Cincinnati Children's Gets Serious About Missed Well-Child Visits

A new messaging program embedded in the EHR is helping the hospital connect with parents who have avoided or skipped important medical check-ups for their children.

Well-child visits are often neglected in today's fast-paced world, with some experts estimating that as many as half of all scheduled visits are missed. But researchers at Cincinnati Children's Hospital Medical Center say an automated messaging program embedded in the electronic health record platform can boost that rate dramatically—and improve clinical outcomes.

"There's a lot of value here in something that isn't that difficult to do," says William Brinkman, MD, Med, MSc, a board-certified pediatrician and director of the Division of General and Community Pediatrics at Cincinnati Children's.

Brinkman and Anne Berset, BA, a clinical research coordinator at Cincinnati Children's, used a messaging platform in a pilot project involving some 900 families of patients aged 6 to 17 years old, spread across three primary care practices in 2021. Using a platform that could deliver phone and text messages, they saw an almost 50% increase in scheduled well-child visits.

"There was a significant increase in the scheduling and completion of appointments after receiving the standard and tailored message compared with no message, indicating that simple outreach nudges via patient portal may prompt action," the two wrote in an analysis of the project published in November 2022 in the Journal of the American medical Association (JAMA). "The standard message group had higher rates of receiving COVID-19 vaccination within 8 weeks, suggesting that messages that reengage patients subsequently provide opportunities to promote healthy behaviors, such as vaccine acceptance."

William Brinkman, MD, Med, MSc, director of the Division of General and Community Pediatrics at Cincinnati Children's Hospital Medical Cener. Photo courtesy Cincinnati Children's.

Brinkman and Berset launched their program during the height of the COVID-19 pandemic, when access to healthcare services was in flux. Because of the virus, many healthcare organizations were shifting many in-person services to virtual platforms, and families were postponing or cancelling what they considered non-vital healthcare services. This included well-child visits, which plunged by at least 20% during the pandemic.

And while in-person healthcare appointments increased as the pandemic waned, Brinkman and Berset said parents still weren't bringing their children back to the office.

"Healthcare access was shifting all over the place," says Brinkman. "It became really glaringly obvious that something needed to be done" to boost interest and attendance.

It was also important, they said, to make parents aware of the value of a well-child visit.

"There's definitely a lot of education that needs to be done," says Berset. "Folks don't specifically know what a well-child visit is. They don't understand the value."

Anne Berset, BA, clinical research coordinator at Cincinnati Children's Hospital Medical Center. Photo courtesy Cincinnati Children's.

For their program, Brinkman and Berset chose a platform that could personalize a message to parents and send it via different modalities—text or phone—based on the recipient's preferences. They opted for this platform after studying other, similar programs and talking to patients and medical assistants who call and text families on a regular basis.

Brinkman says it's important to fit the messaging into a provider's regular workflow. This was done by going through the EHR and tacking the messages onto an already existing program—in this case a message regarding COVID-19 vaccinations. The message was personalized to include the patient's first name, reminded parents that their child was due for a well-child visit, and asked them to either call or use the patient portal to set up an appointment.

Berset says they learned through the program that some 44% of patients are using their patient portal.

"A lot of people were expecting that number to be higher, but that's OK," she says. "Finding out that the patient portal was successful in reaching patients was definitely rewarding for us. And it told us that we still have work to do."

They also found that this platform resonates with underserved populations, many of whom face barriers to accessing healthcare because they don't have the access, technology, or broadband capacity to attend virtual visits. But they do have smartphones.

Above all else, the project proved that simple, succinct phone and text messages are capable of nudging parents into scheduling well-child visits, and that a messaging platform can also bridge that gap between making that appointment and following through.

And that's important, particularly at this time. Brinkman notes that those well-child visits have picked up a variety of health concerns, both minor and serious, that weren't caught during the pandemic because of the skipped appointments.

"When [parents] came back in for the check-ups, there was a lot more to deal with," he says.

Brinkman and Berset are using the results of the pilot program to make it a permanent fixture in primary care and pediatric practices across the health system, as well as in HealthVine, the hospital's Medicaid accountable care organization, which serves more than 130,000 children.

Both see a lot of room for continued study. They'd like to test the value of different messages and modalities, as well as trying new strategies to boost patient portal adoption—which in turn may be an important step in boosting access to care for underserved populations.

"Using patient portals offers an additional layer in the approach to engage families, as outreach attempts need to be varied, especially in marginalized populations," they concluded in their study. "Future qualitative research should be done to (1) incorporate multiple communication modes, such as videos and storytelling; (2) offer and encourage choice; (3) develop patient-centered messages by cocreating with families; and (4) use interventions that leverage effective community partnerships and trust."