How to Rethink Population Health in This Strange New Normal


As we transition out of the shelter-in-place phase of the COVID-19 pandemic and ramp up in-person care, it is important for practices to establish a strategy to re-engage patients. Most quality measures have steeply declined as these appointments were delayed for patient safety. In fact, Epic EHR data showed a “recent abrupt drop- between 86% and 94% – in preventive cancer screenings performed across the United States, presumably due to access disruptions caused by COVID-19” (Epic Health Research Network, 2020, para. 1).

Resume patient outreach aimed at improving clinical outcomes

Rethinking how we provide care to patients in this new world requires thoughtful planning and strategy. Since most routine care was understandably deferred in the height of the pandemic, we are partnering with our clients to rethink how to best resume patient outreach aimed at improving clinical care outcomes with the goal of gaining momentum on these important quality measures.

When Providertech works with our clients, we partner to send engaging messaging with a clear call to action using HIPAA compliant text messaging. Many times, this eliminates an unnecessary in-office visit. During the pandemic, we worked with our clients to send HIPAA compliant messages that reflected the current public health landscape. For our chronic disease patient populations, that meant we used secure messaging to encourage them to schedule a virtual visit while keeping them safe at home. This was new for many patients who had never received virtual care, and clear communication via text helped to ensure they remained engaged in their care. For other clients, we helped to text ways for patients to stay up-to-date on routine screenings without risking exposure in the office setting. For example, some of our clients used secure texting to offer patients who had an office visit within the last 12 months to have a home screening kit or mammography requisition sent directly to their home rather than obtaining it in the office. In just one week, a practice received responses from over 450 patients for colorectal cancer screening alone.  

Scale communication to your most at-risk patients using HIPAA compliant texting

Even for those of us that live and breathe healthcare as our day-to-day work, navigating the complex healthcare spectrum can be confusing at best! Using automated and HIPAA compliant texting to scale patient communication is a method to reach your population effectively while also providing support and navigation within the intricate web of healthcare.

We work with our client to prioritize a variety of populations, including:

Those with chronic diseases, such as:

  • Diabetes
  • Heart Failure (CHF)
  • Coronary Artery Disease (CAD)
  • Asthma & COPD
  • Mental Health

Patients in need of preventative care and screening, like:

  • Wellness visits from newborns through Medicare patients
  • Cancer screenings (e.g. cervical, breast, colorectal, and lung)

And high-risk populations:

  • Social Determinants of Health (SDOH) variables
  • High utilizers

Our customizable approach integrates a secure, HIPAA compliant texting platform with your electronic health record, allowing you to target your patients based on defined criteria such as age, diagnosis, lab values, visit history. For example, a population health outreach campaign for patients with diabetes could use secure texting to communicate with patients whose HbA1c levels exceeding 9.0% who have also not completed a visit in the past 90 days.

We work with practices to identify these key populations. Once the population is established, we send HIPAA compliant messages automatically, incorporating behavioral economics techniques to increase the likelihood of interaction with the messaging and follow-through with the recommended care. By applying best practices in HIPAA compliance with our text messaging platform, your protected health information (PHI) is secure and HIPAA compliant.

Maximize your resources with automated text messaging

Automated and secure messaging that is HIPAA compliant allows you to maximize your resources while safeguarding patient data. Instead of your care team spending the day making one outbound call after another, they can receive inbound texts or calls from your patients and assist them by either scheduling an appointment or utilizing standing orders as referenced above. These approaches can be customized to match your internal workflows and yield not only improved clinical outcomes but also higher patient satisfaction with support beyond the office visit.

Think about your patients with open gaps in care

Are you trying to address each of these open gaps during a routine office visit? That is a lot to expect during a short office visit and can cause overwhelm and burnout for your provider teams. Amplifying the roles of your care teams will allow the various roles—especially your nurses—to operate at the top of their license and accentuate their natural communication skills within your organization.  

What about supporting your patients during a transition in care, such as after hospital discharge? Are you trying to reach each patient telephonically? This often results in a vicious game of phone tag, limiting the number of patients you successfully reach. While a post-discharge visit is essential, engaging your patients earlier and more consistently via text messaging may help identify concerning symptoms or misunderstood instructions. What if you could automate secure text messages to these patients, guiding them through what to do next? From scheduling care to triaging early warning signs, HIPAA compliant texts could provide the essential navigation missing during the precarious post-discharge period.

How we can help

Regardless of how your practice has managed your populations in the past, the pandemic has changed the script. Providertech can help support your practice by implementing consistent and targeted outreach leveraging HIPAA compliant texting. We can also help you launch virtual care visits or get the most out of your current telehealth platform by automating pre-visit communication using text messaging. Additionally, we’ve expanded our tools to support new check-in processes that allow patients to send a HIPAA compliant text upon arrival.

Managing population health can feel overwhelming for a practice. Not sure where to start?

Ask yourself the following questions as a guide:

  • What populations represent the highest risk due to multiple co-morbidities?
  • What populations are overlooking important preventative care?
  • What has already been tried to manage these populations? 

To yield the greatest results, start by identifying your highest risk populations and align your efforts to engage them with HIPAA compliant text messaging.  Automated patient outreach allows you to reach the right patients with the right resources, as you prioritize the needs of the patients who need you most while you maximize your resources and generate more consistent engagement than manual outreach. That translates to better outcomes for your patients and improved financial success for your practice.


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