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Catch complications between appointments

A surgery center saw its patients post-operation at the 90-day follow-up, and until then relied on the patient to call if something went wrong. The clinic now automates patient check-ins earlier and more frequently via text message or email so critical patient symptoms reach a nurse immediately.

Post-operative Recovery Check-in
Frequency
Starts 14 Jan 2026
Repeats day 3, day 14,  day 30, day 90,  6mo,  1yr
Ends 1yr CMS assessment

Clinical Challenge

A surgery center came to us because it had no way to check on a patient between the operation and the 90-day follow-up appointment. For those three months the clinic relied on the patient to call if something went wrong, and patients do not always call. Earlier or more frequent visits bring no reimbursement, and many of these patients travel a long way to be seen, so bringing them back in was never a realistic answer. The center could not afford a team of nurses to work through call lists either, and when it asked its IT department for a way to reach patients directly, the request went onto a waitlist two to three years long.

In this particular center, the silence was doing real damage. A complication that would have been simple to treat went unreported for as long as the patient chose to wait, caused ER visits and re-admissions, and none of those three months produced a record the surgeons could work from.

The center also has a CMS reporting deadline coming, and meeting it means obtaining a scored assessment on every joint replacement patient on a fixed schedule. Limited staffing and IT resources will make this difficult to achieve.

Impact

Complications found late

An infection at week two is a prescription. At week six it is an admission.

No measurable progress

The chart holds a recollection from the 90-day visit, which the surgeons cannot study.

Cannot meet the 2027 deadline

The CMS joint replacement measure is mandatory in 2027, and it needs a patient score a year after surgery.

“We don't hear from a patient until something has already gone wrong.”

Surgeon, orthopedic surgery center

Clinical Solution

The surgery center and EVAL started with the 90-day visit questionnaire the clinic was already sending out by mail and created 3 digital instruments that can be automatically delivered digitally (text msg or email) on a schedule. The three digital instruments includes a quick short form that patients can receive almost immediately to report recovery progress, a long form to thoroughly assess recovery progress, and a 12-month CMS joint replacement measure.

Each digital instrument is scheduled for the patient with pre-set schedule defaults for fast scheduling at discharge.

Clinical staff receive reports daily from patients and monitor the results, calling in the patients that need immediate attention or that have not responded within the timeframe. 

1 Day of surgery

The patient goes home after surgery

The patient is discharged with a 90-day appointment on the calendar and nothing scheduled in between.

Discharge summary Tue 04 Total knee replacement J. Doe, MD · Orthopedics Next appointment: day 90
2 Same afternoon

A nurse starts the follow-up schedule

A nurse assigns the clinic's post-op follow-up to the patient once. The schedule covers days 3, 14, 30 and 90, then a short review at six and twelve months.

Follow-up schedule Wound check Day 3 · Recovery check-in Scheduled Day 14 · Recovery check-in Scheduled Recovery milestone Day 30 · Recovery check-in Scheduled Day 90 · Recovery check-in Scheduled Outcomes measure Month 6 · Long recovery check-in Scheduled Month 12 · CMS joint replacement Scheduled
3 Day 14

The check-in sends itself

It goes out by text and email on the day it is due. Nobody has to remember to send it, and nobody has to call to ask.

It has been 14 days since your surgery. How is your recovery going?

me.eval.health/7d1b9c

4 That evening

The patient answers on their own phone

One tap of the secure link opens the questions in the phone's browser. No app, no account, no portal password.

Is there any redness or drainage around the incision? None Redness only Redness and drainage Drainage with a fever
5 Minutes later

Wound symptoms raise a critical flag

Answers are scored against the thresholds the surgeons set. Redness, drainage and fever together cross the critical threshold as soon as the patient submits.

Post-op follow-up
Wound symptoms 4of 6
Possible wound infection CRITICAL

This answer combination crosses the critical threshold and is flagged for immediate review.

6 Next morning

Staff work two short lists

The dashboard shows the results that need a call and the patients who have not replied. Everyone recovering as expected stays off the call sheet.

Urgent 2 Critical / High
Overdue 5 Past due date
Sep 03 Day 14 recovery check-in CRITICAL
Sep 03 Day 30 recovery check-in OVERDUE
7 Day 90

The visit opens with three months of answers

The surgeon sees how the patient reported their recovery at day 3, 14 and 30, and has a baseline to measure this knee against the last one.

Recovery to date
Day 3 34 of 100
Day 14 58 of 100
Day 30 71 of 100

What's your clinical challenge?

Bring us the workflow that is costing your clinic time, and we will partner with you to find a solution that works for your team. 

1

Discovery call

We meet with your team to learn the challenge first-hand, then map where the workflow breaks down and what it is costing the clinic.

2

Solution proposal

EVAL designs a digital workflow that solves the challenge and returns with an implementation plan and the outcomes to expect.

3

Clinical pilot

Run the solution with one provider group to confirm it works as intended, then adjust as it rolls out to the rest of the clinic.

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