When the COVID-19 pandemic began, many patients delayed or missed health screenings and visits with providers as they sought to limit their exposure to the virus. According to the CDC, the number of women who received breast cancer screenings through the agency's early detection program declined by 87% in April 2020. 

The University of Texas Medical Branch, a safety-net system based in Galveston, is using a population health analytics engine that integrates with its EHR to find and address these potential gaps in care. 

Craig S. Kovacevich, associate vice president of community and population health at UTMB, told MobiHealthNews the Discover application allows them to use the large amounts of data they've collected, looking at the clinic, provider and patient level for areas where they can improve outcomes.

"So it really was all about drilling down and trying to identify first and foremost where those opportunities are," Kovacevich said. "And many of those we found were kind of low-hanging fruit, things that are basic, like immunizations, vaccinations, different types of screenings, that sometimes just get overlooked in the day-to-day healthcare environment."

So how does the health system reach out and close those gaps? It depends on the patient population, what their stated preferences are, and how they've responded to these nudges in the past. The team of laypeople, medical assistants and RNs use phone calls, reminders through their patient portal MyChart, text messages, mailers and partnerships with payers to ensure patients get screenings and other health services. 

"One of the other components that we have done a lot of work in is really diving into the no-shows, trying to see which patients are not showing up and then doing some deep dives," Kovacevich said. "And learning that we may have great opportunities to reach out and get a hold of Miss Smith or Mr. Jones, but maybe they are a one-car family and the other spouse is working during the day. And so while we've scheduled that appointment and have them on the books, they're not showing up because they have transportation issues."

The analytics engine has also enabled the system to pre-chart for primary care appointments, adding extra services that might have been missed without overwhelming a provider's schedule.  

A team behind the scenes can look into upcoming appointments, checking if there's a missed screening or vaccination that could be easily tacked on. They reach out to patients to let them know and note the service in the EHR, so providers are aware of the care gap. 

Kovacevich said this is particularly important for a safety-net provider caring for patients who are disproportionately low-income, on Medicaid or uninsured.

"Max-packing a visit – doing as much as we can while we have that patient in front of us – is really a good best practice for us," he said. "Because if you have a population that may have some of these barriers that cause them not to be able to come in as routinely or have that higher no-show rate that I mentioned, the ability to get as much done when we can is critical."

The HIMSS session "Population Health Analytics: Moving the Needle in a Pandemic" will take place on Tuesday, March 15, from 4:15 p.m. to 5:15 p.m. in Orange County Convention Center WF4.