We've said before that claims data and history are the keys to building the appropriate primary care team. But it's more than that; they are important parts of providing the right care, to the right patients, at the right cost.

But the effectiveness of advanced primary care and population health in general also relies on outreach.


Data is great, but it can't stop there.

We can have all the medical claims data in the world, but the only way to make an impact is if patients are coming to the clinic.

Download Now: Benefit Strategy Design: Solving An Impossible Task

Dr. Kevin Wang, CMO of Vera Whole Health, explains.

“We know the American Cancer Society says that patients who are 45 and have an average risk should be given the option for screening for colon cancer. That's the easy part—to say, in general, that certain patients need it. But the hard part is, how do you know which specific patients?”

This is where registries come in.

How do registries work?

Essentially, registries are patient lists. Dr. Wang calls them “outreach lists” for care coordinators. They're used to identify and prioritize patients who need better health engagement based on risk factors like:

  • A history of colon cancer
  • A history of breast cancer
  • Osteoporosis screening
  • Poor A1C control

These are just a few examples. But then they're overlaid on top of the patient’s overall medical engagement, a picture emerges.

We ask questions like:

  • When was the last time they saw the primary care provider?
  • Have they received care in the emergency room?
  • Have they been seen at an urgent care facility?

All of this helps us prioritize patients, so care teams can contact those who have the most immediate needs.

Registries also inform the outreach message.

Advanced primary care brings the benefits of this kind of data together with the advantages of a close relationship between patients and the care team.

Since care teams understand the context and the priority of patients on their outreach list, they communicate with them through personal, relevant messages.

For instance, we may have 20 priority patients on our outreach list. We also know that 12 have never completed an Annual Whole Health Evaluation.

Using that, Vera can partner with our clients to figure out what campaigns, messages, and incentives are likely to motivate a patient to come to the clinic.

Maybe it’s a financial incentive. For example, to help patients we’ve identified as a priority to schedule an Annual Whole Health Evaluation, we could call them up and offer $50 if they schedule an appointment.

The possibilities are endless, but it all relies on the patient registry—the priority list from the population the clinic is serving.

The goal is to get these at-risk patients in to see the primary care provider to address the gaps in care.

Registries are already proving successful.

Dr. Wang shares,

“We had a man in his mid-fifties. Because of the registry, we knew he needed a colonoscopy. But for many reasons, the patient didn’t want to do it — and he wasn’t convinced he needed it. So instead, we had him do a non-evasive spit card as a good screening to start with. The patient tested positive. He then got a colonoscopy and we found two pre-malignant lesions that were successfully removed. Through the registry, we knew the patient had a gap in care. And we also knew a screening could have a positive benefit. Which to me is awesome.”

That’s just one example. But when it translates into hundreds of patients getting the appropriate screenings and right clinical outcomes, the potential for large-scale success is huge.

If you’re interested in reading more, download our FREE white paper, Benefit Strategy Design: Solving An Impossible Task today.

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