USA Today

If you’re enrolled in the Empire Blue Cross/Blue Shield plan in New York, your doctor might soon get a call from your insurer.

The results of this lab test don’t look good, the insurer’s medical director tells your doctor. Why haven’t you been given additional tests? Or, why are you on this drug when another would do?

Big Brother, meet Marcus Welby.

While all insurers collect data about patients’ medical care, and some steer high-risk patients into disease-management programs, Empire goes a step further: Its computer system points out potential medical problems doctors may have missed.

In the year since it began sifting through medical records and claims, Empire’s program has caught a number of problems, such as a 47-year-old New York man who was prescribed a potentially lethal combination of drugs. “This is the kind of thing that prevents medical mistakes,” says Dr. Bill Osheroff, a medical director at Empire.

But the program also raises debate about how far an insurer should go. “Maybe they shouldn’t be seeing my lab results just to pay my bill,” says Robert Gellman, a privacy consultant in Washington, D.C.

More records on computers

Nationally, as more insurers, doctors and others put records into computer systems, debate about such programs will intensify.

* Already, many insurers analyze prescription information, looking for potential mistakes or drugs that interact.

* At least one pharmacy-benefits firm, owned by drugmaker Merck, reviews what drugs patients are taking and then may call doctors to urge them to switch patients to less-expensive, similar medications.

* Kaiser Permanente has computerized its Northwest and Colorado divisions, allowing doctors to type in notes, write prescriptions and order lab tests. The system even “tells” on patients who don’t fill a prescription or get a requested blood test.

“Patients seem delighted with this system,” says Dr. Andrew Wiesenthal, associate medical director of the Colorado Permanente Medical Group. “It’s clear to patients that this system means that wherever they go, the doctors and nurses will know what they need to know.”

Privacy expert Zoe Hudson of Georgetown University agrees that some efforts to use medical information are beneficial, but urges limits be set.

“It’s nice to have a second pair of eyes making sure you’re getting good care,” Hudson says. “But consumers should have worries about once there is that kind of access, what’s stopping them from getting information that might not be in the patients’ interests?”

Spotting problems early

In its first year, Empire says the program identified about 120,000 members with potential problems, such as adverse drug reactions, missed screenings for preventable diseases and overlooked test results. Empire’s medical director called the doctors of about 4,000 patients.

While a percentage of patients “hate to have anyone have such information,” only 1% of the 430,000 members covered by the program have asked to be exempted, says Empire CEO Michael Stocker.

Some skeptics, however, say that 1% rate is not a good indicator of the program’s popularity. “You might have had the same 1% return if you asked people if they want the service,” says Peter Kane, executive director of the National Coalition for Patient Rights in Andover, Mass.

“If patients want to have this kind of Big Brother organization over them,” Kane says, “they should be signing off for them to do so.”

Empire’s program is made possible by the increasing use of electronic medical claims and records, and software that sifts through data looking for medical red flags. Red-flagged medical records are sent to software developer Active Health Management. After review by Active, some records are sent back to Empire, where the medical directors may call doctors to discuss specific patients’ care.

“There is enormous value in getting this information to doctors,” says Empire’s Stocker. Employers like the plan, too.

“We’ve never found anything else in the quality area that helps us sell business,” says Stocker. “This is different. (Employers) want to hear about how we’re helping doctors.”

But skeptics remain.

“It seems to me that medical directors who do not examine patients are not in the best position to be second-guessing doctors,” says HMO critic Jamie Court of Consumers for Quality Care.