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Already in the chart
Why hospitals keep losing patients they already diagnosed
3 min read
David Kirk, MD
Chief Medical Officer,
Regard
Regard
"A few weeks ago, we had a patient admitted who quickly died from aortic stenosis. My hospital had actually diagnosed the patient at least two years prior, when fixing it was still easy. But I never got the chance to see that patient. Your tool is exactly what we need to never miss a patient like him again."
A physician told me this recently, and, unfortunately, it's a common occurrence. Ask any service line leader or CMIO for a version of this story, and they'll have one ready to go.
A murmur turns up during an urgent care visit, and the covering physician orders an echo. It comes back showing moderate-to-severe aortic stenosis, preserved heart function, and a normal right ventricle, making the patient a straightforward candidate for TAVR. The report recommends a referral to structural heart, but the patient has no primary care doctor to route it through, and the physician who ordered the echo has already moved on to the next patient. The referral sits in the report and goes nowhere.
Over the next eighteen months, the patient shows up three more times. Twice, they came to the emergency department for syncope, charted as dehydration, and once for overnight observation for heart failure that resolves quickly with diuresis. Each of those encounters is clinically defensible on its own. The teams in the room made reasonable calls based on what a single visit showed them, but the disease was written across four visits, and no single visit gave anyone a reason to go back and read the other three.
Why qualified patients don't get the lifesaving procedures they need
What's worth examining is why a finding this clear doesn't reliably turn into a referral or a follow-up.
The first reason is that these findings are often unstructured data: "Moderate-to-severe aortic stenosis with preserved right ventricular function" is a sentence in an echo report, not a code in a structured field. The dehydration read on the syncope visit and the diuresis note on the heart failure admission are free text too. Registries, quality flags, and most population health tools run on structured data such as problem lists, ICD codes, discrete lab values. A sentence in a radiology impression or a nurse's note doesn't show up there, no matter how many times it's charted.
Another reason these patients are hard to locate is that finding them has traditionally depended on manual chart review, with care navigators reading through stacks of notes, one patient and one condition at a time, to painstakingly piece together fragmented, unstructured data.
And while manual review works, it doesn't scale. Teams can only cover a handful of high-priority conditions this way, and even for those, they typically catch only a fraction of the patients who'd qualify for a TAVR procedure. Once a referral clears that bar, tracking whether it actually happens is a problem of its own. Unlike a diagnosis, a referral doesn't come with a deadline. Nothing forces the consult to get scheduled, and no one is assigned to check back if it doesn't, so it simply sits until someone happens to notice it never happened. By the time many of these patients finally reach a structural heart team, they've developed severe pulmonary hypertension, a failing right ventricle, and frailty, and are labeled too sick for a procedure that would have been routine two years earlier.
How missing TAVR candidates translates to financial loss for health systems
Fragmented care does not only cost patients a missed diagnosis. It costs health systems the procedure. And the leak is larger than most leaders assume:
61–72%
of specialist visits went outside their network in a Harvard study of Medicare patients, even for provider groups with many of their own specialists1
38.9%
of referral attempts had no appointment date on record in one large health system. Another study found 46% of faxed referrals never led to a scheduled visit.2
The loss is downstream. When a patient slips away before the procedure, the system forfeits not just the visit but the imaging, the follow-ups, and the intervention itself, which is where the margin lives. The patients already in your building are an incredible opportunity.
What changes at population scale
A chart reviewer can work through unstructured notes carefully for one patient and one disease. No hospital can staff that same process across its entire population, checking for every condition hidden in free text.
The technology required should read the unstructured record the same way a clinician would, at the scale of an entire population and across many conditions at once, rather than one flagged patient and one condition at a time.
Two industry developments are raising the stakes on this at the same time:
01
Medicare finalized new TAVR coverage rules in September 2026. The rules drop the study requirement for patients with symptomatic severe aortic stenosis, cover patients without symptoms when treated within approved studies, and remove hospital volume minimums.3 More patients now qualify, and more of them are the ones most likely to sit unnoticed in an echo report: no referral, no flag.
02
Commercial payers are tightening from the other direction. CDI leaders tell us they're seeing denials on diagnoses that appear only in an answered query, on the logic that a condition serious enough to matter should show up elsewhere in the record too.
Medicare is widening who qualifies, while payers are tightening what counts as proof. Either way, a finding that sits unread in the chart costs more than it used to.
Some health systems have already built for this:
01
Kaiser Permanente Southern California's SureNet has run electronic surveillance across its membership since 2006, growing to more than 80 distinct programs, with a 61% success rate on the care lapses they flag.4
02
Brigham and Women's built ambulatory safety nets on the same model, routing abnormal lung imaging and colonoscopy results into tracked, navigator-driven follow-up. After outreach, 44% of overdue colon patients and 57% of lung nodule patients had follow-up scheduled or completed.5
Most health systems already have someone responsible for this kind of work: a navigator, a quality nurse, a CDI specialist. The job is staffed, but it's the volume that's impossible: reading every note, for every patient, across every condition.
See the patients your screening missed. Free.
Count of missed cases, dollar value attached, evidence on every finding. Under 4 hours of IT, results in under two weeks, zero commitment.
References
- Barnett ML, McWilliams JM. Changes in specialty care use and leakage in Medicare accountable care organizations. American Journal of Managed Care. 2018;24(5):e141–e149.
- Patel MP, Schettini P, O'Leary CP, Bosworth HB, Anderson JB, Shah KP. Closing the referral loop: an analysis of primary care referrals to specialists in a large health system. Journal of General Internal Medicine. 2018;33(5):715–721. Weiner M, El Hoyek G, Wang L, et al. A web-based generalist–specialist system to improve scheduling of outpatient specialty consultations in an academic center. Journal of General Internal Medicine. 2009;24(6)
- Centers for Medicare & Medicaid Services. Final decision memo: transcatheter aortic valve replacement (CAG-00430R2). September 10, 2026
- Kanter MH, Wakach W, Timmins R, Mitchell JE, Silverman AR, Imley TM. An electronic clinical surveillance system to reduce failure to follow up abnormal lab results and failure to order needed tests: description and methods. Journal of Applied Laboratory Medicine. 2025;10(5):1362–1375.
- Emani S, Sequist TD, Lacson R, et al. Ambulatory safety nets to reduce missed and delayed diagnoses of cancer. The Joint Commission Journal on Quality and Patient Safety. 2019;45(8):552–557.
