Patient Identification Starts in the Practices Already Seeing the Patient
The practices already treating these patients can act on information about them.
A family physician sees a man in his sixties this morning for his diabetes follow-up. He also has a sore knee, needs a refill, and has uncontrolled blood pressure even though he’s on three medications. The visit runs about 18 minutes, close to the average for a primary care exam in the United States.[1] The physician adjusts his diabetes medicine, orders labs, and books him back in three months. Whether his blood pressure needs a workup for resistant hypertension doesn’t come up.
The practice has a few other patients like him. Reps for hard-to-control blood pressure therapies do not call on it. What reaches the office is display ads and email—and rarely anything that tells the staff some of their patients may be due for that workup or what it involves.
Where the target list stops
Brand teams rank clinicians by the patients they treat, and the target list comes from the top of that ranking. Below it sit community practices like this one, each with a handful of these patients, including some that have never prescribed a brand. For most brands, these practices are white space.
A diagnosis, and often a stage, is what puts a treatment decision in front of the clinician. A brand’s own analysis can show where patients in its disease area are likely undiagnosed, not yet staged, or not yet treated. That is where its education and support programs belong. A clinical notification can tell the practices treating them which guideline applies to some of their patients and the next step their staff can take.
Many patients have not yet been diagnosed, staged, or treated
Some conditions go years without a diagnosis. Others are diagnosed but not yet staged or not yet treated the way guidelines recommend. A few examples from national studies:
Kidney disease: About 9 in 10 adults with chronic kidney disease do not know they have it.[2] In one national lab’s records of adults with diabetes or high blood pressure, nearly 9 in 10 had the blood test for kidney function, and about 1 in 5 had the urine test that finds and stages early kidney damage.[3]
Heart failure: In recent years, about 15% of patients newly diagnosed in the hospital with heart failure with reduced ejection fraction (the heart pumps weakly) and eligible for all four recommended medicine classes were prescribed all four.[4]
Rare disease: Reaching a diagnosis takes more than six years on average, with nearly 17 doctor visits, hospital stays, and other trips for care along the way.[5]
Many of these patients have appointments but might be lacking a diagnosis or clear treatment plan. Sometimes the guideline makes the next step clear. After a new approval, or where several options fit, the choice is less obvious.
Feedback about a clinician’s own patients can change practice
Telling clinicians how their own patients were cared for is one of the most studied ways to change clinical practice. A 2026 Cochrane review of 292 studies found that it improves recommended care modestly on average. It works better where there is the most room to improve, when the report is about the individual clinician, and when it comes with an action plan.[6] A notification follows the same idea: It is about the practice’s own patients and names a next step.
A notification tells the practice that some of its patients may be due for a next step under the guideline. It links to its source so staff can check it: a medical society guideline or statement or, for a newly approved therapy, the prescribing information approved by the Food and Drug Administration. It names one thing the practice can do: Pull a list of matching patients, order the staging test, recheck at the next visit, or refer to a specialist with the workup done.
For the family practice above, a notification might say that some patients filling three or more blood pressure medicines may still be above goal. For patients above goal on three medicines of different classes at the highest tolerated doses, one of them a diuretic, an American Heart Association scientific statement recommends confirming the reading with home or ambulatory measurement, confirming the patient takes the medicines as prescribed, reviewing other drugs that raise blood pressure, and screening for secondary causes.[7] The notification explains how to find these patients in the practice’s records and attaches a one-page evaluation pathway.
Treatment patterns show which practices have patients due for a next step
For a practice off the target list, the patterns across its patients show where a next step may be due. A condition is diagnosed, and the test that stages it has not been done in the past year. Or patients have tried two or more treatments for a condition, and a newly approved therapy is approved for patients with that history.
At the family practice, the notification arrives by fax, the channel the office chose. The medical assistant who handles blood pressure follow-ups pulls the patients on three or more medicines and flags the ones not at goal. When the man comes back in three months, the physician has the pathway in front of her, and the decision is hers.
Where SignalTx™ fits
SignalTx, from Aventria Health Group, sends clinical notifications to practices whose patients’ treatment patterns fit a program’s clinical criteria, across a network of 3.3 million opted-in NPIs. The notifications go to the clinician and their staff through the channels they chose: electronic health record inbox, fax, text, or email. Most prescribers in the network chose two or more. For a brand, that reaches the white space with notifications based on patterns across the practice’s own patients. It works alongside the point-of-care programs a brand already runs.
Notifications never name a patient, and each passes the brand’s medical, legal, and regulatory review and a clinical review board before it goes out. Before approval, a program can run unbranded disease awareness. After approval, notifications state the approved indication and important safety information and link to the full prescribing information. Our ReCaptRx™ platform works later in the same journey, when a prescription is rejected or never picked up.
References
Neprash HT, Everhart A, McAlpine D, Smith LB, Sheridan B, Cross DA. Measuring primary care exam length using electronic health record data. Med Care. 2021;59(1):62-66. doi:10.1097/MLR.0000000000001450
Centers for Disease Control and Prevention. Chronic kidney disease in the United States. March 31, 2026. Accessed October 19, 2026. https://www.cdc.gov/kidney-disease/php/data-research/index.html
Alfego D, Ennis J, Gillespie B, et al. Chronic kidney disease testing among at-risk adults in the US remains low: real-world evidence from a national laboratory database. Diabetes Care. 2021;44(9):2025-2032. doi:10.2337/dc21-0723
Greene SJ, Ayodele I, Pierce JB, et al. Eligibility and projected benefits of rapid initiation of quadruple therapy for newly diagnosed heart failure. JACC Heart Fail. 2024;12(8):1365-1377. doi:10.1016/j.jchf.2024.03.001
EveryLife Foundation for Rare Diseases (now RARE Foundation) and the Lewin Group. The cost of delayed diagnosis in rare disease: a health economic study. September 14, 2023. Accessed October 19, 2026. https://www.rareadvocates.org/resources/delayed-diagnosis-study-english
Ivers N, Yogasingam S, Lacroix M, et al. Audit and feedback: effects on professional practice. Cochrane Database Syst Rev. 2026;6:CD000259. Updated June 22, 2026. Accessed October 19, 2026. doi:10.1002/14651858.CD000259.pub5
Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018;72(5):e53-e90. doi:10.1161/HYP.0000000000000084
Patient Identification
