Preventive health: Getting rid of the middleman (uh-oh, that’s us!)


As physicians, we find that preventive health is, frankly, really difficult. It requires thinking about a changing list of recommendations unprompted by the symptoms for which patients present. Compounding that challenge is that, in doing preventive health well, we need to have personalized discussions with our patients and this requires they come into the office, which doesn’t always happen on a regular basis. Furthermore, when patients do come in, they usually are presenting for an acute care visit, so there is little time set aside to discuss preventive health.

Dr. Chris Notte and Dr. Neil Skolnik of Abington (Pa.) Jefferson Health

Dr. Chris Notte and Dr. Neil Skolnik

For all these reasons and many others, the data suggest that we are not particularly good at performing preventive health maintenance. We are much better at figuring out diagnostic dilemmas and choosing among competing medications or procedures to most effectively address acute and chronic medical problems. Let’s examine the data to see if there is a shred of truth in what we are saying; then let’s look at a potential solution to the dilemma of preventive health that we all believe in and that we carry out less frequently than any of us would like.

First, let’s look at recent data on cancer screening reported by the CDC1:

  • Mammography: 72% of women aged 50–74 years reported having had a mammogram within the past 2 years.
  • Pap test: 83% of women reported being up to date with cervical cancer screening.
  • Colorectal cancer screening: 62% of men and women reported colorectal cancer screening test use consistent with USPSTF recommendations.

Of note, colorectal cancer screening has improved dramatically over he last 15 years, while screening for breast and cervical cancer has largely plateaued.1

Our success with cancer screening – or lack thereof depending upon one’s perspective – looks quite good next to national vaccination rates for adults. The immunization rate for commonly recommended vaccines are as follows2:

  • The Tdap vaccination rate is 20%.
  • The tetanus-diphtheria vaccination rate is 62%.
  • The herpes zoster vaccination rate is 28%.
  • The influenza vaccination rate is 43%.
  • The pneumococcal vaccination rate among high-risk persons aged 19-64 years is 20% and among adults aged greater than or equal to 65 years is 61%.

Of adults who had health insurance and at least 10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended.

In the business literature there is a great deal of disagreement about the value of the “middleman.” The term middleman describes someone who brings the product from the producer, or factory, to the consumer. On the one hand, if the factory can sell the product directly to the consumer, the consumer can save money and the factory can make more money. On the other hand, if the middleman can help the consumer make a better choice among the variety of products available, then the middleman provides value and the consumer benefits.3

Traditionally, clinicians have served the role of the middleman for preventive health activities, knowing what to recommend to patients and informing them of the correct preventive health choices that fit their needs. The problem with this concept is that preventive health recommendations are largely demographically based, are tied to population-based risk assessment, and usually require very little individual judgment.

We as physicians are good at – and I believe truly enjoy – exercising judgment. We love thinking things through and helping the person in front of us. We are not as good at remembering unprompted information in the middle of busy visits that are often made for unrelated reasons. Most of the people who have not had a colonoscopy or pneumococcal vaccine have not decided against the procedure after a detailed discussion with their physician. On the contrary, the service was never recommended, or it was recommended, but the patient did not follow up to have the procedure performed.

Let’s now imagine another approach. You’re a patient and once a year you click on an email that shows up in your inbox from your doctor with the words “Preventive Health” in the subject line. The EHR – based on your gender, age, and a query of what has been documented in your chart – has determined the preventive health activities that are recommended for you. You can choose to pursue, opt out, or get more information for each of the recommended preventive services as you read through them.

If you choose to have more information, it is provided in a structured format that allows you to drill down to the level of detail that you desire. In all probability, you will find a greater level of detail and accuracy of information about each preventive service than could possibly be provided during a routine office visit. Specifics about the risks and benefits of the procedure will also be more extensive, as it is unlikely your care providers are able to keep all of the details and risk ratios in their heads. If desired, you as a patient can take your time to read and digest the information, sleep on it, and come back to it to make an informed decision. This is not something you can do during a routine office visit.

If you choose to opt out of the procedure, just click the “declined” box. Otherwise, when you’ve made all of your decisions and indicate that you’re done, the necessary prescriptions for blood work and x-rays, as well as referrals to the appropriate specialists, will print out. An entry will also be made in the electronic record showing you’ve been provided preventive health recommendations that are appropriate for your age and sex and made your preferred choices. At any point, if you feel you’d like further discussion with your physician, you can make an appointment electronically through the interface.

The hurdles for implementing such a system are real, but they are solvable, and the development of such an approach is inevitable, enviable, and will ultimately be good for both patients and their providers. Patients will get more predictable and complete recommendations for preventive care and providers will have more time to do what we enjoy and are most skilled at – talking with patients to clarify diagnoses, decide upon treatment, and clarify questions that come up about preventive health recommendations.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records.


1. White A et al. Cancer screening test use – United States, 2015. MMWR Morb Mortal Wkly Rep. 2017 Mar 3;66(8):201-6.

2. Williams WW et al. Surveillance of vaccination coverage among adult populations – United States, 2014. MMWR Surveill Summ. 2016 Feb 5;65(1):1-36.

3. Conerly B. Don’t eliminate the middleman – He’s much too valuable. Forbes. Oct 28, 2015.


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