Preventive Reminder Ordering AssistanCe Via Texting for Improved Visit Encounters (PROACTIVE)

A substantial portion of the United States population remains overdue for key screenings, despite availability and insurance coverage of preventive health services. Barriers for completion and remaining up to date with screening include patients not remaining actively engaged with their care team, time constraints during office visits, and operational strain. This project aims to implement and evaluate a primary care visit-based program that harmonizes multiple preventive health and chronic disease management care gaps, reduces staff burden, and improves ordering and subsequent patient follow through on completion of overdue care gaps.

In this study, we will evaluate nudges to clinicians and patients to help increase screening completion for multiple care gaps identified as high priority by primary care, including imaging (Mammogram, DEXA) and labs (Diabetes Management (Hemoglobin A1C, Basic Metabolic Panel, and Urine Microalbumin), Hepatitis C, and Lipids). This will be a 6 month, stepped-wedge, pragmatic trial conducted at Penn Medicine.

Study Overview

• Status: Not yet recruiting
• Conditions: Behavior, Health
• Intervention / Treatment: Behavioral: Pre-visit and post-visit patient messaging; Behavioral: Default pended order; Behavioral: EHR communication

Detailed Description

A substantial portion of the United States population remains overdue for preventive care screenings, despite availability of health services. This gap in care persists due to both patient and clinician facing barriers. Patients may not always remain actively engaged with their care team, while clinicians are impacted by time constraints and the complexity of managing multiple care tasks during visits. One population health strategy to address these barriers is visit-based nudges, which is anchored around office visits and uses methods such as pre-visit texting to patients and pended orders for clinicians. In a previous study aimed at improving influenza vaccination rates, pre-visit texting and automated pended orders used within an office visit increased vaccination rates by 5 percentage points. Another prior study, aimed at improving mammogram completion, utilized pended orders and post-visit texting to increase screening rates by 5 percentage points at six months for intervention patients. Both studies have demonstrated the impact of leveraging multiple nudges to both patients and clinicians and have highlighted the need to integrate these aspects into one large scalable program to create a cohesive patient experience. Building upon our prior work and in collaboration with primary care, we propose to develop and evaluate an integrated visit-based preventive health program with nudges to both clinicians and patients using a stepped wedge design, with the goal of implementing this system across primary care practices.

• Study Type: Interventional
• Enrollment (Estimated): 16416
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Shivan Mehta; Phone Number: 215-898-9807; Email: shivan.mehta@pennmedicine.upenn.edu
• Study Contact Backup: Name: Caitlin Brophy; Email: Caitlin.Brophy@pennmedicine.upenn.edu

Study Locations

• United States
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19104
      • University of Pennsylvania Health System
      • Contact: Caitlin Brophy; Phone Number: 267-566-4956; Email: caitlin.brophy@pennmedicine.upenn.edu
      • Principal Investigator: Shivan Mehta

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

All patients must meet the following criteria to be eligible:

1. 18 years or older
2. A scheduled new or return (non-urgent/sick) primary care visit at one of the study practices
3. Overdue for at least one of the included care gaps according to Health Maintenance: Mammogram, DEXA, Hemoglobin A1C, Basic Metabolic Panel, Urine Microalbumin, Lipids, Hepatitis C
4. Last eligible office visit was greater than or equal to 3 months ago

Exclusion Criteria:

