plan. To qualify, a medical practice must have at least 30 percent of its patients covered by Medicaid, the government insurance program for the poor, or Medicare, the program for the elderly. This assures the program is not subsidizing carriage-trade physicians.

Among the things the EMR software does is display automatically the recommended tests, interventions and therapeutic goals for a person with a specific diagnosis.

For example, the electronic "chart" for a patient with diabetes displays blood pressure and LDL cholesterol targets. It reminds the practitioner when it is time to order the blood-glucose test called hemoglobin A1c, whether the patient has gotten a flu shot, or which drug might be appropriate for a given condition. Once the problem is addressed, the reminder goes away. The software also allows a physician to see what percentage of his or her patients is reaching their therapeutic goals -- and how this compares with other clinicians in the practice.

The office economics of preventive care can be tricky, however.

Many physicians are paid based on how many problems they address and how long it takes to see the patient. Often, insurance companies won't pay for both treatment and preventive services in the same visit.

Some health plans pay completely for annual prevention-oriented visits but require patients to pay part of the fee for an appointment that addresses a medical problem.

Patients sometimes don't report a problem until they arrive for their prevention visit. This may force the practitioner to ask the patient to schedule another appointment to address that problem, which can create resentment.

-- David Brown