The follow-up gap nobody is talking about.

YOUR HEALTH — Issue No. 18

Between Visits — The Follow-Up Gap Nobody Is Talking About

A personal note before we start:

I was genuinely excited to write this issue. Keeping up with everything that matters about our health is hard — for patients and for clinicians alike. This is a problem that absolutely exists, there is no perfect fix, and it does not get talked about enough. That is exactly why it needed an issue.

— Kyle

Every year at a Medicare wellness visit, I go through the same checklist.

Mammogram — when was the last one? Colorectal cancer screening — up to date? DEXA scan for bone density — done? PSA for the men. Pap smear for women. Low-dose CT for lung cancer screening in patients with a significant smoking history.

These are the tests that quality measures track. The ones insurance metrics are built around. The ones my EMR flags and reminds me about. And they are important — genuinely important. Each one exists because catching something early saves lives.

But there is another list. One that nobody tracks. One that lives in the space between those standard reminders — and that is what I want to talk about today.

What the EMR does well

Electronic health records have transformed medicine in ways that are easy to take for granted. Medication lists, allergy records, lab trends over time, visit notes accessible across systems — the infrastructure of modern care depends on them.

And for population-level preventive care — the standard screening checklist — EMRs work remarkably well. The reminders fire. The gaps get flagged. Your provider knows you are due for a colonoscopy before you walk in the door.

Incidental findings are reported in approximately 15 to 30 percent of all diagnostic imaging and 20 to 40 percent of CT examinations. That is not a small number. At the volume of imaging that happens in American healthcare every year — that is an enormous number of findings that need individualized follow-up. And the EMR, for all its strengths, was not built to track them at the patient level.

What falls through the cracks

Here is where the honest conversation begins — and I want to be clear before it does: this is not about blame. Not of patients. Not of providers. What I am about to describe is a structural problem — a gap built into the way healthcare information flows — not a failure of care or attention.

Incidental imaging findings:

A patient has a CT scan of the abdomen during a hospital stay. The radiologist notes a small renal lesion — likely benign, but worth repeating in six months to confirm it has not changed. That recommendation lives in the radiology report. The report gets scanned into the chart. The hospitalist sees it. The patient is discharged.

Six months later — who orders the repeat CT? The hospitalist who saw the original report has moved on. The primary care provider may never have seen the radiology report directly. The patient, relieved to be home from the hospital, may not remember the specific recommendation. The follow-up falls through the cracks — not because anyone was negligent, but because the system has no reliable mechanism to track individualized follow-up recommendations over time.

This happens more than most patients realize. A carotid doppler showing 50% stenosis that needs a repeat in a year. An echocardiogram showing mild aortic valve changes that needs monitoring for progression. A CT finding a 4cm aorta that warrants annual surveillance. Each of these generates a recommendation. None of them have a built-in tracking system.

Outside test results — the cross-system problem:

A different version of the same gap happens when imaging or testing occurs outside your primary care provider's health system entirely. A life screening event. A hospital in another city. A specialist at a different practice.

According to a 2025 survey of clinicians, only 44% agree their EHR provides expected integration with outside organizations — and clinicians in 2026 are still sending healthcare records through fax. When results travel across health systems — if they arrive at all — they typically arrive as a faxed document or scanned PDF. That document gets filed in the chart. But it does not become structured data. It does not generate alerts. It does not connect to the reminder systems that drive follow-up.

Your primary care provider may see it. They may not — particularly if it arrived without a direct communication flagging its significance. And even if they did see it, a recommendation buried in a scanned document from an outside facility has no automatic mechanism to resurface at the right moment.

The information made it into your chart. The follow-up may not have made it into your care.

Family history:

Family history is one of the most powerful risk factors in medicine — and one of the most inconsistently tracked over time. At a new patient visit, a provider takes a careful family history. It gets documented in the chart. And then, in most EMR systems, it sits relatively static — rarely revisited, rarely updated, rarely connected back to the clinical decisions it should be informing.