As this trial is integrated with routine clinical operations, there will be no exclusion criteria. However, for each care gap independently, we will exclude all patient visits throughout the remaining trial duration after the patient's first eligible office visit within the trial duration. In other words, each patient will contribute data from at most one eligible office visit.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Control Condition; During the control condition, clinics will receive standard of care.
Experimental: Active Intervention; During the active intervention, clinics will receive both clinician and patient facing nudges. Patient nudges will be pre- and post-visit text message reminders about their overdue care gaps. Clinician nudges will be default pended orders for overdue care gaps and an EHR Smart Data Element communication banner notifying the provider that a pre-visit reminder was sent to the patient and that orders have been pended for their review.	Behavioral: Pre-visit and post-visit patient messaging; The patient nudges will be delivered by a series of one to three text messages. Patients will receive the pre-visit text message 2 days prior to their scheduled primary care visit. This message will remind them that they are overdue for their preventive care imaging and/or labs and encourage them to speak with their provider about screening completion during their upcoming appointment. All patients who complete their primary care visit and whose provider signed at least one of their pended orders will be sent post-visit text messages 7 and 14 days after completion, if they have not yet scheduled or completed their overdue labs and/or imaging. The messages delivered at 7 and 14 days will remind patients that appointments for lab and imaging are available for them and provide phone number(s) to call for scheduling and a link to complete scheduling online. Patients will also have the option to engage with a bi-directional support menu via text message.; Behavioral: Default pended order; The default pended orders will be automatically placed into the patient's primary care visit encounter via a custom Epic extension for each included care gap (mammogram, DEXA, hemoglobin A1C, basic metabolic panel, urine microalbumin, lipids, and Hepatitis C) that the patient is overdue for according to their Health Maintenance status. Clinical staff will have the option of signing the order or dismissing it if they deem it inappropriate for a given patient.; Behavioral: EHR communication; An electronic health record (EHR) communication will be visible to the provider and entire care team during the visit encounter. This smart data element (SDE) communication will display in the patient's EHR encounter as a section in pre-charting, check-in, and rooming, and will notify the clinician and care team that a pre-visit communication was sent to the patient regarding their overdue status for their preventive care imaging and/or labs.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mammogram Screening Completion (3 months)	The primary outcome is the proportion of patients overdue who complete a mammogram within 3 months after the first eligible primary care visit.	Within 3 months after first eligible primary care visit.
Hepatitis C Screening Completion (3 months)	The primary outcome is the proportion of patients overdue who complete Hepatitis C screening within 3 months after the first eligible primary care visit.	Within 3 months after first eligible primary care visit.
Lipids Screening Completion (3 months)	The primary outcome is the proportion of patients overdue who complete lipids screening within 3 months after the first eligible primary care visit.	Within 3 months after first eligible primary care visit.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
DEXA Screening Completion (3 months)	The secondary outcome is the proportion of patients overdue who complete DEXA screening within 3 months after the first eligible primary care visit.	Within 3 months after the first eligible primary care visit.
Hemoglobin A1C Screening Completion (3 months)	The secondary outcome is the proportion of patients overdue who complete Hemoglobin A1C screening within 3 months after the first eligible primary care visit.	Within 3 months after the first eligible primary care visit.
Basic Metabolic Panel Screening Completion (3 months)	The secondary outcome is the proportion of patients overdue who complete Basic Metabolic Panel screening within 3 months after the first eligible primary care visit.	Within 3 months after the first eligible primary care visit.
Urine Microalbumin Screening Completion (3 months)	The secondary outcome is the proportion of patients overdue who complete Urine Microalbumin screening within 3 months after the first eligible primary care visit.	Within 3 months after the first eligible primary care visit.
Mammogram Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete a mammogram within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
Hepatitis C Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete Hepatitis C screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
Lipids Screening Completion (6 months)	The primary outcome is the proportion of patients overdue who complete lipids screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
DEXA Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete DEXA screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
Hemoglobin A1C Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete Hemoglobin A1C screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
Basic Metabolic Panel Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete Basic Metabolic Panel screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.
Urine Microalbumin Screening Completion (6 months)	The secondary outcome is the proportion of patients overdue who complete Urine Microalbumin screening within 6 months after the first eligible primary care visit.	Within 6 months after the first eligible primary care visit.

Collaborators and Investigators

• Sponsor: University of Pennsylvania
• Investigators: Principal Investigator: Shivan Mehta, University of Pennsylvania

Study record dates

Study Major Dates

• Study Start (Estimated): June 8, 2026
• Primary Completion (Estimated): February 23, 2027
• Study Completion (Estimated): May 23, 2027

Study Registration Dates

• First Submitted: June 3, 2026
• First Submitted That Met QC Criteria: June 3, 2026
• First Posted (Actual): June 9, 2026

Study Record Updates

• Last Update Posted (Actual): June 9, 2026
• Last Update Submitted That Met QC Criteria: June 3, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Behavioral Economics; Preventive Health; EHR Nudge
• Additional Relevant MeSH Terms: Behavior; Health Behavior
• Other Study ID Numbers: 859571

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No