A Research-Based Approach to Product Development for FQHCs, FCCs, and Tribal Health Organizations: How We Built Automated Gaps-in-Care Journeys
by Orit Mohamed, CareMessage Director of Product
In 2023, the healthcare landscape was changing quickly and drastically. Automation was no longer just a luxury but a necessity in order to scale up staff while still maintaining quality of care. FQHCs, FCCs, and Tribal Health Organizations knew that they needed to find a way to implement this technology to address patients’ clinical needs, but there wasn’t a ready-made solution that was made for safety-net organizations. As a result, these organizations still relied on cumbersome manual workflows that limited their impact on clinical outcomes.
Focusing on Critical Problems Through Customer Research
Through in-depth qualitative conversations and research with customers, CareMessage’s Integration Team learned that the repetition of manual group messages was draining valuable time and resources from clinic staff. Our group messaging feature was already a popular tool for targeting patients with gaps-in-care, but there was an opportunity to make it even more efficient and free up staff time from our FQHCs and Free Clinics who were already short on resources.
Our development process began with a simple yet powerful question: How might we automatically identify and query patients who are overdue for a diabetes management appointment directly from a customer’s EHR and subsequently enroll those patients into a series of text messages once they’ve met the set criteria?
What began as a simple question quickly evolved into a sprawling, years-long endeavor, demanding research, and user-first development at each pivotal step along the way.
Building for Clinical Impact in Underserved Populations
Our goal was ambitious: to automate this entire process through integrations with major EHRs. We chose Diabetes Management as the use case to validate our approach because it disproportionately affects safety-net populations and is a critical UDS measure.
We partnered with major EHR providers, including athenaHealth Marketplace and NextGen’s Developer Program, while empowering our Engineering Team to lead the charge and explore whether the EHR APIs could provide the necessary data. They also spent long hours identifying whether our internal tools could support the integration and what clinical data should be exported. Sandbox data and proofs-of-concept confirmed that automating the export of patients based on diabetes-related clinical data and enrolling them into CareMessage’s Outreach feature was indeed possible.
With the technical framework in place, we moved on to testing with real patient data. We launched our Innovation Partners Program, collaborating with key customers who supported us in the design of impactful integrations tailored to their needs and the needs of their patients.
Validation Through Results
Our pilot customers validated the pain points we were hearing across the country. Health Centers lacked the time and resources to consistently message patients with gaps-in-care. The manual process of doing so was simply too time-consuming.
One of our most compelling case studies comes from an FQHC in Texas. They identified a critical patient population: adults aged 18–75 with type 2 diabetes (A1c > 9) who hadn’t been in for an appointment recently and had no upcoming appointments.
The Outreach messages were crafted in both English and Spanish, with the operational workflow ensuring that patients who responded “YES” received follow-up calls from health center staff. After six months of messaging, the results were clear. One pilot customer saw:
- 68% of patients messaged booked at least one appointment
- On average, patients enrolled in the Automated Gaps-in-Care Journeys booked five appointments
- One patient even had 23 new appointments booked within seven months of their first message
One additional patient’s journey highlights the profound impact of this automation. After multiple messages, a patient finally responded to a diabetes follow-up prompt, leading to an appointment booking. This initial visit cascaded into further appointments for additional diabetes care, including eye exams, stretching well into 2025. This single automated text message triggered a series of healthcare interactions that will significantly improve this patient’s health outcomes.
For the FQHC, the integration saved precious staff hours and provided a reliable way to ensure diabetes care outreach continued even when their quality team was stretched thin. As they put it, “the [Automated Gaps-in-Care Journeys] messaging works in the background, regardless of whether or not our quality team is there.”
Scaling for the Future
At CareMessage, we are incredibly excited about the technical value we’re delivering to our customers with this automation. This is just the beginning — we’re poised to deliver even more innovative solutions around messaging content, messaging workflows, and more use cases beyond Diabetes.
The Automated Gaps-in-Care Journeys: Diabetes Integration represents more than just a technological achievement. It is a testament to our commitment to making healthcare more accessible, efficient, and impactful. This journey has been about more than just building a product — it’s been about building a future where healthcare providers can focus more on patient care and less on manual processes.
I am proud of what we have accomplished and look forward to the continued positive impact this integration will have on our customers and their patients. For more information on CareMessage’s Automated Gaps-in-Care Journeys, contact hello@caremessage.org.
Orit Mohamed is the Director of Product at CareMessage, where she leads a team of product managers, designers, and user researchers to drive the company’s product strategy and roadmap. With a strong commitment to building technology solutions that address societal challenges, Orit is particularly focused on advancing equity for marginalized communities. She also leads the interoperability and API teams at CareMessage, working to develop impactful health technology that improves the lives of health center staff and the patients they serve. Orit’s background spans Public Service, Journalism, and Higher Education, always centered on racial and economic equity. She holds a degree in Political Economy from the University of California, Berkeley.