A patient whose father had colon cancer needs colonoscopies more frequently than standard screening intervals. A patient with multiple first-degree relatives who had heart attacks needs aggressive cardiovascular risk management. A patient whose mother was diagnosed with glioblastoma — even after a normal brain MRI — needs that history kept active and relevant to future symptom evaluation.

The problem is not that providers don't know these things. The problem is that family history, once documented, can get buried. Even in health systems with full EMR adoption, longitudinal data continuity remains incomplete — with direct consequences for clinical care. A provider covering a visit may not scroll back through the family history section of a chart from three years ago. The information exists. It does not reliably resurface when it matters.

Why scheduling far in advance does not fully solve it:

The obvious question is: why not just schedule the follow-up test at the time of the recommendation?

Sometimes that happens. But the gap between recommendation and completion is wider than it looks. Patients cancel appointments for tests they don't fully understand the purpose of. Scheduling systems at many facilities cannot book out six or twelve months. The patient forgets why the test was ordered by the time it arrives on the calendar. A new insurance situation changes what is covered. Life intervenes.

Before automated intervention, 88.7% of colonoscopy follow-up recommendations defaulted to a standard interval regardless of individual findings — meaning personalized follow-up was the exception rather than the rule even within a single health system with full EMR capability. If that is true for colonoscopy — one of the most systematized follow-up processes in medicine — it is certainly true for the dozens of other individualized recommendations that don't have the same infrastructure behind them.

This is a shared responsibility — and nobody's fault

The structural gap described above is not a failure of any individual provider or patient. It is a design limitation of a system built for population-level care that was never intended to track the individualized details that are unique to each patient over time.

Providers cannot be expected to remember every incidental finding, every outside result, and every piece of family history for every patient across years of care. That is not humanly possible. EMRs were built to support that memory — but their architecture was designed around standard workflows, not individualized surveillance.

Patients cannot be expected to remember every recommendation from every specialist visit and every imaging report. That is not a reasonable ask either.

What is reasonable is a shared tool — something the patient maintains and brings to every visit, and something the provider can glance at in seconds and immediately know what matters, what needs follow-up, and what family history should be informing today's clinical decisions.

The Plain Medicine solution

Plain Medicine Members now have access to the Plain Medicine Watchlist — a printable tracking document built specifically for this gap.

It is not a medical record. It is not a substitute for your chart. It is a personal health tracking document — something you bring to appointments, update when new recommendations are made, and use to make sure the things worth following up on don't get lost between visits.

What it tracks:

The Watchlist puts the continuity of your care in your hands — where it belongs.

Plain Medicine Members receive a biannual reminder to review and update their Watchlist — a prompt to pull it out, check what is due, and bring it to their next provider visit.

A word to providers:

If a patient walks into your exam room with a completed Plain Medicine Watchlist — you will be relieved.

Not because it tells you something you didn't know — but because it surfaces what might otherwise require scrambling through years of chart notes, scanned documents, and specialist letters to piece together. A patient who hands you a one-page summary of their active findings, their pertinent family history, and their outstanding follow-up items has just made your job meaningfully easier. The 20-minute visit suddenly has a roadmap.

That is what the Watchlist is for — not just the patient, but the clinical relationship itself.

Something worth saying plainly:

The gap between what your chart contains and what actually drives your care is real. It is not anyone's fault. But it is yours to help close.

Know what was found. Know what needs follow-up. Know what your family history means for your future care. Write it down. Update it. Bring it with you.

Between visits — that information is yours to keep. And it might be the most important document in the room.

The Member deep-dive this week covers the Plain Medicine Watchlist in detail — what goes in each section, how to use it at provider visits, and how to have the follow-up conversation with your provider when a recommendation has been missed.

Next week: Hormones after 50 — Part 1. What menopause actually does to your body, what the data shows about hormone therapy, and why millions of women stopped a treatment they didn't need to stop.

Plain Medicine is published for educational purposes only and does not constitute medical advice or establish a patient-provider relationship. Always consult your healthcare provider before making medical decisions.

— Kyle